Chapter 12: Physical Assessment My Nursing Test Banks

Chapter 12: Physical Assessment

Cooper and Gosnell: Foundations and Adult Health Nursing, 7th Edition

MULTIPLE CHOICE

1.The nurse is collecting data during an initial assessment. What can be seen, heard, measured, or felt and is objective?

a. Symptom
b. Observation
c. Sign
d. Assessment

ANS: C

A sign can be seen, heard, measured, or felt.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 286

OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC:NCLEX: N/A

2.As part of an assessment, the nurse asks the patient for subjective information related to the present illness. What are the subjective findings perceived by the patient?

a. Assessments
b. Symptoms
c. Signs
d. Observations

ANS: B

Symptoms are subjective indications of illness that are perceived by the patient.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 287

OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC:NCLEX: N/A

3.Any disturbance of a structure or function of the body is a pathologic condition. What is the term for this condition?

a. Injury
b. Condition
c. Disease
d. Pathology

ANS: C

A disease is any disturbance of a structure or function of the body.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 287

OBJ: 2 TOP: Disease KEY: Nursing Process Step: Assessment

MSC:NCLEX: N/A

4.The nurse is assessing a patient for collection of subjective and objective data. What will this data provide the basis for making?

a. Care plan
b. Medical diagnosis
c. Nursing assessment
d. Nursing diagnosis

ANS: D

Nurses rely on assessment of signs and symptoms to formulate a nursing diagnosis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 287

OBJ: 11 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC:NCLEX: N/A

5.The nurse is discussing the origin of diabetes with a diabetic patient. What will the nurse discuss as the most appropriate explanation for the cause of this disease?

a. Pituitary
b. Adrenals
c. Pancreas
d. Thyroid

ANS: C

Diabetes mellitus results from dysfunction of the pancreas.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 287

OBJ: 2 TOP: Disease KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

6.There are four categories of factors that increase an individuals vulnerability to develop a disease: genetic, physiological, age, and lifestyle. What is the term for these factors?

a. Risk factors
b. Causative factors
c. Etiologic factors
d. Hazardous factors

ANS: A

Risk factors are placed into four categories.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 288

OBJ: 3 TOP: Disease KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

7.When discussing diabetes with a patient, the nurse describes this disease as falling into which group in terms of duration?

a. Acute
b. Organic
c. Chronic
d. Functional

ANS: C

Diabetes mellitus is an example of a chronic disease.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 288

OBJ: 4 TOP: Disease KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

8.What is the term used to describe a disease where there has been a partial or complete disappearance of clinical and subjective characteristics of the disease?

a. Acute
b. Functional
c. Chronic
d. Remission

ANS: D

Remission means there has been partial or complete disappearance of the clinical and subjective characteristics.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 288

OBJ: 4 TOP: Disease KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

9.What type of disease results in a structural change in an organ that interferes with its functioning?

a. Functional disease
b. Organic disease
c. Acute disease
d. Chronic disease

ANS: B

An organic disease results in a structural change in an organ.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 288

OBJ: 2 TOP: Disease KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

10.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.

ANS: B

Inflammation is a protective response.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 288

OBJ: 5 TOP: Disease KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

11.A nursing assessment is a process of collecting data to establish a database. The information contained in the database is a basis for:

a. a complete physical examination.
b. a medical assessment.
c. an individualized plan of care.
d. writing nursing orders.

ANS: C

The information contained in the database is the basis for an individualized plan of care.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 290

OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC:NCLEX: N/A

12.The nurse is meeting a patient for the first time. What is the first thing the nurse will do to initiate a nurse-patient relationship?

a. Appear interested
b. Introduce herself/himself
c. Provide support
d. Communicate trust

ANS: B

The first step in a nurse-patient relationship is for the nurse to introduce herself/himself.

PTS: 1 DIF: Cognitive Level: Application REF: Page 293-294

OBJ:9TOP:Nurse-patient relationship

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity

13.What should a patient interview being conducted by the nurse convey to the patient?

a. The nurse has feelings of concern.
b. The nurse has limited time.
c. The nurse is very intelligent.
d. The nurse has answers to problems.

