The nurse has been assigned to care for a 62 year-old man. After introducing herself to the patient and explaining that she will be performing a nursing assessment, what is the first area to be assessed after taking vital signs?

assess for level of consciousness and orientation

check for pitting edema

assess the skin

listen to lung sounds

Answer and Explanation

The Correct Answer is A

A. Assess for level of consciousness and orientation – Level of consciousness (LOC) and orientation are crucial in evaluating neurological status, overall health, and potential signs of deterioration. This assessment provides immediate information about the patient’s cognitive function and responsiveness.

B. Check for pitting edema – Assessing for pitting edema is important but is not the first priority unless the patient has signs of fluid overload or heart failure.

C. Assess the skin – Skin assessment is essential but should be performed after ensuring the patient's neurological stability.

D. Listen to lung sounds – While lung auscultation is an important part of the assessment, it follows after assessing consciousness and orientation.

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Correct Answer is D

Explanation

A. Apnea – Apnea refers to the temporary cessation of breathing, not rapid breathing.

B. Orthopnea – Orthopnea is difficulty breathing while lying flat, not an increased respiratory rate.

C. Dyspnea – Dyspnea is the sensation of difficult or labored breathing, not necessarily rapid breathing.

D. Tachypnea – Tachypnea is an abnormally fast respiratory rate, often seen in conditions like fever, anxiety, or respiratory distress.

A. bruits B. tympany C. crackles D. Thrill

Correct Answer is C

Explanation

A. Bruits – Bruits are abnormal vascular sounds heard over arteries, often due to turbulence from a narrowed vessel.

B. Tympany – Tympany is a drum-like sound produced during percussion over areas filled with air, such as the stomach.

C. Crackles – Crackles (rales) are discontinuous, bubbling breath sounds often heard on inspiration. They are associated with conditions like pneumonia, heart failure, and pulmonary fibrosis.

D. Thrill – A thrill is a palpable vibration over an artery or heart valve, indicating turbulent blood flow.

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The nurse has been assigned to care for a 62 year-old man. After introducing herself to the patient and explaining that she will be performing a nursing assessment, what is the first area to be assessed after taking vital signs?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An abnormal rapid rate of breathing seen in many disease conditions is called:

Correct Answer is D

Explanation

Short, discrete, interrupted crackling or bubbling adventitious breath sounds heard most commonly on inspiration is termed:

Correct Answer is C

Explanation

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