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During a physical assessment the nurse notes a patient has profuse secretions of sweat. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Cyanosis
- C. Diaphoresis
- D. Ecchymosis
Correct Answer: C
Rationale: Diaphoresis is the secretion of sweat, especially the profuse secretion associated with an elevated body temperature, physical exertion, exposure to heat, and mental or emotional stress.
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The nurse is developing a nursing care plan for a newly admitted patient. What is the first step the nurse will take in developing this care plan?
- A. Health history
- B. Review of systems
- C. Family history
- D. Nursing assessment
Correct Answer: D
Rationale: The nursing assessment is the critical step in forming the nursing care plan.
A health care provider needs to assess a patient for a heart murmur. In what position should the nurse place the patient?
- A. Sims
- B. Prone
- C. Lithotomy
- D. Lateral recumbent
Correct Answer: D
Rationale: The lateral recumbent position aids in detecting heart murmurs.
A condition in which a patient experiences bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood is known as ____.
Correct Answer: cyanosis
Rationale: Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood.
When assessing a patient the nurse notes that the patient is unable to lie flat to breathe. When the nurse assists the patient into a sitting position the patient is able to breathe more easily. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Cyanosis
- C. Jaundice
- D. Orthopnea
Correct Answer: D
Rationale: Orthopnea is an abnormal condition in which a person must sit or stand to breathe deeply or comfortably. It occurs in many disorders of the respiratory and cardiac systems.
During a physical assessment the nurse observes a patient experiencing a sudden audible expulsion of air from the lungs. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Cyanosis
- C. Coughing
- D. Ecchymosis
Correct Answer: C
Rationale: Coughing is a sudden audible expulsion of air from the lungs. Coughing is an essential protective response that serves to clear the lungs, bronchi, or trachea of irritants and secretions or to prevent aspiration of foreign material into the lungs. It is a common sign of diseases of the larynx, bronchi, and lungs.