ANS: A

The nurse must convey feelings of concern.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 294

OBJ: 9 TOP: Interview KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

14.What does the nurse recognize as the initial step in conducting an assessment of a patient?

a. A body systems review
b. The nursing health history
c. Biographical data
d. The present illness

ANS: B

The nursing health history is the initial step in the assessment process.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 295

OBJ: 11 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

15.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 nursing diagnosis
b. A nursing care plan
c. Appropriate interventions
d. Nursing orders

ANS: C

The data collected related to the present illness must be detailed and comprehensive to allow planning of appropriate interventions.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 296

OBJ: 10 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

16.During the nursing interview, several histories are taken. What is the history that involves data concerning habits and lifestyle patterns?

a. Family history
b. Environmental history
c. Past health history
d. Psychosocial history

ANS: C

The nurse identifies habits and lifestyle patterns under the past health history.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 296

OBJ: 10 TOP: Interview KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

17.The nurse uses a systematic method for collecting data on all body systems, including normal functioning and any noted changes. What is this method?

a. Nursing interview
b. Review of systems
c. Nursing assessment
d. Health history

ANS: B

A review of systems is a systematic method.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 296-297, Box 12-1

OBJ: 11 TOP: Interview KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

18.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

ANS: D

The nursing assessment is the critical step in forming the nursing care plan.

PTS: 1 DIF: Cognitive Level: Application REF: Page 298

OBJ: 11 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

19.The patient should be assessed as soon as possible after admission. Who performs this initial assessment?

a. Physician
b. Charge nurse
c. LPN/LVN
d. RN

ANS: D

The initial assessment is done by the registered nurse.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 298

OBJ: 8 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

20.A patient was admitted with a complaint of abdominal pain. Later, the nurse observed the patient demonstrating dyspnea. What type of assessment does this change in condition require?

a. Individualized
b. Focused
c. Specialized
d. Systematic

ANS: B

When the nurse observes a change in the patients condition, the assessment is focused.

PTS: 1 DIF: Cognitive Level: Application REF: Page 298

OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

21.When performing a nursing physical assessment, the nurse uses a head-to-toe approach. Where will the nurse begin when using this method?

a. Skin assessment
b. Neurologic assessment
c. Circulatory assessment
d. Respiratory assessment

ANS: B

When performing a head-to-toe assessment, the nurse begins with a neurologic assessment.

PTS: 1 DIF: Cognitive Level: Application REF: Page 300, Box 12-8, 301

OBJ: 11 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

22.An older adult patient is being assessed for skin turgor. The nurse identifies decreased skin turgor demonstrated by slow return of the skin to the previous position after being grasped and raised. What can the nurse conclude is responsible for this assessment?

a. Dehydration
b. Edema
c. Skin breakdown
d. Malnutrition

ANS: A

Dehydration results in decreased skin turgor.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 302

OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

23.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

ANS: C

Crackles are usually heard during inspiration.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 304

OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

24.Auscultating the heart sounds should result in a lubb-dupp sound when using the bell and the diaphragm of the stethoscope. What causes the lubb 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

ANS: C

The lubb-dupp sound of the heart is caused by the closing of the AV and semilunar valves, respectively.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 305-306

OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

25.The nurse assesses a patient for capillary refill after the fingernail is compressed for 5 seconds. What should the nurse expect the refill time to be?

a. 1 second
b. 2 seconds
c. 3 seconds
d. 4 seconds

ANS: C

Capillary refill should take fewer than 3 seconds.

PTS: 1 DIF: Cognitive Level: Application REF: Page 308

OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

26.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 min-ute?

a. 2-10
b. 3-20
c. 4-32
d. 5-40

ANS: C

The normal rate of bowel sounds per minute is 4 to 32.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 308

OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

27.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. 10-15 seconds
b. 20-25 seconds
c. 30-35 seconds
d. 40-45 seconds

ANS: A

The 2+ pitting edema is identified because the pitting edema disappears in 10 to 15 seconds.

PTS: 1 DIF: Cognitive Level: Application REF: Page 110, Box 12-10

OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

28.Various techniques are used by the nurse when performing a physical assessment. One of these techniques is percussion. What is percussion  used to determine?

a. Sounds for auscultation
b. Data about physical features
c. Changes in structural integrity
d. Density of underlying tissue

ANS: D

The sounds indicate the density of the underlying tissue.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 293, Box 12-4

OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

29.The nurse is obtaining a history of a patients present illness. The PQRST system is used for the interview. What does the R stand for in this system?

a. Random
b. Region
c. Result
d. Recent

ANS: B

In the PQRST system, the R stands for region.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 295, Box 12-6

OBJ: 10 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

30.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

ANS: B

Deep palpation is used to detect tenderness or masses of the abdomen.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 309

