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During a physical assessment the nurse notes that a patient's heart rate is 56 beats/min. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Cyanosis
- C. Diaphoresis
- D. Bradycardia
Correct Answer: D
Rationale: Bradycardia is a circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute.
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The nurse is performing auscultation of breath sounds on a respiratory patient. The sounds heard on inspiration and expiration are low-pitched coarse gurgling and have a snoring sound. What best identifies these sounds?
- A. Crackles
- B. Plural friction rub
- C. Rhonchi
- D. Sonorous wheezes
Correct Answer: D
Rationale: Sonorous wheezes have a low-pitched, coarse, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and large airways.
There are four categories of factors that increase an individual's vulnerability to develop a disease: genetic physiologic age and lifestyle. What is the term for these factors?
- A. Risk factors
- B. Causative factors
- C. Etiologic factors
- D. Hazardous factors
Correct Answer: A
Rationale: Risk factors are placed into four categories.
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.
What should the nurse begin by assessing when performing a head-to-toe assessment?
- A. Support system
- B. Skin integrity
- C. Pain level
- D. Neurologic status
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.
Which are infectious diseases?
- A. Measles
- B. Pneumonia
- C. Hay fever
- D. Tuberculosis
- E. Osteoarthritis
- F. Acquired immunodeficiency syndrome
Correct Answer: A,B,D,F
Rationale: Infectious diseases result from the invasion of microorganisms into the body. Examples of infectious diseases include acquired immunodeficiency syndrome (AIDS), tuberculosis, measles, and pneumonia. Hay fever is a manifestation of an allergic reaction, and osteoarthritis is an example of a degenerative disease.