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During a head-to-toe assessment the nurse assesses the patient's perineal area. Which area should the nurse assess next?
- A. Chest
- B. Arms
- C. Abdomen
- D. Legs and feet
Correct Answer: D
Rationale: When performing a head-to-toe assessment, the nurse begins with a neurologic assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order.
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During a head-to-toe assessment the nurse assesses the patient's abdomen. Which area should the nurse assess next?
- A. Chest
- B. Arms
- C. Legs and feet
- D. Perineal area
Correct Answer: D
Rationale: When performing a head-to-toe assessment, the nurse begins with a neurologic assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order.
Listening for bowel sounds should be done over all four quadrants of the abdomen using the diaphragm of the stethoscope. What is the normal rate of bowel sounds per minute?
- A. 2 to 10
- B. 3 to 20
- C. 4 to 32
- D. 5 to 40
Correct Answer: C
Rationale: The normal rate of bowel sounds per minute is 4 to 32.
During a physical assessment the nurse notes a patient has a bluish discoloration of the skin and mucous membranes. How should the nurse document this finding?
- A. Dyspnea
- B. Cyanosis
- C. Diaphoresis
- D. Ecchymosis
Correct Answer: B
Rationale: Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood.
During a physical assessment the nurse notes a patient passes frequent loose liquid stools. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Cyanosis
- C. Diaphoresis
- D. Diarrhea
Correct Answer: D
Rationale: Diarrhea is the frequent passage of loose liquid stools. It generally results from increased motility in the colon. This is usually a sign of an underlying disorder. The characteristics of the diarrhea give evidence as to the source. Dark black, tarry stools can mean there is bleeding in the intestines. Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract.
The nurse uses a systematic method for collecting data on all body systems including normal functioning and any noted changes. What is this method?
- A. Nursing interview
- B. Review of systems
- C. Nursing assessment
- D. Health history
Correct Answer: B
Rationale: A review of systems is a systematic method.