OBJ: 8 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

31.The nurse is performing auscultation of breath sounds on a respiratory patient. The sounds heard on inspiration and expiration are low-pitched, coarse, gurgling, and have a snoring sound. What best identifies these sounds?

a. Crackles
b. Plural friction rub
c. Rhonchi
d. Sonorous wheezes

ANS: D

Sonorous wheezes have a low-pitched, coarse, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and large airways.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 304

OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

32.What is the suggested sequence for a systematic approach to begin auscultating the thorax?

a. Anterior thorax
b. Apices
c. Left lateral thorax
d. Right lateral thorax

ANS: B

The suggested sequence for a systematic auscultation of the thorax is to begin with the apices.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 304

OBJ: 11 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

33.A nurse is gathering objective data when admitting a patient. Which assessment finding reported by the patient is considered objective?

a. Complains of nausea
b. States, I hurt all over.
c. Complains of feeling anxious
d. Appears to be anxious

ANS: D

Objective data can be seen, heard, measured, or felt by the examiner. It is information that is observable and measurable and can be verified by more than one person. Anxiety is the only objective assessment finding. All other options are examples of subjective data.

PTS: 1 DIF: Cognitive Level: Application REF: Page 286

OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

34.A nurse is gathering objective data when admitting a patient. Which assessment finding is considered objective data?

a. The patient complains of chest pain.
b. The patient states, I am having trouble breathing.
c. The patient complains of coughing up sputum.
d. The patient expectorates red-tinged sputum.

ANS: D

Objective data can be seen, heard, measured, or felt by the examiner. It is information that is observable and measurable and can be verified by more than one person. Expectoration of red-tinged sputum is the only objective assessment finding. All other options are examples of subjective data.

PTS: 1 DIF: Cognitive Level: Application REF: Page 286

OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

35.A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?

a. Complains of chest pain
b. Is experiencing dyspnea
c. Appears to be anxious
d. Expectorates red-tinged sputum

ANS: A

Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Chest pain is the only subjective assessment finding. All other options are examples of objective data.

PTS: 1 DIF: Cognitive Level: Application REF: Pages 287

OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

36.A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?

a. Complains of pruritus
b. Is experiencing erythema
c. Appears to be experiencing pruritus
d. Has a generalized rash

ANS: A

Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Pruritus is the only subjective assessment finding. All other options are examples of objective data.

PTS: 1 DIF: Cognitive Level: Application REF: Pages 287

OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

37.A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?

a. Complains of diplopia
b. Is experiencing nystagmus
c. Demonstrates facial grimacing
d. Has a generalized rash

ANS: A

Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Diplopia is the only subjective assessment finding. All other options are examples of objective data.

PTS: 1 DIF: Cognitive Level: Application REF: Pages 287

OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

38.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

ANS: D

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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 300, Box 12-8

OBJ: 11 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

39.During a head-to-toe assessment, the nurse assesses the patients abdomen. Which area should the nurse assess next?

a. Chest
b. Arms
c. Legs and feet
d. Perineal area

ANS: D

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.

PTS:1DIF:Cognitive Level: Application

REF: Pages 300, Box 12-8; 309-310 OBJ: 11 TOP: Assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

40.During a head-to-toe assessment, the nurse assesses the patients perineal area. Which area should the nurse assess next?

a. Chest
b. Arms
c. Abdomen
d. Legs and feet

ANS: D

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.

PTS: 1 DIF: Cognitive Level: Application REF: Page 300, Box 12-8; 310

OBJ: 11 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

41.During a neurologic assessment, the nurse notes a patient has a unilateral, dilated, and nonreactive pupil. This is a sign that the patient is experiencing pressure on which cranial nerve?

a. I
b. II
c. III
d. IV

ANS: C

The third cranial nerve runs parallel to the brainstem. The function of the oculomotor nerve is essential for eye movements. A traumatic brain injury can result in increased intracranial pressure, edema to the brainstem with pressure on cranial nerve III, causing the ominous sign of a unilateral, dilated, and nonreactive pupil.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 301

OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

42.A physician needs to insert a vaginal speculum into a patient for a vaginal examination. In what position should the nurse place the patient?

a. Sims
b. Prone
c. Lithotomy
d. Dorsal recumbent

ANS: C

The lithotomy position provides maximal exposure of genitalia and facilitates insertion of a vaginal speculum.

PTS: 1 DIF: Cognitive Level: Application REF: Page 292, Table 12-2

OBJ: 6 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

43.A physician needs to assess extension of a patients hip joint. In what position should the nurse place the patient?

a. Sims
b. Prone
c. Lithotomy
d. Dorsal recumbent

ANS: B

Prone position is used to assess extension of a patients hip joint.

