While conducting an assessment of the patient, the nurse recognizes that after verifying biographical data, the initial step is:

the nursing health history

a body systems review

the present illness

a focused review

Answer and Explanation

The Correct Answer is A

A. The nursing health history – The nursing health history is the first step after collecting biographical data. It includes the chief complaint, past medical history, and social factors affecting health.

B. A body systems review – A body systems review (ROS) is done later in the assessment to gather additional information on each organ system.

C. The present illness – The present illness is part of the nursing health history but is not the first step after verifying biographical data.

D. A focused review – A focused review targets specific concerns rather than serving as the initial step in a comprehensive assessment.

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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.

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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While conducting an assessment of the patient, the nurse recognizes that after verifying biographical data, the initial step is:

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Naxlex Comprehensive Predictor Exams

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

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

Correct Answer is C

Explanation

When performing the nursing physical assessment, the nurse uses head-to-toe organization. When using this method, the nurse begins with a:

The elderly patient is being assessed for skin turgor. Which of the following actions should the nurse take?

A nurse is collecting data from a 70-year-old man who has coronary artery disease (CAD) and hypertension (HTN) Which of the following findings will the nurse report as "signs?" (select all that apply)

While conducting an assessment of the patient, the nurse recognizes that after verifying biographical data, the initial step is:

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

Free flow or withdrawal of fluids from a wound or a cavity is termed:

The protective response of body tissues to irritation, injury or pathogens is:

The nurse is collecting data during an initial assessment. The patient tells the nurse, "i have a tremendous headache and my stomach is upset." These findings are called: