When the color of the sclera is yellow due to bilirubin that infiltrates all tissues of the body it is called:

jaundice

erythema

ecchymosis

Fetid

Answer and Explanation

The Correct Answer is A

A. Jaundice – Jaundice results from elevated bilirubin levels, commonly due to liver disease, hemolysis, or bile duct obstruction. The yellow discoloration is most noticeable in the sclera.

B. Erythema – Erythema refers to redness of the skin, often due to inflammation or increased blood flow.

C. Ecchymosis – Ecchymosis refers to bruising caused by blood leakage under the skin.

D. Fetid – Fetid refers to a foul odor, not a discoloration of tissues.

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Correct Answer is A

Explanation

A. The nursing health history – The nursing health history is the first step after collecting biographical data. It includes the chief complaint, past medical history, and social factors affecting health.

B. A body systems review – A body systems review (ROS) is done later in the assessment to gather additional information on each organ system.

C. The present illness – The present illness is part of the nursing health history but is not the first step after verifying biographical data.

D. A focused review – A focused review targets specific concerns rather than serving as the initial step in a comprehensive assessment.

A. bradycardia B. tachycardia C. dyspnea D. Tachypnea

Correct Answer is B

Explanation

A. Bradycardia – Bradycardia is a slow heart rate below 60 beats per minute.

B. Tachycardia – Tachycardia is defined as a heart rate exceeding 100 beats per minute, which can result from fever, stress, dehydration, or cardiac conditions.

C. Dyspnea – Dyspnea refers to difficulty breathing, not an increased heart rate.

D. Tachypnea – Tachypnea is an abnormally rapid respiratory rate, not a rapid heart rate.

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When the color of the sclera is yellow due to bilirubin that infiltrates all tissues of the body it is called:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

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

Correct Answer is B

Explanation

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

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

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:

Redness or inflammation of the skin or mucous membranes resulting from dilation and congestion of superficial capillaries is termed:

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

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:

As the assessment continues the nurse notes an abnormal swishing sound with auscultation of the carotid artery. The term for this sound is:

An abnormally slow heart rate, below 60 beats per minute is called: