Nokea
What is the third assessment technique in a standard physical examination?
- A. Auscultation
- B. Percussion
- C. Inspection
- D. Palpation
Correct Answer: A
Rationale: The usual sequence of assessment is inspection, palpation, auscultation, and lastly percussion.
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The nurse assesses a patient for capillary refill after the fingernail is compressed for 5 seconds. What should the nurse expect the refill time to be?
- A. 1 second
- B. 2 seconds
- C. 3 seconds
- D. 4 seconds
Correct Answer: C
Rationale: Capillary refill should take fewer than 3 seconds.
A health care provider documents that a patient has a sallow complexion. How does the nurse interpret this information?
- A. Yellow color to the skin
- B. Blue color to the skin
- C. Red color to the skin
- D. Gray color to the skin
Correct Answer: A
Rationale: Sallow is an unhealthy, yellow color; usually said of a complexion or skin.
When assessing a patient the patient complains of an uncomfortable sensation leading to an urge to scratch. The nurse notes the patient scratches frequently. How should the nurse document this finding?
- A. Dyspnea
- B. Cyanosis
- C. Jaundice
- D. Pruritus
Correct Answer: D
Rationale: Pruritus is a symptom of itching and an uncomfortable sensation leading to an urge to scratch. Some causes are allergy, infection, jaundice, elevated serum urea, and skin irritation.
The nurse is preparing to perform a physical assessment. What essential supplies should this nurse gather?
- A. Flashlight
- B. Gloves
- C. Red pen
- D. Thermometer
- E. Scissors
Correct Answer: A,B,D,E
Rationale: Items essential to the nurse's assessment are a penlight or flashlight, a stethoscope, a blood pressure cuff, a thermometer, gloves, gait belt, watch with second hand, scissors, black pen, and a tongue blade.
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.