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 C

Explanation

A. Tachycardia. – Tachycardia refers to a heart rate above 100 beats per minute, not a slow heart rate.

B. Tachypnea. – Tachypnea describes rapid breathing, not a slow heart rate.

C. Bradycardia. – Bradycardia is a heart rate below 60 beats per minute. It may be normal in athletes but can indicate conduction abnormalities or medication effects in other individuals.

D. Apnea. – Apnea is the absence of breathing, not a slow heart rate.

A. Press the skin over the client's ankle bone B. Lightly palpate the skin using the fingertips C. Grasp a fold of skin on the client's forearm or near the sternum D. Observe for non blanching, pinpoint-size, red or purple spots on the skin of the abdomen

Correct Answer is C

Explanation

A. Press the skin over the client's ankle bone. – The skin over bony prominences does not provide an accurate assessment of turgor due to reduced subcutaneous tissue in elderly clients.

B. Lightly palpate the skin using the fingertips. – Light palpation assesses texture and moisture but does not evaluate skin turgor.

C. Grasp a fold of skin on the client’s forearm or near the sternum. – Skin turgor is best assessed by gently pinching the skin on the forearm or sternum. Delayed return to normal indicates dehydration or decreased skin elasticity due to aging.

D. Observe for non-blanching, pinpoint-size, red or purple spots on the skin of the abdomen. – This describes petechiae, which indicate capillary fragility or bleeding disorders, not skin turgor.

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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

An abnormally slow heart rate, below 60 beats per minute is called:

Correct Answer is C

Explanation

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

Correct Answer is C

Explanation

The most frequently used skill in the physical nursing assessment is:

Auscultation of the heart sounds will result in a lubb-dupp sound when using the bell and the diaphragm of the stethoscope. The lub part of the sound is caused by the:

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:

Although the signs and symptoms of both infection and inflammation include erythema, edema, and pain, the major difference is that inflammation:

The nurse is obtaining a history of the patient's present illness. The PQRST system is being used for the interview. In this system the R is:

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

A nursing assessment is a process of collecting data to establish a database. The information contained in the database is the basis for:

When the color of the sclera is yellow due to bilirubin that infiltrates all tissues of the body it is called: