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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.
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During a physical assessment the nurse notes a patient has a bluish discoloration of the skin and mucous membranes. How should the nurse document this finding?
- A. Dyspnea
- B. Cyanosis
- C. Diaphoresis
- D. Ecchymosis
Correct Answer: B
Rationale: Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood.
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.
The signs and symptoms of both infection and inflammation include erythema edema and pain. What is considered the major difference between infection and inflammation?
- A. Inflammation is a result of bacteria.
- B. Inflammation is a protective response.
- C. Inflammation is a disease process.
- D. Inflammation produces tissue damage.
Correct Answer: B
Rationale: Inflammation is a protective response.
A health care provider documents that a patient is having purulent drainage from a wound. What does the nurse understand is most likely the cause?
- A. Ringworm
- B. Viral infection
- C. Fungal infection
- D. Bacterial infection
Correct Answer: D
Rationale: Purulent drainage is a creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of tissues. Bacterial infection is the most common cause. The character of the pus, including its color, consistency, quantity, or odor, may be of diagnostic significance.
When assessing a patient the nurse notes that the patient is unable to lie flat to breathe. When the nurse assists the patient into a sitting position the patient is able to breathe more easily. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Cyanosis
- C. Jaundice
- D. Orthopnea
Correct Answer: D
Rationale: Orthopnea is an abnormal condition in which a person must sit or stand to breathe deeply or comfortably. It occurs in many disorders of the respiratory and cardiac systems.