Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which individual typically would be responsible for collecting the subjective data on a client during the initial comprehensive assessment?
A. Technician
Technician: Technicians generally perform specific tasks or tests rather than collecting comprehensive subjective data.
B. Secretary
Secretary: A secretary's role is administrative and does not involve direct patient assessment or data collection.
C. Nurse
Nurse: Nurses are typically responsible for collecting subjective data from clients during the initial comprehensive assessment, including patient history and current health concerns.
D. Physician
Physician: While physicians review and interpret data, they often rely on nurses to collect detailed subjective information during initial assessments.
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Full Explanation
A. Technician: Technicians generally perform specific tasks or tests rather than collecting comprehensive subjective data.
B. Secretary: A secretary's role is administrative and does not involve direct patient assessment or data collection.
C. Nurse: Nurses are typically responsible for collecting subjective data from clients during the initial comprehensive assessment, including patient history and current health concerns.
D. Physician: While physicians review and interpret data, they often rely on nurses to collect detailed subjective information during initial assessments.
Similar Questions
The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following?
A. Stasis ulceration
Stasis ulceration: While stasis ulcers can occur in the context of venous insufficiency, the description of warm skin and brown pigmentation more directly suggests venous insufficiency.
B. Arterial occlusion
Arterial occlusion: This condition typically presents with cold, pale skin and possible pain or cramping, rather than warm skin and pigmentation.
C. Dependent edema
Dependent edema: Dependent edema involves swelling due to fluid accumulation but does not necessarily cause pigmentation changes around the ankles.
D. Venous insufficiency
Venous insufficiency: Warm skin and brown pigmentation around the ankles are indicative of venous insufficiency, a condition where blood flow in the veins is impaired, leading to these symptoms.
Full Explanation
A. Stasis ulceration: While stasis ulcers can occur in the context of venous insufficiency, the description of warm skin and brown pigmentation more directly suggests venous insufficiency.
B. Arterial occlusion: This condition typically presents with cold, pale skin and possible pain or cramping, rather than warm skin and pigmentation.
C. Dependent edema: Dependent edema involves swelling due to fluid accumulation but does not necessarily cause pigmentation changes around the ankles.
D. Venous insufficiency: Warm skin and brown pigmentation around the ankles are indicative of venous insufficiency, a condition where blood flow in the veins is impaired, leading to these symptoms.
When the nurse collects objective data, which finding requires immediate follow-up?
A. Moist nasal mucosa
Moist nasal mucosa: This is generally a normal finding and does not usually require immediate follow-up unless there are other symptoms suggesting infection or other issues.
B. Cerumen in the ear
Cerumen in the ear: While cerumen can impact hearing, it is typically not an urgent issue and can be managed with appropriate ear care.
C. Enlarged lymph node in the neck
Enlarged lymph node in the neck: Enlarged lymph nodes can indicate an underlying infection or malignancy, especially if persistent or accompanied by other symptoms, thus requiring immediate follow-up.
D. Acne lesions on the face and upper chest
Acne lesions on the face and upper chest: Acne is common and usually not an urgent concern unless it is severe or causing significant distress.
Full Explanation
A. Moist nasal mucosa: This is generally a normal finding and does not usually require immediate follow-up unless there are other symptoms suggesting infection or other issues.
B. Cerumen in the ear: While cerumen can impact hearing, it is typically not an urgent issue and can be managed with appropriate ear care.
C. Enlarged lymph node in the neck: Enlarged lymph nodes can indicate an underlying infection or malignancy, especially if persistent or accompanied by other symptoms, thus requiring immediate follow-up.
D. Acne lesions on the face and upper chest: Acne is common and usually not an urgent concern unless it is severe or causing significant distress.
The nurse is using the finger pads of the hand to palpate a body part. The nurse would best be able to detect which finding?
A. Pulses
Pulses: The finger pads are particularly effective for detecting the presence, strength, and regularity of pulses due to their sensitivity and the ability to apply gentle pressure.
B. Vibrations
Vibrations: Vibrations are best assessed with the ulnar surface of the hand rather than the finger pads.
C. Fremitus
Fremitus: Fremitus, or the vibrations transmitted through the chest wall, is best assessed using the palmar or ulnar surface of the hand.
D. Temperature
Temperature: Temperature is more effectively assessed using the back of the hand, not the finger pads.
Full Explanation
A. Pulses: The finger pads are particularly effective for detecting the presence, strength, and regularity of pulses due to their sensitivity and the ability to apply gentle pressure.
B. Vibrations: Vibrations are best assessed with the ulnar surface of the hand rather than the finger pads.
C. Fremitus: Fremitus, or the vibrations transmitted through the chest wall, is best assessed using the palmar or ulnar surface of the hand.
D. Temperature: Temperature is more effectively assessed using the back of the hand, not the finger pads.