CHAPTER 13: PHYSICAL ASSESSMENT |Cooper: Foundation of Nursing, 9th Edition|

C HAPTER 13: P HYSICAL A SSESSMENT
Cooper: Foundation of Nursing, 9th Edition




MULTIPLE CHOICE


1. During a physical assessment, the nurse notes a patient has a bluish
discoloration of the skin a nd mucous membranes. How should the nurse
document this finding?
a. Dyspnea
b. Cyanosis
c. Diaphoresis
d. Ecchymosis



ANS: B



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



DIF: Cognitive Level: Knowledge REF: p. 314 OBJ: 13
TOP: Assessment KEY: Nursing Process Step:
Assessment MSC: NC LEX: Physiological Integrit y



2. During a physical assessment, the nurse notes a patient has a lack of
appetite resulting in an inabilit y to eat. What should the nurse document
that the patient is experiencing?
a. Dyspnea
b. Asthenia
c. Anorexia

, d. Ecchymosis



ANS: C



Anorexia is a lack of appetite resulting in the inabilit y to eat. This
s ymptom can occur in many disease conditions.



DIF: Cognitive Level: Knowledg e REF: p. 314 OBJ: 13
TOP: Assessment KEY: Nursing Process Step:
Assessment MSC: NC LEX: Physiological Integrit y



3. During a physical assessment, the nurse notes a patient has a loss of
strength and energy. What should the nurse document that the patien t is
experiencing?
a. Dyspnea
b. Cyanosis
c. Asthenia
d. Ecchymosis



ANS: C



Asthenia is a condition of debilit y, loss of strength and energy, and
depleted vitalit y.



DIF: Cognitive Level: Knowledge REF: p. 314 OBJ: 13
TOP: Assessment KEY: Nursing Process Step:
Assessment MSC: NC LEX: Physiological Integrit y

,4. During a physical assessment, the nurse notes that a patient’s heart rate is
56 beats/min. What should the nurse document that the patient is
experiencing?
a. Dyspnea
b. Cyanosis
c. Diaphoresis
d. Bradycardia



ANS: D



Bradycardia is a circulatory condition in which the m yocardium
contracts steadil y but at a rate of less than 60 contractions per minute.



DIF: Cognitive Level: Application REF: p. 314 OBJ: 13
TOP: Assessment KEY: Nursing Process Step:
Assessment MSC: NC LEX: Physiological Integrit y



5. During a physical assessment, the patient complains of difficult y in
passing stools. What should the nurse document that the patient is
experiencing?
a. Dyspnea
b. Cyanosis
c. Constipation
d. Ecchymosis



ANS: C



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

, DIF: Cognitive Level: Knowledge REF: p. 314 OBJ: 13
TOP: Assessment KEY: Nursing Process Step:
Assessment MSC: NC LEX: Phys iological Integrit y



6. 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?
a. Dyspnea
b. Cyanosis
c. Coughing
d. Ecchymosis



ANS: C



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 co mmon sign of
diseases of the larynx, bronchi, and lungs.



DIF: Cognitive Level: Knowledge REF: p. 314 OBJ: 13
TOP: Assessment KEY: Nursing Process Step:
Assessment MSC: NC LEX: Physiological Integrit y



7. During a physical assessment, the nurse notes a p atient has profuse
secretions of sweat. What should the nurse document that the patient is
experiencing?
a. Dyspnea
b. Cyanosis