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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.
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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 pruritus.
- B. Is experiencing erythema.
- C. Appears to be experiencing pruritus.
- 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. Pruritus is the only subjective assessment finding. All other options are examples of objective data.
The nurse is assessing a patient for collection of subjective and objective data. What will this data provide the basis for making?
- A. Care plan
- B. Medical diagnosis
- C. Nursing assessment
- D. Patient problem
Correct Answer: D
Rationale: Nurses rely on assessment of signs and symptoms to formulate a patient problem.
A condition in which there is a lack of appetite resulting in the inability to eat is known as ____.
Correct Answer: anorexia
Rationale: Anorexia is a lack of appetite resulting in the inability to eat. It can occur in many disease conditions.
When assessing a female for risk factors associated with coronary artery disease what information should the nurse include?
- A. Family history of illness
- B. Diet
- C. Smoking
- D. Exercise
- E. Number of pregnancies
Correct Answer: A,B,C,D
Rationale: With the exception of information relative to pregnancies, all options would be informative about risk for heart disease.
When assessing a patient the nurse notes a yellow tinge to the patient's skin. How should the nurse document this finding?
- A. Dyspnea
- B. Cyanosis
- C. Jaundice
- D. Ecchymosis
Correct Answer: C
Rationale: Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver.