Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is assessing the seven attributes of a client's symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information?
A. History of present illness
History of present illness: The OLD CART mnemonic is used to evaluate the characteristics of a symptom, which is documented under the history of present illness.
B. Initial Information
Initial Information: This section includes basic demographic and background information rather than detailed symptom analysis.
C. Review of Systems
Review of Systems: This section includes a systematic review of body systems and their functions, not the detailed attributes of a specific symptom.
D. Health Patterns
Health Patterns: This section covers the client’s overall health patterns and lifestyle but not the detailed attributes of a specific symptom.
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Full Explanation
A. History of present illness: The OLD CART mnemonic is used to evaluate the characteristics of a symptom, which is documented under the history of present illness.
B. Initial Information: This section includes basic demographic and background information rather than detailed symptom analysis.
C. Review of Systems: This section includes a systematic review of body systems and their functions, not the detailed attributes of a specific symptom.
D. Health Patterns: This section covers the client’s overall health patterns and lifestyle but not the detailed attributes of a specific symptom.
Similar Questions
The nurse is assessing an older adult client at a hospice unit. The client cannot speak or communicate, but the client's daughter is there and answers all the questions as best as she can. What type of data source is the daughter?
A. Subjective
Subjective: Subjective data refers to information reported by the patient directly, which is not applicable in this case since the client cannot communicate.
B. Tertiary
Tertiary: This term is not commonly used in the context of data sources in health assessments.
C. Secondary
Secondary: Secondary data is information provided by someone other than the patient, such as a family member or caregiver, which is applicable here since the daughter is providing the information.
D. Primary
Primary: Primary data is directly obtained from the patient, not from a secondary source like the daughter.
Full Explanation
A. Subjective: Subjective data refers to information reported by the patient directly, which is not applicable in this case since the client cannot communicate.
B. Tertiary: This term is not commonly used in the context of data sources in health assessments.
C. Secondary: Secondary data is information provided by someone other than the patient, such as a family member or caregiver, which is applicable here since the daughter is providing the information.
D. Primary: Primary data is directly obtained from the patient, not from a secondary source like the daughter.
The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?
A. Reduce all environmental noise.
Reduce all environmental noise: Minimizing environmental noise ensures that bowel sounds can be clearly heard during auscultation.
B. Percuss the region before auscultating.
Percuss the region before auscultating: Percussion is not necessary before auscultation for detecting bowel sounds; auscultation should be done first.
C. Palpate the region before auscultating.
Palpate the region before auscultating: Palpation can alter bowel sounds or cause false findings, so it is best to auscultate first.
D. Assist the client to a sitting position.
Assist the client to a sitting position: The client’s position is less critical than reducing background noise; the client can be in various positions as long as the area is accessible.
Full Explanation
A. Reduce all environmental noise: Minimizing environmental noise ensures that bowel sounds can be clearly heard during auscultation.
B. Percuss the region before auscultating: Percussion is not necessary before auscultation for detecting bowel sounds; auscultation should be done first.
C. Palpate the region before auscultating: Palpation can alter bowel sounds or cause false findings, so it is best to auscultate first.
D. Assist the client to a sitting position: The client’s position is less critical than reducing background noise; the client can be in various positions as long as the area is accessible.
During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? (Select all that apply.)
A. Wait until the end of the physical assessment to reassess the radial pulse.
Wait until the end of the physical assessment to reassess the radial pulse: If the radial pulse is irregular, it is important to reassess it to confirm irregularity. However, waiting until the end of the assessment is not recommended; it is better to reassess promptly.
B. Reassess the client's pedal pulse on the other foot.
Reassess the client's pedal pulse on the other foot: This is not related to assessing the regularity of the radial pulse.
C. Assess the client's 51 and 52 sounds for regularity.
Assess the client's 51 and 52 sounds for regularity: These terms are not standard in assessing pulse regularity; the focus should be on the apical pulse for an irregular radial pulse.
D. Assess the client's apical pulse for a full minute.
Assess the client's apical pulse for a full minute: The apical pulse should be assessed for a full minute to accurately determine the heart rate and rhythm, especially if the radial pulse is irregular.
Full Explanation
A. Wait until the end of the physical assessment to reassess the radial pulse: If the radial pulse is irregular, it is important to reassess it to confirm irregularity. However, waiting until the end of the assessment is not recommended; it is better to reassess promptly.
B. Reassess the client's pedal pulse on the other foot: This is not related to assessing the regularity of the radial pulse.
C. Assess the client's 51 and 52 sounds for regularity: These terms are not standard in assessing pulse regularity; the focus should be on the apical pulse for an irregular radial pulse.
D. Assess the client's apical pulse for a full minute: The apical pulse should be assessed for a full minute to accurately determine the heart rate and rhythm, especially if the radial pulse is irregular.