Nokea
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.
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The nurse is performing auscultation of breath sounds on a respiratory patient. The sounds heard on inspiration and expiration are low-pitched coarse gurgling and have a snoring sound. What best identifies these sounds?
- A. Crackles
- B. Plural friction rub
- C. Rhonchi
- D. Sonorous wheezes
Correct Answer: D
Rationale: Sonorous wheezes have a low-pitched, coarse, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and large airways.
Discoloration of an area of the skin or mucous membrane that is caused by the extravasation of blood into the subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls is known as ____.
Correct Answer: ecchymosis
Rationale: Ecchymosis is discoloration of an area of the skin or mucous membrane caused by the extravasation of blood into the subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls.
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.
Symptoms that are perceived by the patient are known as ____ data.
Correct Answer: subjective
Rationale: Symptoms are subjective indications of illness that are perceived by the patient. Symptoms are referred to as subjective data.
A patient was admitted with a complaint of abdominal pain. Later the nurse observed the patient demonstrating dyspnea. What type of assessment does this change in condition require?
- A. Individualized
- B. Focused
- C. Specialized
- D. Systematic
Correct Answer: B
Rationale: When the nurse observes a change in the patient's condition, the assessment is focused.