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The nurse assesses a patient for capillary refill after the fingernail is compressed for 5 seconds. What should the nurse expect the refill time to be?
- A. 1 second
- B. 2 seconds
- C. 3 seconds
- D. 4 seconds
Correct Answer: C
Rationale: Capillary refill should take fewer than 3 seconds.
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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.
A health care provider needs to assess a patient's rectal area. In what position should the nurse place the patient?
- A. Sims
- B. Prone
- C. Lithotomy
- D. Knee-chest
Correct Answer: D
Rationale: Knee-chest position provides maximum exposure of the rectal area.
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.
What should a patient interview being conducted by the nurse convey to the patient?
- A. The nurse has feelings of concern.
- B. The nurse has limited time.
- C. The nurse is very intelligent.
- D. The nurse has answers to problems.
Correct Answer: A
Rationale: The nurse must convey feelings of concern.
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.