Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
While performing an assessment, the nurse presses the client's arm with the tip of her thumb, holds for a few seconds, and releases. The nurse observes the client as shown. What is the nurse assessing?
A. Pitting edema
Pitting edema: Pressing on the skin and observing how it rebounds (if it leaves an indentation) is used to assess for pitting edema, which indicates fluid retention in the tissues.
B. Capillary refill
Capillary refill: This test involves pressing on the nail beds and observing the time it takes for color to return, not pressing on the arm.
C. Skin temperature
Skin temperature: This is assessed by palpating the skin, not by pressing with the thumb.
D. Peripheral pulses
Peripheral pulses: This involves palpating pulse points to assess their presence and strength, not pressing on the arm to check for edema.
This question is an excerpt from Nurse Dive's nursing test bank - Ati health assessment proctored exam. Take the full exam now
Full Explanation
A. Pitting edema: Pressing on the skin and observing how it rebounds (if it leaves an indentation) is used to assess for pitting edema, which indicates fluid retention in the tissues.
B. Capillary refill: This test involves pressing on the nail beds and observing the time it takes for color to return, not pressing on the arm.
C. Skin temperature: This is assessed by palpating the skin, not by pressing with the thumb.
D. Peripheral pulses: This involves palpating pulse points to assess their presence and strength, not pressing on the arm to check for edema.
Similar Questions
When assessing for appendicitis, what signs might the nurse look for? (Select all that apply.)
A. Rovsing sign
Rovsing sign: This sign involves pain in the right lower quadrant when palpating the left lower quadrant, indicating appendicitis.
B. Obturator sign
Obturator sign: Pain on internal rotation of the hip when the knee is flexed can indicate irritation of the appendix.
C. Murphy sign
Murphy sign: This sign is used to assess for cholecystitis, not appendicitis.
D. Psoas sign
Psoas sign: Pain with extension of the right leg can indicate irritation of the appendix due to the psoas muscle.
Full Explanation
A. Rovsing sign: This sign involves pain in the right lower quadrant when palpating the left lower quadrant, indicating appendicitis.
B. Obturator sign: Pain on internal rotation of the hip when the knee is flexed can indicate irritation of the appendix.
C. Murphy sign: This sign is used to assess for cholecystitis, not appendicitis.
D. Psoas sign: Pain with extension of the right leg can indicate irritation of the appendix due to the psoas muscle.
A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate an understanding of the waveforms when they identify which component as indicating ventricular repolarization (relaxation).
A. ST segment
ST segment: Represents the period between ventricular depolarization and repolarization.
B. QRS complex
QRS complex: Represents ventricular depolarization.
C. T wave
T wave: Indicates ventricular repolarization, or relaxation, after the QRS complex.
D. P wave
P wave: Represents atrial depolarization.
Full Explanation
A. ST segment: Represents the period between ventricular depolarization and repolarization.
B. QRS complex: Represents ventricular depolarization.
C. T wave: Indicates ventricular repolarization, or relaxation, after the QRS complex.
D. P wave: Represents atrial depolarization.
A client complains of a burning sensation in the esophagus after eating. Which associated condition should the nurse most suspect?
A. Pancreatic cancer
Pancreatic cancer: Typically associated with abdominal pain, weight loss, and jaundice rather than a burning sensation in the esophagus.
B. Acute pancreatitis
Acute pancreatitis: Causes severe abdominal pain, nausea, and vomiting, but not usually a burning sensation in the esophagus.
C. Acid reflux
Acid reflux: Also known as gastroesophageal reflux disease (GERD), this condition commonly causes a burning sensation in the esophagus after eating.
D. Gastric ulcer
Gastric ulcer: Generally causes pain in the upper abdomen and may be associated with indigestion, but not specifically a burning sensation in the esophagus.
Full Explanation
A. Pancreatic cancer: Typically associated with abdominal pain, weight loss, and jaundice rather than a burning sensation in the esophagus.
B. Acute pancreatitis: Causes severe abdominal pain, nausea, and vomiting, but not usually a burning sensation in the esophagus.
C. Acid reflux: Also known as gastroesophageal reflux disease (GERD), this condition commonly causes a burning sensation in the esophagus after eating.
D. Gastric ulcer: Generally causes pain in the upper abdomen and may be associated with indigestion, but not specifically a burning sensation in the esophagus.