Fundamentals Hesi 3

3

A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing has been prescribed when there is no history of health problems. What is an appropriate nursing response? 1 "You will need to ask your healthcare provider; it is not part of the usual tests for people your age." 2 "There must be concern of a family history of colon cancer; that is a primary reason for an occult blood stool test." 3 "It is performed routinely starting at your age as part of an assessment for colon cancer." 4 "There must have been a positive finding after a digital rectal examination performed by your healthcare provider."

2

A client experiencing chills and fever is admitted to the hospital. After assessing the client's vitals and medical history, the nurse concluded that the client's fever pattern is remittent. Which assessment finding led to this conclusion? 1 The client's temperature returns to an acceptable value at least once in the past 24 hours 2 The client's fever spikes and falls without a return to normal temperature levels 3 Periods of febrile episodes and periods with acceptable temperature values occur 4 The client has a constant body temperature continuously above 38°C with minimal fluctuation

3

A client is diagnosed with acquired immunodeficiency syndrome (AIDS). When examining the client's oral cavity, the nurse assesses white patchy plaques on the mucosa. The nurse recognizes that this finding most likely represents what opportunistic infection? 1 Cytomegalovirus 2 Histoplasmosis 3 Candida albicans 4 Human papillomavirus

3

A client shows an increase in rate respirations that are abnormally deep and regular. What condition would the nurse expect? 1 Hypoventilation 2 Biot's respiration 3 Kussmaul's respiration 4 Cheyne-Stokes respiration

3

A client who underwent a physical examination reports itching after 2 days. Which condition should the nurse suspect? 1 Eczema 2 Hypersensitivity 3 Contact dermatitis 4 Anaphylactic shock

4

A nurse assesses a client with dry and brittle hair, flaky skin, a beefy-red tongue, and bleeding gums. The nurse recognizes that these clinical manifestations are most likely a result of what? 1 A food allergy 2 Noncompliance with medications 3 Side effects from medications 4 A nutritional deficiency

3

A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present? 1 Headache 2 Pallor 3 Paresthesias 4 Blurred vision

3

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as what? 1 Vesicular 2 Bronchial 3 Crackles 4 Rhonchi

1

A nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. What type of pain does the client experience? 1 Visceral pain 2 Somatic pain 3 Referred pain 4 Intractable pain

3

A registered nurse (RN) is performing a physical examination of a client with chronic obstructive pulmonary disease. Which abnormal nail bed patterns can be expected in this client? 1 Spoon-shaped nails 2 Transverse depressions in nails 3 Softening of nail beds and flat nails 4 Red or brown linear streaks in nail bed

1

A student nurse is assessing the blood pressure of a client with the client's arm unsupported. What are the expected errors in the obtained readings? 1 False high reading 2 False low diastolic reading 3 False high systolic reading 4 False high diastolic reading

4

An 82-year-old retired schoolteacher is admitted to a nursing home. During the physical assessment, the nurse may identify which ocular problem common to persons at this client's developmental level? 1 Tropia 2 Myopia 3 Hyperopia 4 Presbyopia

1

An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 113° F. Which condition does the nurse suspect in the client? 1 Heat stroke 2 Heat exhaustion 3 Accidental hypothermia 4 Malignant hyperthermia

1,3,2,5,4

Arrange the sequence of events occurring during a fever secondary to pyrogens in chronological order Correct 1. Immune system response is triggered 2. Body temperature is increased 3. The set point of the hypothalamus is raised 4. Heat loss responses are initiated 5. Pyrogens are destroyed

4

How does the World Health Organization (WHO) define "health"? 1 A condition when people are free of disease 2 A condition of life rather than pathological state 3 An actualization of inherent and acquired human potential 4 A state of complete physical, mental, and social well-being

1,3,4,5,2

The nurse applies the nursing process while caring for clients. What is the correct order of steps of the nursing process? Correct 1. Assessment 2. Evaluation 3. Diagnosis 4.Planning 5. Implementation

2

The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data? 1 The client weighs 151 lbs (68.5 Kg). 2 The client's pain is 7 on a scale of 1 to 10. 3 The client's fasting blood sugar is 95 mg/dL. 4 The client's blood pressure is 140/90 mm/Hg

2

The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion? 1 Cocaine 2 Atropine 3 Morphine 4 Pilocarpine

1

What is the inflammation of the skin at the base of the nail called? 1 Paronychia 2 Koilonychia 3 Beau's lines 4 Splinter hemorrhage

2,3,4

When should the nurse consider family members as the primary source of information? Select all that apply 1 The client is an elderly adult. 2 The client is an infant or child. 3 The client is brought in as an emergency. 4 The client is critically ill and disoriented. 5 The client visits the outpatient department

3

Which assessing technique involves tapping a client's skin with the fingertips to cause vibrations in the underlying tissues? 1 Palpation 2 Inspection 3 Percussion 4 Auscultation

1

Which assessment finding of the skin refers to elasticity? 1 Turgor 2 Edema 3 Texture 4 Vascularity

3

Which assessment is expected when a client is placed in the lithotomy position during physical examination? 1 Assessment of the heart 2 Assessment of the rectum 3 Assessment of the female genitalia 4 Assessment of the musculoskeletal system

3

Which clinical condition will result in changes in the integrity of the arterial walls and small blood vessels? 1 Contusion 2 Thrombosis 3 Atherosclerosis 4 Tourniquet effect

4

Which integumentary finding is related to skin texture? 1 Elasticity 2 Vascularity 3 Fluid buildup 4 Character of the surface

2,3

Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? Select all that apply 1 Axilla 2 Fingers 3 Ear lobes 4 Forehead 5 Upper thorax

3

Which site is best used to inspect a client who is suspected to have jaundice? 1 Skin 2 Palm 3 Sclera 4 Conjunctiva

3

Which type of breathing pattern alteration is manifested with hypercarbia? 1 Eupnea 2 Tachypnea 3 Hypoventilation 4 Kussmaul's respiration

2

While assessing the pupils of a client, a healthcare professional notices pupillary dilatation. Which drug intake might have resulted in this condition? 1 Cocaine 2 Atropine 3 Morphine 4 Pilocarpine

1,2,4,3

What is the sequence of techniques used while assessing the abdomen? 1. Inspection 2. Auscultation 3. Palpation 4. Percussion