PTS: 1 DIF: Cognitive Level: Application REF: Page 292, Table 12-2

OBJ: 6 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

44.A physician needs to assess a patient for a heart murmur. In what position should the nurse place the patient?

a. Sims
b. Prone
c. Lithotomy
d. Lateral recumbent

ANS: D

The lateral recumbent position aids in detecting heart murmurs.

PTS: 1 DIF: Cognitive Level: Application REF: Page 292, Table 12-2

OBJ: 6 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

45.A physician needs to assess a patients rectal area. In what position should the nurse place the patient?

a. Sims
b. Prone
c. Lithotomy
d. Knee-chest

ANS: D

Knee-chest position provides maximum exposure of the rectal area.

PTS: 1 DIF: Cognitive Level: Application REF: Page 292, Table 12-2

OBJ: 6 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

46.A nurse needs to auscultate a patients lung sounds. In what position should the nurse place the patient?

a. Sims
b. Prone
c. Sitting
d. Lithotomy

ANS: C

Sitting upright provides full expansion of the lungs and provides better visualization of symmetry of upper body parts.

PTS: 1 DIF: Cognitive Level: Application REF: Page 292, Table 12-2

OBJ: 11 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

47.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

ANS: B

Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1

OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

48.During a physical assessment, the nurse notes a patient has a lack of appetite resulting in an inability to eat. What should the nurse document that the patient is experiencing?

a. Dyspnea
b. Asthenia
c. Anorexia
d. Ecchymosis

ANS: C

Anorexia is a lack of appetite resulting in the inability to eat. This symptom can occur in many disease conditions.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1

OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

49.During a physical assessment, the nurse notes a patient has a loss of strength and energy. What should the nurse document that the patient is experiencing?

a. Dyspnea
b. Cyanosis
c. Asthenia
d. Ecchymosis

ANS: C

Asthenia is a condition of debility, loss of strength and energy, and depleted vitality.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1

OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

50.During a physical assessment, the nurse notes that a patients heart rate is 56 beats per minute. What should the nurse document that the patient is experiencing?

a. Dyspnea
b. Cyanosis
c. Diaphoresis
d. Bradycardia

ANS: D

Bradycardia is a circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute.

PTS: 1 DIF: Cognitive Level: Application REF: Page 289, Table 12-1

OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

51.During a physical assessment, the patient complains of difficulty in passing stools. What should the nurse document that the patient is experiencing?

a. Dyspnea
b. Cyanosis
c. Constipation
d. Ecchymosis

ANS: C

Constipation is difficulty in passing stools or an incomplete or infrequent passage of hard stools. There are many causes, both organic and functional.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1

OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

52.During a physical assessment, the nurse observes a patient experiencing a sudden audible expulsion of air from the lungs. What should the nurse document that the patient is experiencing?

a. Dyspnea
b. Cyanosis
c. Coughing
d. Ecchymosis

ANS: C

Coughing is a sudden audible expulsion of air from the lungs. Coughing is an essential protective response that serves to clear the lungs, bronchi, or trachea of irritants and secretions or to prevent aspiration of foreign material into the lungs. It is a common sign of diseases of the larynx, bronchi, and lungs.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1

OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

53.During a physical assessment, the nurse notes a patient has profuse secretions of sweat. What should the nurse document that the patient is experiencing?

a. Dyspnea
b. Cyanosis
c. Diaphoresis
d. Ecchymosis

ANS: C

Diaphoresis is the secretion of sweat, especially the profuse secretion associated with an elevated body temperature, physical exertion, exposure to heat, and mental or emotional stress.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1

OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

54.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

ANS: D

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.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1

OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

55.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

ANS: B

Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract.

PTS: 1 DIF: Cognitive Level: Application REF: Page 289, Table 12-1

OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

56.A nurse is caring for a patient with congestive heart failure. During the physical assessment, the nurse notes the patient is experiencing difficulty breathing. What should the nurse document that the patient is experiencing?

a. Dyspnea
b. Cyanosis
c. Diaphoresis
d. Ecchymosis

ANS: A

Dyspnea is shortness of breath or difficulty in breathing that may be caused by certain heart and lung conditions, strenuous exercise, or anxiety.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1

OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

57.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

ANS: D

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).

PTS: 1 DIF: Cognitive Level: Application REF: Page 289, Table 12-1

OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

58.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

ANS: C

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.

