N225 Health Assessment MIDTERM REVIEW

N225 Health Assessment MIDTERM REVIEW The nurse is conducting a physical assessment of a new patient. What data does the nurse collect that are measurable? A. Subjective B. Effective C. Affective D. Objective D. Objective Rationale: Objective data is information gathered from the physical examination and laboratory tests. This information is primarily factual and descriptive. Bates p. 12 The four areas to consider during the general survey include: Physical appearance, body structure, mobility, and behavior. A. Dress, medical history, nonverbal behavior, and mobility. B. Ethnicity, gender, age, and socioeconomic status. C. Physical appearance, body structure, mobility, and behavior. D. Physical appearance, gender, ethnicity, and affect. C. Physical appearance, body structure, mobility, and behavior Rationale: The general survey notes the patient's overall appearance and apparent age, level of consciousness, facial features, and expressions, demeanor and affect, posture, gait, motor activity, speech, skin color and lesions, dress and personal hygiene. Bates p 122. The nurse notes the appearance of freckles while assessing a patient's skin. What is the appropriate term to use when documenting? A. Patches B. Macules C. Bullea D. Vesicles B. Macules Rationale: Macules are non palpable lesions with local changes in skin color that are less than 1.0 cm. Bates p196. The nurse performs a head and neck assessment on an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action? A. Position the patient supine and reattempt palpation. B. Refer the patient to their primary care provider. C. Perform a focused endocrine exam D. Document this as an expected assessment finding. D. Document this as an expected assessment finding. Rationale: The thyroid gland is usually easier to feel in a long slender neck than in a short stocky one. In some people, however the thyroid gland is partially or wholly substernal and not palpable during physical assessment. Bates p 225 While assessing a patient for allergies, they state they are allergic to penicillin. Which response is best? A. "I'll write your allergy on your chart so you will not receive any." B. "Please describe what happens to you when you take penicillin?" C. "How often have you received penicillin? D. "Are you allergic to any other drugs?" B. "Please describe what happens to you when you take penicillin?"