Question 1

During a physical assessment,the nurse notes a patient has a loss of strength and energy.What should the nurse document that the patient is experiencing?

Accepted Answer

Asthenia is a condition of debility,loss of strength and energy,and depleted vitality.

Question 2

A nurse is caring for a patient with congestive heart failure.During the physical assessment,the nurse notes the patient is experiencing difficulty breathing.What should the nurse document that the patient is experiencing?

Accepted Answer

Dyspnea is shortness of breath or difficulty in breathing that may be caused by certain heart and lung conditions,strenuous exercise,or anxiety.

Question 3

A physician needs to assess a patient's rectal area.In what position should the nurse place the patient?

Accepted Answer

Knee-chest position provides maximum exposure of the rectal area.

Question 4

A nurse needs to auscultate a patient's lung sounds.In what position should the nurse place the patient?

Accepted Answer

Sitting upright provides full expansion of the lungs and provides better visualization of symmetry of upper body parts.

Question 5

During a physical assessment,the nurse notes that a patient's heart rate is 56 beats per minute.What should the nurse document that the patient is experiencing?

Accepted Answer

Bradycardia is a circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute.

Question 6

During a physical assessment,the nurse notes that a patient has bright red blood in the feces.What does the nurse recognize as the most likely cause of this bleeding?

Accepted Answer

Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract.

Question 7

During a neurologic assessment,the nurse notes a patient has a unilateral,dilated,and nonreactive pupil.This is a sign that the patient is experiencing pressure on which cranial nerve?

Accepted Answer

The third cranial nerve runs parallel to the brainstem.The function of the oculomotor nerve is essential for eye movements.A traumatic brain injury can result in increased intracranial pressure,edema to the brainstem with pressure on cranial nerve III,causing the ominous sign of a unilateral,dilated,and nonreactive pupil.

Question 8

A patient has discoloration of an area of their mucous membrane caused by extravasation of blood into the subcutaneous tissue.What should the nurse document that the patient has?

Accepted Answer

Ecchymosis is discoloration of an area of the skin or mucous membrane caused by the extravasation of blood into subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls (also called a bruise).

Question 9

A physician needs to insert a vaginal speculum into a patient for a vaginal examination.In what position should the nurse place the patient?

Accepted Answer

The lithotomy position provides maximal exposure of genitalia and facilitates insertion of a vaginal speculum.

Question 10

When assessing a patient,the nurse notes a yellow tinge to the patient's skin.How should the nurse document this finding?

Accepted Answer

Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver.

Question 11

A physician needs to assess extension of a patient's hip joint.In what position should the nurse place the patient?

Accepted Answer

Prone position is used to assess extension of a patient's hip joint.

Question 12

When admitting a patient to the hospital,the nurse notes the patient has mild sunburn.How should the nurse document this finding?

Accepted Answer

Erythema is redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries; erythema is seen in mild sunburn.

Question 13

During a physical assessment,the nurse notes a patient has profuse secretions of sweat.What should the nurse document that the patient is experiencing?

Accepted Answer

Diaphoresis is the secretion of sweat,especially the profuse secretion associated with an elevated body temperature,physical exertion,exposure to heat,and mental or emotional stress.

Question 14

During a physical assessment,the nurse notes a patient has a bluish discoloration of the skin and mucous membranes.How should the nurse document this finding?

Accepted Answer

Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood.

Question 15

During a physical assessment,the nurse observes a patient experiencing a sudden audible expulsion of air from the lungs.What should the nurse document that the patient is experiencing?

Accepted Answer

Coughing is a sudden audible expulsion of air from the lungs.Coughing is an essential protective response that serves to clear the lungs,bronchi,or trachea of irritants and secretions or to prevent aspiration of foreign material into the lungs.It is a common sign of diseases of the larynx,bronchi,and lungs.

Question 16

During a physical assessment,the nurse notes a patient passes frequent loose liquid stools.What should the nurse document that the patient is experiencing?

Accepted Answer

Diarrhea is the frequent passage of loose liquid stools.It generally results from increased motility in the colon.This is usually a sign of an underlying disorder.The characteristics of the diarrhea give evidence as to the source.Dark black,tarry stools can mean there is bleeding in the intestines.Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract.

Question 17

A physician needs to assess a patient for a heart murmur.In what position should the nurse place the patient?

Accepted Answer

The lateral recumbent position aids in detecting heart murmurs.

Question 18

When assessing a patient with hepatitis,the nurse notes a yellow tinge to the patient's skin.What does the nurse understand as the most likely cause of the jaundice?

Accepted Answer

Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver.

Question 19

During a physical assessment,the nurse notes a patient has a lack of appetite resulting in an inability to eat.What should the nurse document that the patient is experiencing?

Accepted Answer

Anorexia is a lack of appetite resulting in the inability to eat.This symptom can occur in many disease conditions.

Question 20

During a physical assessment,the patient complains of difficulty in passing stools.What should the nurse document that the patient is experiencing?

Accepted Answer

Constipation is difficulty in passing stools or an incomplete or infrequent passage of hard stools.There are many causes,both organic and functional.

Quiz 12: Physical Assessment

During a physical assessment,the nurse notes a patient has a loss of strength and energy.What should the nurse document that the patient is experiencing?

A nurse is caring for a patient with congestive heart failure.During the physical assessment,the nurse notes the patient is experiencing difficulty breathing.What should the nurse document that the patient is experiencing?

A physician needs to assess a patient's rectal area.In what position should the nurse place the patient?

A nurse needs to auscultate a patient's lung sounds.In what position should the nurse place the patient?

During a physical assessment,the nurse notes that a patient's heart rate is 56 beats per minute.What should the nurse document that the patient is experiencing?

During a physical assessment,the nurse notes that a patient has bright red blood in the feces.What does the nurse recognize as the most likely cause of this bleeding?

During a neurologic assessment,the nurse notes a patient has a unilateral,dilated,and nonreactive pupil.This is a sign that the patient is experiencing pressure on which cranial nerve?

A patient has discoloration of an area of their mucous membrane caused by extravasation of blood into the subcutaneous tissue.What should the nurse document that the patient has?

A physician needs to insert a vaginal speculum into a patient for a vaginal examination.In what position should the nurse place the patient?

When assessing a patient,the nurse notes a yellow tinge to the patient's skin.How should the nurse document this finding?

A physician needs to assess extension of a patient's hip joint.In what position should the nurse place the patient?

When admitting a patient to the hospital,the nurse notes the patient has mild sunburn.How should the nurse document this finding?

During a physical assessment,the nurse notes a patient has profuse secretions of sweat.What should the nurse document that the patient is experiencing?

During a physical assessment,the nurse notes a patient has a bluish discoloration of the skin and mucous membranes.How should the nurse document this finding?

During a physical assessment,the nurse observes a patient experiencing a sudden audible expulsion of air from the lungs.What should the nurse document that the patient is experiencing?

During a physical assessment,the nurse notes a patient passes frequent loose liquid stools.What should the nurse document that the patient is experiencing?

A physician needs to assess a patient for a heart murmur.In what position should the nurse place the patient?

When assessing a patient with hepatitis,the nurse notes a yellow tinge to the patient's skin.What does the nurse understand as the most likely cause of the jaundice?

During a physical assessment,the nurse notes a patient has a lack of appetite resulting in an inability to eat.What should the nurse document that the patient is experiencing?

During a physical assessment,the patient complains of difficulty in passing stools.What should the nurse document that the patient is experiencing?