PTS: 1 DIF: Cognitive Level: Application REF: Page 289, Table 12-1

OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

59.When assessing a patient with hepatitis, the nurse notes a yellow tinge to the patients skin. What does the nurse understand as the most likely cause of the jaundice?

a. Heart
b. Liver
c. Brain
d. Intestines

ANS: B

Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 289, Table 12-1

OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

60.When assessing a patient, the nurse notes a yellow tinge to the patients skin. How should the nurse document this finding?

a. Dyspnea
b. Cyanosis
c. Jaundice
d. Ecchymosis

ANS: C

Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver.

PTS: 1 DIF: Cognitive Level: Application REF: Page 289, Table 12-1

OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

61.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

ANS: D

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.

PTS: 1 DIF: Cognitive Level: Application REF: Page 289, Table 12-1

OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

62.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

ANS: A

Pallor is an unnatural paleness or absence of color in the skin; it may result from a decrease in hemoglobin and erythrocytes.

PTS: 1 DIF: Cognitive Level: Application REF: Page 290, Table 12-1

OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

63.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

ANS: D

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.

PTS: 1 DIF: Cognitive Level: Application REF: Page 290, Table 12-1

OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

64.A physician 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

ANS: D

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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 290, Table 12-1

OBJ: 5 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

65.A physician 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

ANS: A

Sallow is an unhealthy, yellow color; usually said of a complexion or skin.

PTS: 1 DIF: Cognitive Level: Application REF: Page 290, Table 12-1

OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

66.A physician documents that a patient has a scleral icterus. How does the nurse describe the color of the patients sclera?

a. Red
b. Blue
c. Green
d. Yellow

ANS: D

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.

PTS: 1 DIF: Cognitive Level: Application REF: Page 290, Table 12-1

OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

67.A physician 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

ANS: A

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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 290, Table 12-1

OBJ: 12 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

68.When assessing a female for risk factors associated with coronary artery disease, what information should the nurse include? (Select all that apply.)

a. Family history of illness
b. Diet
c. Smoking
d. Exercise
e. Number of pregnancies

ANS: A, B, C, D

With the exception of information relative to pregnancies, all options would be informative about risk for heart disease.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 288

OBJ: 3 TOP: Risk factors KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

69.Which are infectious diseases? (Select all that apply.)

a. Measles
b. Pneumonia
c. Hay fever
d. Tuberculosis
e. Osteoarthritis
f. Acquired immunodeficiency syndrome

ANS: A, B, D, F

Infectious diseases result from the invasion of microorganisms into the body. Examples of infectious diseases include acquired immunodeficiency syndrome (AIDS), tuberculosis, measles, and pneumonia. Hay fever is a manifestation of an allergic reaction, and osteoarthritis is an example of a degenerative disease.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 287

OBJ:2TOP:Infectious disease

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

70.The nurse is preparing to perform a physical assessment. What essential supplies should this nurse gather? (Select all that apply.)

a. Flashlight
b. Gloves
c. Red pen
d. Thermometer
e. Scissors

ANS: A, B, D, E

Items essential to the nurses assessment are a penlight or flashlight, a stethoscope, a blood pressure cuff, a thermometer, gloves, gait belt, watch with second hand, scissors, black pen, and a tongue blade.

PTS: 1 DIF: Cognitive Level: Application REF: Page 291, Box 12-2

OBJ:7TOPhysical assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

COMPLETION

71.The nurse notes that a patient has difficulty breathing in the supine position, and the patient admits that he sleeps in a recliner at home. These are cardinal signs of ____________ disease.

ANS:

COPD

pulmonary

Long-term pulmonary disease makes it difficult for the patient to breathe without distress in the supine position. These patients frequently sleep in a recliner chair.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 304-305

OBJ:12TOP:Chest assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

72.When auscultating the chest, a nurse hears crackles in both lower lobes. To further assess this finding, the nurse should ask the patient to ______________.

ANS:

cough

It is a useful assessment to determine that the patient can clear the secretions by coughing.

PTS: 1 DIF: Cognitive Level: Application REF: Page 305

OBJ: 11 TOP: Crackles KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

73.The nurse observes that an older adult patient has no hair on the lower legs. The nurse should assess further for the sufficiency of _________ ________.

ANS:

arterial flow

Reduced arterial flow causes lack of hair on the lower extremities due to inadequate blood flow.

