A nursing assessment is a process of collecting data to establish a database. The information contained in the database is the basis for:

a complete physical examination

a medical assessment

writing nursing orders

an individualized plan of care

Answer and Explanation

The Correct Answer is D

A. A complete physical examination – While a physical examination is part of data collection, the primary goal of a nursing assessment is to guide nursing care rather than conduct a full medical examination.

B. A medical assessment – Medical assessments are conducted by physicians to diagnose diseases, while nursing assessments focus on holistic patient care.

C. Writing nursing orders – Nursing orders are based on the care plan but do not encompass the entire purpose of the assessment.

D. An individualized plan of care – The primary purpose of a nursing assessment is to collect data to create a care plan tailored to the patient's specific needs.

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Correct Answer is A

Explanation

A. Exudate – Exudate is fluid rich in proteins and cells that escapes from blood vessels due to inflammation or injury.

B. Pus – Pus is a thick, yellowish-white exudate containing dead cells and bacteria, specifically associated with infection.

C. Drainage – Drainage is a general term for any fluid leaving the body, including exudate, blood, or serous fluid.

D. Discharge – Discharge is a broader term referring to any material exiting the body, including normal secretions and infectious material.

A. erythema B. ecchymosis C. fetid D. Sallow

Correct Answer is B

Explanation

A. Erythema. – Erythema is redness caused by increased blood flow, not blood leakage into tissues.

B. Ecchymosis. – Ecchymosis, commonly known as a bruise, results from blood leaking into the subcutaneous tissue due to trauma or coagulation disorders.

C. Fetid. – Fetid describes a foul odor, not a skin discoloration.

D. Sallow. – Sallow refers to a yellowish or pale complexion, often due to anemia or illness, not blood extravasation.

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A nursing assessment is a process of collecting data to establish a database. The information contained in the database is the basis for:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Fluid, cells or other substances that have been slowly discharged from body cells or blood vessels, through small pores or breaks in the cell membrane are called:

Correct Answer is A

Explanation

Discoloration of an area of the skin or mucous membranes caused by extravasation of blood into subcutaneous tissue is termed:

Correct Answer is B

Explanation

The nurse uses a systematic method for collecting data on all body systems including normal functioning and any noted changes. This system is:

An abnormal accumulation of fluid in the interstitial spaces is described as:

When performing a physical examination of the patient, the nurse uses a technique that is particularly useful in identifying areas of tenderness. This technique is:

An abnormal rapid rate of breathing seen in many disease conditions is called:

You answer Ms. B's call light just after lunch. She complains of severe abdominal pain. What type of assessment should you perform?

An abnormally rapid heart rate above 100 beats per minute is called:

The main reason that auscultation precedes palpation of the abdomen is to:

The term used to describe a disease where there has been a partial or complete disappearance of clinical and subjective characteristics of the disease is: