Nokea
During a physical assessment the nurse notes that a patient has bright red blood in the feces. What does the nurse recognize as the most likely cause of this bleeding?
- A. Bleeding in the upper intestinal tract
- B. Bleeding in the lower intestinal tract
- C. Bleeding in the entire intestinal tract
- D. Consumption of cranberry juice
Correct Answer: B
Rationale: Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract.
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A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?
- A. Complains of diplopia
- B. Is experiencing nystagmus
- C. Demonstrates facial grimacing
- D. Has a generalized rash
Correct Answer: A
Rationale: Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Diplopia is the only subjective assessment finding. All other options are examples of objective data.
A patient has edema of the lower extremities. The nurse is assessing whether it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds the nurse identifies 2+ pitting edema. When did the edema disappear?
- A. 10 to 15 seconds
- B. 20 to 25 seconds
- C. 30 to 35 seconds
- D. 40 to 45 seconds
Correct Answer: A
Rationale: The 2+ pitting edema is identified because the pitting edema disappears in 10 to 15 seconds.
An abnormally rapid rate of breathing that is seen in many disease conditions is known as ____.
Correct Answer: tachypnea
Rationale: Tachypnea is an abnormally rapid rate of breathing that is seen in many disease conditions.
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.
An abnormal condition in which a person must sit or stand to breathe deeply or comfortably is known as ____.
Correct Answer: orthopnea
Rationale: Orthopnea is an abnormal condition in which a person must sit or stand to breathe deeply or comfortably.