The nurse noted which of the following about the patient’s skin during her monitoring assessment. (Select all that apply)

Tachypnea

Temperature

Turgor

Tympany

Answer and Explanation

Correct Answer : B,C

Normal skin temperature for healthy adults ranges between 92.3 and 98.4 Fahrenheit or 33-37 Celsius, far lower than the 98.6 F average core temp. Changes in skin temperature may indicate potential illness or injuries.

To check for skin turgor, the healthcare provider grasps the skin between two fingers so that it is tented up. Commonly the lower arm or abdomen is checked. The skin is held for a few seconds and then released. Skin with normal turgor snaps rapidly back to its normal position.

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Correct Answer is C

Explanation

"Pain is whatever the person experiencing it says it is," to include in the orientation. This definition reﬂects the concept of pain as a subjective experience that cannot be directly observed or measured, but only reported by the individual experiencing it. It emphasizes the importance of believing and acknowledging the patient's report of pain, and not relying solely on objective indicators or assumptions about the cause or intensity of pain. This definition also aligns with current standards of pain assessment and management, which prioritize patient-centered care and the use of self-report measures to guide treatment decisions.

A. Report of scalp itching each evening B. Loss of hair on bilateral legs C. Patient description of pain in an extremity D. Complaint of numbness on the right hand,

Correct Answer is B

Explanation

Objective data refers to measurable and observable information gathered during a patient assessment, such as physical signs, laboratory values, and other measurable data. In this case, the loss of hair on bilateral legs can be observed and measured, making it an objective finding. Options a, c, and d are all subjective data as they rely on the patient's report or description of their symptoms, which cannot be directly observed or measured.

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The nurse noted which of the following about the patient’s skin during her monitoring assessment. (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is working at a pain clinic and is preparing orientation for new staﬀ nurses. Which of the following definitions of pain would the nurse correctly choose to include in the orientation?

Correct Answer is C

Explanation

The nurse would document which of the following as objective data obtained during a patient assessment?

Correct Answer is B

Explanation

A 58-year-old patient is going home today. The nurse does her final assessment of the patient. Which of the following would be considered a normal finding?

What term describes the amount of pain stimulation that is needed for an individual to feel pain?

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The nurse noted which of the following about the patient’s skin during her monitoring assessment. (Select all that apply)