The nurse is meeting a patient for the first time. The initial step in initiating a nurse-patient relationship is for the nurse to:

introduce her/himself

communicate trust

provide support

appear interested

Answer and Explanation

The Correct Answer is A

A. Introduce her/himself. – Introducing oneself establishes a professional relationship, sets the tone for communication, and makes the patient feel acknowledged and comfortable.

B. Communicate trust. – While trust is essential, it is built over time through consistent and reliable care rather than being the first step in the interaction.

C. Provide support. – Providing support is part of therapeutic communication, but it is not the initial step in forming a nurse-patient relationship.

D. Appear interested. – While showing interest is important, the first step is to introduce oneself to establish identity and professional presence.

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Correct Answer is D

Explanation

A. Percussion – Percussion involves tapping the body to assess underlying structures, not feeling for texture or consistency.

B. Auscultation – Auscultation is listening to body sounds (e.g., heart, lungs, and bowels) using a stethoscope, not feeling structures.

C. Inspection – Inspection is visual observation, not a tactile assessment.

D. Palpation – Palpation involves using the hands to assess the texture, size, consistency, and location of body structures, such as organs or lymph nodes.

A. assess for level of consciousness and orientation B. check for pitting edema C. assess the skin D. listen to lung sounds

Correct Answer is A

Explanation

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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The nurse is meeting a patient for the first time. The initial step in initiating a nurse-patient relationship is for the nurse to:

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Naxlex Comprehensive Predictor Exams

The technique used in physical examination where the examiner feels the texture, size, consistency and location of certain parts of the body with the hands s

Correct Answer is D

Explanation

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?

Correct Answer is A

Explanation

The patient has been found to have edema of the lower extremities. The nurse is assessing whether or not it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 4+ pitting edema because the rebound time is:

Any disturbance of the structure or function of the body is a pathological condition. This condition is termed a/an:

An abnormal accumulation of fluid in the interstitial spaces is described as:

When a disease results in a structural change in an organ that interferes with its functioning, this is a/an:

Which would be included in an assessment of the peripheral vascular system? (select all that apply)

Fluid, cells or other substances that have been slowly discharged from body cells or blood vessels, through small pores or breaks in the cell membrane are called:

The nurse uses a systematic method for collecting data on all body systems including normal functioning and any noted changes. This system is:

Adventitious breath sounds that have a whistling or sighing sound due to narrowing of the lumen of a respiratory passage are termed: