Nokea
What should the nurse begin by assessing when performing a head-to-toe assessment?
- A. Support system
- B. Skin integrity
- C. Pain level
- D. Neurologic status
Correct Answer: D
Rationale: When performing a head-to-toe assessment, the nurse begins with a neurologic assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order.
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During a physical assessment the nurse notes a patient passes frequent loose liquid stools. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Cyanosis
- C. Diaphoresis
- D. Diarrhea
Correct Answer: D
Rationale: Diarrhea is the frequent passage of loose liquid stools. It generally results from increased motility in the colon. This is usually a sign of an underlying disorder. The characteristics of the diarrhea give evidence as to the source. Dark black, tarry stools can mean there is bleeding in the intestines. Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract.
A health care provider documents that a patient has a scleral icterus. What is the cause of this coloring?
- A. Bilirubin
- B. Hemoglobin
- C. Serum potassium
- D. Serum magnesium
Correct Answer: A
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.
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.
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.
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.