Nokea
When assessing a patient with hepatitis the nurse notes a yellow tinge to the patient's skin. What does the nurse understand as the most likely cause of the jaundice?
- A. Heart
- B. Liver
- C. Brain
- D. Intestines
Correct Answer: B
Rationale: Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver.
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During a physical assessment the nurse listens for adventitious lung sounds. Crackles are classified as fine medium or coarse. When are these sounds most often auscultated?
- A. During expiration
- B. Following expiration
- C. During inspiration
- D. Following inspiration
Correct Answer: C
Rationale: Crackles are usually heard during inspiration.
A patient has discoloration of an area of their mucous membrane caused by extravasation of blood into the subcutaneous tissue. What should the nurse document that the patient has?
- A. Dyspnea
- B. Cyanosis
- C. Diaphoresis
- D. Ecchymosis
Correct Answer: D
Rationale: Ecchymosis is discoloration of an area of the skin or mucous membrane caused by the extravasation of blood into subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls (also called a bruise).
A symptom of itching and an uncomfortable sensation leading to an urge to scratch is known as ____.
Correct Answer: pruritus
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.
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.
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.