The nurse would document which of the following as objective data obtained during a patient assessment?
Report of scalp itching each evening
Loss of hair on bilateral legs
Patient description of pain in an extremity
Complaint of numbness on the right hand,
The Correct Answer is B
Objective data refers to measurable and observable information gathered during a patient assessment, such as physical signs, laboratory values, and other measurable data. In this case, the loss of hair on bilateral legs can be observed and measured, making it an objective finding. Options a, c, and d are all subjective data as they rely on the patient's report or description of their symptoms, which cannot be directly observed or measured.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The examiner uses bimanual palpitation to evaluate the tail of spence.
This statement is true. The tail of Spence is the extension of breast tissue into the axilla, and it is important to evaluate this area during a breast examination. Bimanual palpation, which involves using both hands to examine the breast tissue, is commonly used to assess the tail of Spence.
B. The axillae are not palpated if the breast tissue is normal.
This statement is false. The axillae should be palpated during a breast examination, even if the breast tissue is normal. Lymph nodes in the axilla can sometimes be the first site of metastasis for breast cancer, so it is important to check for any abnormalities in this area.
C. Nipple discharge in pregnant women is considered abnormal.
This statement is false. Nipple discharge is a common occurrence during pregnancy and is usually considered normal, especially in the later stages of pregnancy. However, any sudden or persistent discharge should be evaluated by a healthcare provider.
D. The breasts are inspected as the client changes positions to detect abnormal symmetry.
This statement is false. The breasts should be inspected in a consistent position, such as with the patient sitting or lying down. Changing positions can alter the appearance of the breasts and make it difficult to detect any changes or abnormalities. However, it is important to inspect both breasts and compare them for any signs of asymmetry or abnormalities.
Correct Answer is A
Explanation
When assessing the abdomen, the nurse would expect to auscultate bowel sounds, which are the sounds made by the movement of gas and fluid through the intestines. The normal bowel sounds are characterized as high-pitched, gurgling, and occurring at a rate of 5-30 sounds per minute.
Bruits are abnormal sounds indicating turbulent blood flow and are usually assessed in other areas of the body, such as the epigastric and renal arteries, as well as in the aorta.
Friction rubs are also abnormal sounds, but they are typically heard during auscultation of the heart and lungs.
Low-pitched sonorous sounds are not typical sounds that are expected to be heard during an abdominal assessment
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