The nurse is obtaining a history of the patient's present illness. The PQRST system is being used for the interview. In this system the R is:

region

recent

random

Result

Answer and Explanation

The Correct Answer is A

A. Region – In the PQRST pain assessment method, R stands for Region (location of pain). It helps determine where the patient feels discomfort and whether it radiates.

B. Recent – "Recent" does not correspond to any category in the PQRST system.

C. Random – "Random" is not a part of the PQRST framework.

D. Result – The PQRST method does not include "Result"; instead, it focuses on the characteristics of pain.

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Correct Answer is D

Explanation

A. Nursing assessment – A nursing assessment is the broader process of gathering patient information, including subjective and objective data, but does not specifically refer to a body system review.

B. Nursing interview – A nursing interview is a method used to gather subjective data from the patient, but it does not systematically review all body systems.

C. Health history – A health history includes past medical conditions, surgeries, and family history but does not systematically assess all body systems.

D. Review of systems – The review of systems (ROS) is a structured approach where the nurse systematically collects data about normal function and any changes in each body system.

A. 30 seconds to 1 minute B. 10-15 seconds C. 20 seconds D. 2-5 minutes

Correct Answer is D

Explanation

A. 30 seconds to 1 minute. – This time frame is characteristic of 3+ pitting edema, not 4+.

B. 10-15 seconds. – This time frame is associated with 2+ pitting edema, which indicates a moderate level of fluid retention.

C. 20 seconds. – This time frame is associated with 3+ pitting edema.

D. 2-5 minutes. – 4+ pitting edema is the most severe form, where the indentation remains for 2-5 minutes, indicating significant fluid retention and possible cardiac or renal dysfunction.

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The nurse is obtaining a history of the patient's present illness. The PQRST system is being used for the interview. In this system the R is:

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

Correct Answer is D

Explanation

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:

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:

The patient was admitted with a complaint of abdominal pain. Later the nurse observed the patient demonstrating dyspnea. This change in condition required an assessment called:

Short, discrete, interrupted crackling or bubbling adventitious breath sounds heard most commonly on inspiration is termed:

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

The elderly patient is being assessed for skin turgor. Which of the following actions should the nurse take?

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

The profuse secretion of sweat associated with an elevated body temperature, certain disease conditions, physical exertion, exposure to heat and mental or emotional stress is termed:

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