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When assessing a female for risk factors associated with coronary artery disease what information should the nurse include?
- A. Family history of illness
- B. Diet
- C. Smoking
- D. Exercise
- E. Number of pregnancies
Correct Answer: A,B,C,D
Rationale: With the exception of information relative to pregnancies, all options would be informative about risk for heart disease.
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When collecting data related to the present illness the nurse must obtain detailed and comprehensive data. What does this data help to establish?
- A. A patient problem
- B. A nursing care plan
- C. Appropriate interventions
- D. Nursing orders
Correct Answer: C
Rationale: The data collected related to the present illness must be detailed and comprehensive to allow planning of appropriate interventions.
The nurse is developing a nursing care plan for a newly admitted patient. What is the first step the nurse will take in developing this care plan?
- A. Health history
- B. Review of systems
- C. Family history
- D. Nursing assessment
Correct Answer: D
Rationale: The nursing assessment is the critical step in forming the nursing care plan.
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.
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.
When auscultating the chest a nurse hears crackles in both lower lobes. To further assess this finding the nurse should ask the patient to ____.
Correct Answer: cough
Rationale: It is a useful assessment to determine that the patient can clear the secretions by coughing.