Nokea
When admitting a patient to the hospital the nurse notes the patient has mild sunburn. How should the nurse document this finding?
- A. Dyspnea
- B. Cyanosis
- C. Erythema
- D. Ecchymosis
Correct Answer: C
Rationale: Erythema is redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries; erythema is seen in mild sunburn.
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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.
When performing a physical examination of a patient the nurse uses a technique that is particularly useful in identifying areas of tenderness or masses of the abdomen. What is this technique?
- A. Auscultation
- B. Deep palpation
- C. Light palpation
- D. Percussion
Correct Answer: B
Rationale: Deep palpation is used to detect tenderness or masses of the abdomen.
A patient has edema of the lower extremities. The nurse is assessing whether it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds the nurse identifies 2+ pitting edema. When did the edema disappear?
- A. 10 to 15 seconds
- B. 20 to 25 seconds
- C. 30 to 35 seconds
- D. 40 to 45 seconds
Correct Answer: A
Rationale: The 2+ pitting edema is identified because the pitting edema disappears in 10 to 15 seconds.
Auscultating the heart sounds should result in a "lub-dup" sound when using the bell and the diaphragm of the stethoscope. What causes the "lub" sound?
- A. Opening of the AV valves
- B. Opening of the semilunar valves
- C. Closing of the AV valves
- D. Closing of the semilunar valves
Correct Answer: C
Rationale: The 'lub-dup' sound of the heart is caused by the closing of the AV and semilunar valves, respectively.
An unpleasant sensation caused by noxious (extremely destructive or harmful) stimulation of the sensory nerve endings is ____.
Correct Answer: pain
Rationale: Pain is an unpleasant sensation caused by noxious (extremely destructive or harmful) stimulation of the sensory nerve endings. It is a cardinal symptom of inflammation and is valuable in the diagnosis of many disorders and conditions. Pain has varied manifestations: mild or severe, chronic, acute, burning, dull or sharp, precisely or poorly localized, or referred.