Nokea
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.
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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.
A health care provider needs to insert a vaginal speculum into a patient for a vaginal examination. In what position should the nurse place the patient?
- A. Sims
- B. Prone
- C. Lithotomy
- D. Dorsal recumbent
Correct Answer: C
Rationale: The lithotomy position provides maximal exposure of genitalia and facilitates insertion of a vaginal speculum.
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.
An older adult patient is being assessed for skin turgor. The nurse identifies decreased skin turgor demonstrated by slow return of the skin to the previous position after being grasped and raised. What can the nurse conclude is responsible for this assessment?
- A. Dehydration
- B. Edema
- C. Skin breakdown
- D. Malnutrition
Correct Answer: A
Rationale: Dehydration results in decreased skin turgor.
During a head-to-toe assessment the nurse assesses the patient's perineal area. Which area should the nurse assess next?
- A. Chest
- B. Arms
- C. Abdomen
- D. Legs and feet
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.