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During a physical assessment the patient complains of difficulty in passing stools. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Cyanosis
- C. Constipation
- D. Ecchymosis
Correct Answer: C
Rationale: Constipation is difficulty in passing stools or an incomplete or infrequent passage of hard stools. There are many causes, both organic and functional.
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A health care provider documents that a patient is having purulent drainage from a wound. What does the nurse understand is most likely the cause?
- A. Ringworm
- B. Viral infection
- C. Fungal infection
- D. Bacterial infection
Correct Answer: D
Rationale: Purulent drainage is a creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of tissues. Bacterial infection is the most common cause. The character of the pus, including its color, consistency, quantity, or odor, may be of diagnostic significance.
A nursing assessment is a process of collecting data to establish a database. The information contained in the database is a basis for:
- A. a complete physical examination.
- B. a medical assessment.
- C. an individualized plan of care.
- D. writing nursing orders.
Correct Answer: C
Rationale: The information contained in the database is the basis for an individualized plan of care.
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 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 patient has discoloration of an area of their mucous membrane caused by extravasation of blood into the subcutaneous tissue. What should the nurse document that the patient has?
- A. Dyspnea
- B. Cyanosis
- C. Diaphoresis
- D. Ecchymosis
Correct Answer: D
Rationale: Ecchymosis is discoloration of an area of the skin or mucous membrane caused by the extravasation of blood into subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls (also called a bruise).