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. Is a protective response – Inflammation is a natural immune response that helps contain injury and promote healing, regardless of infection.

B. Is a disease process – Inflammation itself is not a disease; it is a response to injury, infection, or irritation.

C. Produces tissue damage – While excessive or chronic inflammation can cause tissue damage, inflammation itself is not inherently destructive.

D. Is a result of bacteria – Inflammation can be caused by bacteria, viruses, trauma, or autoimmune conditions, not just bacterial infection.

A. 2-20 B. 4-32 C. 2-10 D. 5-30

Correct Answer is D

Explanation

A. 2-20 – This range is too low to be considered normal.

B. 4-32 – This range is broader than the commonly accepted normal range.

C. 2-10 – This range is too low and may indicate hypomotility.

D. 5-30 – The normal rate of bowel sounds is typically 5 to 30 sounds per minute, with variations depending on individual digestion and activity.

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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

Although the signs and symptoms of both infection and inflammation include erythema, edema, and pain, the major difference is that inflammation:

Correct Answer is A

Explanation

Listening for bowel sounds is done over all four quadrants of the abdomen using the diaphragm of the stethoscope. The normal rate of bowel sounds per minute is:

Correct Answer is D

Explanation

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:

While conducting an assessment of the patient, the nurse recognizes that after verifying biographical data, the initial step is:

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

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

When performing the nursing physical assessment, the nurse uses head-to-toe organization. When using this method, the nurse begins with a:

The most frequently used skill in the physical nursing assessment is:

Adventitious breath sounds that have a whistling or sighing sound due to narrowing of the lumen of a respiratory passage are termed:

The patient has been found to have edema of the lower extremities. The nurse is assessing whether or not it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 4+ pitting edema because the rebound time is: