Nokea
The patient should be assessed as soon as possible after admission. Who performs this initial assessment?
- A. Health care provider
- B. Charge nurse
- C. LPN/LVN
- D. RN
Correct Answer: D
Rationale: The initial assessment is done by the registered nurse.
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As part of an assessment the nurse asks the patient for subjective information related to the present illness. What are the subjective findings perceived by the patient?
- A. Assessments
- B. Symptoms
- C. Signs
- D. Observations
Correct Answer: B
Rationale: Symptoms are subjective indications of illness that are perceived by the patient.
A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?
- A. Complains of pruritus.
- B. Is experiencing erythema.
- C. Appears to be experiencing pruritus.
- 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. Pruritus is the only subjective assessment finding. All other options are examples of objective data.
The signs and symptoms of both infection and inflammation include erythema edema and pain. What is considered the major difference between infection and inflammation?
- A. Inflammation is a result of bacteria.
- B. Inflammation is a protective response.
- C. Inflammation is a disease process.
- D. Inflammation produces tissue damage.
Correct Answer: B
Rationale: Inflammation is a protective response.
A circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute is known as ____.
Correct Answer: bradycardia
Rationale: Bradycardia is a circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute.
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.