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When assessing a patient the nurse notes that the patient has an unnatural paleness of color to the skin. How should the nurse document this finding?
- A. Skin pallor
- B. Pruritus
- C. Sallow skin
- D. Jaundice
Correct Answer: A
Rationale: Pallor is an unnatural paleness or absence of color in the skin; it may result from a decrease in hemoglobin and erythrocytes.
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During a head-to-toe assessment the nurse assesses the patient's perineal area. Which area should the nurse assess next?
- A. Chest
- B. Arms
- C. Abdomen
- D. Legs and feet
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.
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.
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.
Listening for bowel sounds should be done over all four quadrants of the abdomen using the diaphragm of the stethoscope. What is the normal rate of bowel sounds per minute?
- A. 2 to 10
- B. 3 to 20
- C. 4 to 32
- D. 5 to 40
Correct Answer: C
Rationale: The normal rate of bowel sounds per minute is 4 to 32.
During a physical assessment the nurse notes that a patient has bright red blood in the feces. What does the nurse recognize as the most likely cause of this bleeding?
- A. Bleeding in the upper intestinal tract
- B. Bleeding in the lower intestinal tract
- C. Bleeding in the entire intestinal tract
- D. Consumption of cranberry juice
Correct Answer: B
Rationale: Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract.