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

the nursing health history

a body systems review

the present illness

a focused review

Answer and Explanation

The Correct Answer is A

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.

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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.

A. past health history B. environmental history C. psychosocial history D. family history

Correct Answer is C

Explanation

A. Past health history. – Past health history focuses on previous medical conditions, surgeries, and treatments, not current lifestyle habits.

B. Environmental history. – Environmental history pertains to exposure to environmental factors such as occupational hazards or pollutants, not lifestyle habits.

C. Psychosocial history. – Psychosocial history includes information about the patient’s lifestyle, habits (e.g., smoking, alcohol use), social relationships, stress levels, and coping mechanisms.

D. Family history. – Family history focuses on genetic and hereditary diseases present in the patient’s family, not personal habits and lifestyle.

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

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Naxlex Comprehensive Predictor Exams

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

During the nursing interview, several histories are taken. The history that involves data concerning habits and lifestyle patterns is called:

Correct Answer is C

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:

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:

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

An abnormal condition in which a person must sit or stand to breathe deeply or comfortably is called:

Any disturbance of the structure or function of the body is a pathological condition. This condition is termed a/an:

When the patient asked the nurse how long it would take to "get over" the diabetes, the nurse explained that she will have this disease throughout her life. Diabetes mellitus is considered a/an:

Auscultation of the heart sounds will result in a lubb-dupp sound when using the bell and the diaphragm of the stethoscope. The lub part of the sound is caused by the:

Febrile is an abnormal elevation of: