Chapter 13 Flashcards
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
c. Sign
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
b. Symptoms
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
c. Disease
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. Patient problem
d. Patient problem
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
c. Pancreas
There are four categories of factors that increase an individual’s vulnerability to develop a disease: genetic, physiologic, age, and lifestyle. What is the term for these factors?
a. Risk factors
b. Causative factors
c. Etiologic factors
d. Hazardous factors
a. Risk factors
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
c. Chronic
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
d. Remission
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
b. Organic disease
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.
b. Inflammation is a protective response.
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.
c. an individualized plan of care.
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.
b. Introduce herself/himself.
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.
a. The nurse has feelings of concern.
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. Biographic data
d. The present illness
b. The nursing health history
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 patient problem
b. A nursing care plan
c. Appropriate interventions
d. Nursing orders
c. Appropriate interventions
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
c. Past health history
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
b. Review of systems
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
d. Nursing assessment
The patient should be assessed as soon as possible after admission. Who performs this initial
assessment?
a. Health care provider
b. Charge nurse
c. LPN/LVN
d. RN
d. RN
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
b. Focused
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
b. Neurologic assessment
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
a. Dehydration
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
c. During inspiration
Auscultating the heart sounds should result in a “lub-dup” sound when using the bell and the
diaphragm of the stethoscope. What causes the “lub” 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
c. Closing of the AV valves
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
c. 3 seconds
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
c. 4 to 32
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 to 15 seconds
b. 20 to 25 seconds
c. 30 to 35 seconds
d. 40 to 45 seconds
a. 10 to 15 seconds
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
d. Density of underlying tissue
The nurse is obtaining a history of a patient’s 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
b. Region
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
b. Deep palpation
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
b. Apices
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
d. Density of underlying tissue
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
d. Appears to be anxious
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.
d. The patient expectorates red-tinged sputum.
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.
a. Complains of chest pain.
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.
a. Complains of pruritus.
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
a. Complains of diplopia
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
d. Neurologic status
During a head-to-toe assessment, the nurse assesses the patient’s abdomen. Which area
should the nurse assess next?
a. Chest
b. Arms
c. Legs and feet
d. Perineal area
d. Perineal area
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
d. Legs and feet
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
c. III
A health care provider 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
c. Lithotomy
A health care provider needs to assess extension of a patient’s hip joint. In what position
should the nurse place the patient?
a. Sims
b. Prone
c. Lithotomy
d. Dorsal recumbent
b. Prone
A health care provider 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
d. Lateral recumbent
A health care provider needs to assess a patient’s rectal area. In what position should the
nurse place the patient?
a. Sims
b. Prone
c. Lithotomy
d. Knee-chest
d. Knee-chest
A nurse needs to auscultate a patient’s lung sounds. In what position should the nurse place
the patient?
a. Sims
b. Prone
c. Sitting
d. Lithotomy
c. Sitting
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
b. Cyanosis
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
c. Anorexia
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
c. Asthenia
During a physical assessment, the nurse notes that a patient’s heart rate is 56 beats/min.
What should the nurse document that the patient is experiencing?
a. Dyspnea
b. Cyanosis
c. Diaphoresis
d. Bradycardia
d. Bradycardia
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. Ecchymosisd. Ecchymosis
c. Constipation
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
c. Coughing
During a physical assessment, the nurse notes a patient has profuse secretions ofsweat.
What should the nurse document that the patient is experiencing?
a. Dyspnea
b. Cyanosis
c. Diaphoresis
d. Ecchymosis
c. Diaphoresis
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
d. Diarrhea
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
b. Bleeding in the lower intestinal tract
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
a. Dyspnea
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
d. Ecchymosis
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
c. Erythema
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
b. Liver
When assessing a patient, the nurse notes a yellow tinge to the patient’s skin. How should
the nurse document this finding?
a. Dyspnea
b. Cyanosis
c. Jaundice
d. Ecchymosis
c. Jaundice
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
d. Orthopnea
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
a. Skin pallor
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
d. Pruritus
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
d. Bacterial infection
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
a. Yellow color to the skin
A health care provider documents that a patient has a scleral icterus. How does the nurse
describe the color of the patient’s sclera?
a. Red
b. Blue
c. Green
d. Yellow
d. Yellow
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
a. Bilirubin
What is the third assessment technique in a standard physical examination?
a. Auscultation
b. Percussion
c. Inspection
d. Palpation
a. Auscultation
