Which technique should the nurse employ to best assess skin turgor?
a. Examine mucous membranes of the mouth.
b. Compare limbs for similar color.
c. Pinch a skinfold on chest to assess for tenting.
d. Palpate the ankles for evidence of pitting edema.
Question 2The nurse recognizes the staging T3, N2, M2 of the patient's cancer. Which interpretation is correct?
a. Small tumor with fewer than two lymph nodes involved.
b. Large tumor that is localized.
c. Small tumor with adjacent nodes involved.
d. Large tumor with extensive lymph node involvement.
Question 3The 75-year-old patient presents to the emergency department with shortness of breath, fatigue, and a dry cough. When information leads the nurse to suspect that this patient should undergo workup for histoplasmosis?
a. The patient reports drinking pond water.
b. The patient lives on a farm and raises chickens.
c. The patient recently went hunting in a wooded area.
d. The patient owns a landscaping company.
Question 4The 26-year-old patient with a malignant neoplasm has experienced a 10-pound weight loss in 3 weeks. To which factor is this patient's rapid weight loss most likely related?
a. Disinterest in eating food in general
b. Changes in the nutritional content of the patient's diet
c. The malignancy's high nutritional demand
d. A self-imposed rigid diet regimen
Question 5The 75-year-old patient asks the nurse if the Pneumovax immunization he took when he was 65 is still protecting him. Which reply is most accurate?
a. Pneumovax protects you for your life-time.
b. Immunity afforded you by Pneumovax lasts only 2 years.
c. Pneumovax protection varies according to your risk factors and living situation.
d. After 6 years, you need a repeat dose of Pneumovax for full immunity.
Question 6During a morning assessment, the nurse observes that the patient displays significant edema of both feet and ankles. Which statement best documents these findings?
a. Pitting edema present in both feet and an-kles
b. Edema in both feet and ankles approx-imately 4 mm deep
c. 4 mm pitting edema quickly resolving
d. Bilateral pitting edema in feet and ankles, 4 mm deep, resolving in 3 seconds
Question 7The 79-year-old patient with bacterial pneumonia becomes increasingly restless, confused, and agitated. The patient's temperature is 100 F, and his pulse, blood pressure, and respirations are elevated since the last assessment 6 hours ago.
What action should the nurse take first?
a. Auscultate the patient's lungs.
b. Assess the patient's oxygen saturation.
c. Administer the mild sedative as ordered.
d. Administer an ordered analgesic for dis-comfort.
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