PTS: 1 DIF: Cognitive Level: Application REF: Page 302

OBJ:12TOP:Vascular assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

74.Signs that are perceived by an examiner and can be seen, heard, measured, or felt are known as ___________ _________.

ANS:

objective data

Objective data is a sign that can be seen, heard, measured, or felt by the examiner.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 286

OBJ:2TOP:Objective data

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

75.Symptoms that are perceived by the patient are known as _____________ ____________.

ANS:

subjective data

Symptoms are subjective indications of illness that are perceived by the patient. Symptoms are referred to as subjective data.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 287

OBJ:2TOP:Subjective data

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

76.A condition in which there is a lack of appetite resulting in the inability to eat is known as _______________.

ANS:

anorexia

Anorexia is a lack of appetite resulting in the inability to eat. It can occur in many disease conditions.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1

OBJ: 4 TOP: Anorexia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

77.A condition of debility, loss of strength and energy, and depleted vitality is known as _________________.

ANS:

asthenia

Asthenia is a condition of debility, loss of strength and energy, and depleted vitality.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1

OBJ: 4 TOP: Asthenia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

78.A circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute is known as _________________.

ANS:

bradycardia

Bradycardia is a circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1

OBJ: 4 TOP: Bradycardia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

79.A condition in which a patient experiences bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood is known as _________________.

ANS:

cyanosis

Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1

OBJ: 4 TOP: Cyanosis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

80.Discoloration of an area of the skin or mucous membrane that is caused by the extravasation of blood into the subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls is known as _________________.

ANS:

ecchymosis

Ecchymosis is discoloration of an area of the skin or mucous membrane caused by the extravasation of blood into the subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1

OBJ: 4 TOP: Ecchymosis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

81.Redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries is known as _________________.

ANS:

erythema

Erythema is redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1

OBJ: 4 TOP: Erythema KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

82.A yellow tinge to the skin that may indicate obstruction in the flow of bile from the liver is known as ___________________.

ANS:

jaundice

Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1

OBJ: 4 TOP: Jaundice KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

83.An abnormal condition in which a person must sit or stand to breathe deeply or comfortably is known as ___________________.

ANS:

orthopnea

Orthopnea is an abnormal condition in which a person must sit or stand to breathe deeply or comfortably.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 289, Table 12-1

OBJ: 4 TOP: Orthopnea KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

84.A symptom of itching and an uncomfortable sensation leading to an urge to scratch is known as _____________.

ANS:

pruritus

Pruritus is a symptom of itching and an uncomfortable sensation leading to an urge to scratch.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 290, Table 12-1

OBJ: 4 TOP: Pruritus KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

85.A creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of tissues is known as ___________ ___________.

ANS:

purulent drainage

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.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 290, Table 12-1

OBJ:4TOPurulent drainage

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

86.An abnormal condition in which the heart contracts regularly but at a rate greater than 100 beats per minute is known as ___________________.

ANS:

tachycardia

Tachycardia is an abnormal condition in which the heart contracts regularly but at a rate greater than 100 beats per minute.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 290, Table 12-1

OBJ: 4 TOP: Tachycardia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

87.An abnormally rapid rate of breathing that is seen in many disease conditions is known as ___________________.

ANS:

tachypnea

Tachypnea is an abnormally rapid rate of breathing that is seen in many disease conditions.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 290, Table 12-1

OBJ: 4 TOP: Tachypnea KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

88.A condition in which there is a temporary loss of consciousness associated with an increased rate of respiration, tachycardia, pallor, perspiration, and coolness of the skin is known as _________________.

ANS:

syncope

Syncope is a temporary loss of consciousness (partial or complete) associated with an increased rate of respiration, tachycardia, pallor, perspiration, and coolness of skin.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 301, Table 12-3

OBJ: 4 TOP: Syncope KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

89._______________ _________and personal characteristics determine health behavior in individuals and families. More than half of all health problems are the result of behavior and lifestyle.

ANS:

Cultural beliefs

Cultural beliefs and personal characteristics determine health behavior in individuals and families. More than half of all health problems are the result of behavior and lifestyle.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 298

OBJ:14TOP:Cultural sensitivity

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

OTHER

90.Arrange these assessment techniques in correct order of a standard physical examination. Put a comma and space between each answer choice (A, B, C, D, etc.).

a. Auscultation

b. Percussion

c. Inspection

d. Palpation

ANS:

C, D, A, B

The usual sequence of assessment is inspection, palpation, auscultation, and lastly percussion.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 293, Box 12-4

OBJ:11TOPhysical examination series

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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