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The nurse uses a systematic method for collecting data on all body systems including normal functioning and any noted changes. What is this method?
- A. Nursing interview
- B. Review of systems
- C. Nursing assessment
- D. Health history
Correct Answer: B
Rationale: A review of systems is a systematic method.
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During a physical assessment the nurse notes a patient has profuse secretions of sweat. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Cyanosis
- C. Diaphoresis
- D. Ecchymosis
Correct Answer: C
Rationale: Diaphoresis is the secretion of sweat, especially the profuse secretion associated with an elevated body temperature, physical exertion, exposure to heat, and mental or emotional stress.
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.
During a physical assessment the nurse notes that a patient's heart rate is 56 beats/min. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Cyanosis
- C. Diaphoresis
- D. Bradycardia
Correct Answer: D
Rationale: Bradycardia is a circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute.
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.
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.