Nokea
The nurse observes that an older adult patient has no hair on the lower legs. The nurse should assess further for the sufficiency of arterial ____.
Correct Answer: flow
Rationale: Reduced arterial flow causes lack of hair on the lower extremities due to inadequate blood flow.
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Various techniques are used by the nurse when performing a physical assessment. One of these techniques is percussion. What is percussion used to determine?
- A. Sounds for auscultation
- B. Data about physical features
- C. Changes in structural integrity
- D. Density of underlying tissue
Correct Answer: D
Rationale: The sounds indicate the density of the underlying tissue.
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.
A health care provider documents that a patient has a scleral icterus. How does the nurse describe the color of the patient's sclera?
- A. Red
- B. Blue
- C. Green
- D. Yellow
Correct Answer: D
Rationale: Scleral icterus means the color of the sclera is yellow. The jaundice is due to coloring of the sclera with bilirubin that infiltrates all tissues of the body.
When performing a nursing physical assessment the nurse uses a head-to-toe approach. Where will the nurse begin when using this method?
- A. Skin assessment
- B. Neurologic assessment
- C. Circulatory assessment
- D. Respiratory assessment
Correct Answer: B
Rationale: When performing a head-to-toe assessment, the nurse begins with a neurologic assessment.
A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?
- A. Complains of diplopia
- B. Is experiencing nystagmus
- C. Demonstrates facial grimacing
- D. Has a generalized rash
Correct Answer: A
Rationale: Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Diplopia is the only subjective assessment finding. All other options are examples of objective data.