Assessment CH5

Question 1

Mr. S is complaining of pain in his chest, difficulty breathing, and a cough. The nurse documents these as examples of:
 Objective data
 Subjective data
 Observable data
 Disease process

Answer 1

subjective data

Question 2

Which of the following terms is described as an abnormal growth of new tissue, either malignant or benign?
 Deficiency disease
 Metabolic disease
 Infectious disease
 Neoplastic disease

Answer 2

neoplastic disease

Question 3

You are taking care of a patient with a leg wound. While assessing the leg you notice redness, swelling, and purulent drainage. These are some of the cardinal signs of:
 Pain
 Ecchymosis
 Infection
 Asthenia

Answer 3

infection

Question 4

You are working on a medical floor and assisting the RN with patient assessments. A new patient is admitted to the floor and the RN takes a health history and performs an assessment. You know that this is the first step in the:
 Nursing process
 Nurse-patient relationship
 Review of systems
 Obtaining the chief complaint

Answer 4

nursing process

Question 5

When documenting assessment findings, which of the following are examples of objective data?
 Chest pain and headache
 Leg pain and calf tenderness
 Redness and swelling of feet
 Dizziness and headache

Answer 5

redness and swelling of feet

Question 6

One of the first steps in gathering data about your patient is to establish the “nurse-patient relationship.” Which of the following are appropriate ways to establish this relationship? Select all that apply.
The nurse communicates trust and confidentiality to patients.
The nurse shows professionalism and competence to patients.
The nurse introduces herself/himself to patients and answers questions the patients may have.
The nurse enters patient rooms without knocking and offers very little information.

Answer 6

all but d

Question 7

While the nurse is performing a physical assessment, the patient complains of dyspnea. This symptom indicates a problem with which of the following body systems?
 Gastrointestinal
 Respiratory
 Neurological
 Peripheral vascular

Answer 7

repiratory

dyspnea- difficulty breathing

Question 8

he process of listening to sounds produced by the body is which physical assessment technique?
 Inspection
 Palpation
 Auscultation
 Percussion

Answer 8

auscultation

Question 9

While assessing a patient's lower extremities, the nurse notes edema around the feet and ankles. When the area is depressed, it lasts for more than 1 minute before the shape returns. The nurse would document this edema as \_\_\_ pitting edema.
 4+
 3+
 2+
 1+

Answer 9

3+

last for more than one minute

4+ (2-5 mintues)
2+ (10-15 seconds)
1+ (1+ pitting edema is slight pitting, no visible change in the shape of the extremity and depression disappears rapidly.)

Question 10

While performing a physical assessment, which of the following findings would indicate a problem? Select all that apply.
Cyanosis of the fingers and toes
Capillary refill

Answer 10

all BUT
capillary refill

and bilateral lung sounds clear

and afebrile