Nokea
What does the nurse recognize as the initial step in conducting an assessment of a patient?
- A. A body systems review
- B. The nursing health history
- C. Biographic data
- D. The present illness
Correct Answer: B
Rationale: The nursing health history is the initial step in the assessment process.
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A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?
- A. Complains of chest pain.
- B. Is experiencing dyspnea.
- C. Appears to be anxious.
- D. Expectorates red-tinged sputum.
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. Chest pain is the only subjective assessment finding. All other options are examples of objective data.
The nurse is assessing a patient for collection of subjective and objective data. What will this data provide the basis for making?
- A. Care plan
- B. Medical diagnosis
- C. Nursing assessment
- D. Patient problem
Correct Answer: D
Rationale: Nurses rely on assessment of signs and symptoms to formulate a patient problem.
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.
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.
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.