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The nurse is collecting data during an initial assessment. What can be seen heard measured or felt and is objective?
- A. Symptom
- B. Observation
- C. Sign
- D. Assessment
Correct Answer: C
Rationale: A sign can be seen, heard, measured, or felt.
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A creamy viscous pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of ____ is known as purulent drainage.
Correct Answer: tissues
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.
A health care provider needs to assess a patient for a heart murmur. In what position should the nurse place the patient?
- A. Sims
- B. Prone
- C. Lithotomy
- D. Lateral recumbent
Correct Answer: D
Rationale: The lateral recumbent position aids in detecting heart murmurs.
What is the third assessment technique in a standard physical examination?
- A. Auscultation
- B. Percussion
- C. Inspection
- D. Palpation
Correct Answer: A
Rationale: The usual sequence of assessment is inspection, palpation, auscultation, and lastly percussion.
When discussing diabetes with a patient the nurse describes this disease as falling into which group in terms of duration?
- A. Acute
- B. Organic
- C. Chronic
- D. Functional
Correct Answer: C
Rationale: Diabetes mellitus is an example of a chronic disease.
A nurse is caring for a patient with congestive heart failure. During the physical assessment the nurse notes the patient is experiencing difficulty breathing. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Cyanosis
- C. Diaphoresis
- D. Ecchymosis
Correct Answer: A
Rationale: Dyspnea is shortness of breath or difficulty in breathing that may be caused by certain heart and lung conditions, strenuous exercise, or anxiety.