HESI - practice notes: health and physical assessment

what position for a rectal exam?

sims

edema chart?

4+ = 8 mm 1+ = 2 mm

fahrenheit to celsius?

Fahrenheit is converted to Celsius by subtracting 32 from the Fahrenheit reading and multiplying the obtained value by 5/9.

what does yogurt contain?

calcium

brown or black mole with red, white, or blue areas indicates ______; irregular shape

melanoma

_____ and _____ promote wound healing

protein and vitamin c

safe and inexpensive routes to measure temperature?

skin, axilla

-condition may be caused by increased amounts of deoxygenated hemoglobin, which may lead in heart disease or lung disease -In clients with anemia, the skin has a pallor due to a reduced amount of oxyhemoglobin -in clients with _____ disease, the skin appears yellow or orange due to increased deposits of bilirubin -In _______ diseases, the skin will lose its pigmentation

-cyanosis -anemia -liver disease -autoimmune diseases

A nurse is assessing an older adult client. Which clinical findings are expected responses to the aging process? Select all that apply. Slowed neurologic responses Lowered intelligence quotient Long-term memory impairment Forgetfulness about recent events Reduced ability to maintain an erection

-slowed neuro responses -forgetfulness about recent events -reduced ability to maintain an erection

The nurse suspects that an intraoperative client has a distended bladder. Which method is correct to assess for this condition? Inspect and palpate in the epigastric region. Auscultate and percuss in the inguinal areas. Percuss and palpate in the hypogastric region. Percuss and palpate bilaterally in the lumbar areas.

percuss and palpate in the hypogastric region

Which Korotkoff sound represents the diastolic pressure in children? Incorrect1 First 2 Second Correct3 Fourth 4 Fifth The fourth Korotkoff sound represents the diastolic pressure in children. The first Korotkoff sound represents the systolic pressure. The fifth Korotkoff sound represents the diastolic pressure in adults and adolescents. A blowing or swishing sound occurs in the second Korotkoff sound.

fourth

clients undergoing diureticc therapy are at risk of ______

heatstroke

The normal range for the respiratory rate in a two-year-old kid (toddler) is between _____ and ____breaths per minute. ______ breaths per minute is the normal respiratory rate in adolescents and adults. The normal respiratory rate in newborns is _____. The normal respiratory rate in infants is _____ breaths per minute.

25 and 32 20 40 50

In older adults the normal temperature range is _______ orally and ___________ rectally. In febrile conditions, the rectal temperature would be more than _____. A rectal temperature of ____ would indicate a fever.

36 to 36.8 C 36.6 to 37.2 C 37.5 C 38.5 C

-According to the Lovett score, a full range of motion against gravity with some resistance can be categorized as _____. -______ can be given if the client exhibits a full range of motion with no resistance -_______ score is given when the client exhibits slight contractility with no movement. -______ on the Lovett scale indicates full range of motion against gravity with full resistance.

G-good F-fair T-trace N-normal

3 parts of NANDA-1 label diagnosis?

NANDA-1 label related factor defining characteristics

While assessing an older adult during a regular health checkup, a nurse finds signs of elder abuse. Which physical findings would further confirm the nurse's suspicion? Presence of hyoid bone damage Presence of cognitive impairment Presence of burns from cigarettes Presence of bed sores. Presence of unexplained bruises on the wrist(s)

Presence of burns from cigarettes Presence of bed sores. Presence of unexplained bruises on the wrist(s)

What should the nurse assess to determine whether a 75-year-old individual is meeting the developmental tasks associated with aging? Achievement of a personal philosophy Adaptation to the children leaving home Attainment of a sense of worth as a person Adjustment to life in an assisted-living facility

attainment of a sense of worth as a person

A nurse is teaching a parenting class. What should the nurse suggest about managing the behavior of a young school-age child? Avoid answering questions. Give the child a list of expectations. Be consistent about established rules. Allow the child to plan the day's activities.

be consistent about established rules

(1) slow breathing (2) cease of respirations for seconds (3) rapid breathing (4) respirations are labored, depth is increased, rate is increased

bradypnea apnea tachypnea hyperpnea

what can elevate the oxygen saturation during an assessment? -nail polish -carbon monoxide -intravascular dyes -skin pigmentation

carbon monoxide

how to convert celsius to fahrenheit

celsius x 9/5 + 32

-lasts over 6 months -health relapses -more than one system affected -irreversible

chronic illness

koilonychias?

concavely curved nails

symptoms that accompany the primary symptoms of the illness and worsen the health condition

concomitant symptoms

pupil constriction or dilation? -heroin -atropine -morphine -pilocarpine

dilation = atropine

In case of the detection of aortic abnormalities, palpation of the epigastric area (which is located at the tip of the sternum) should be performed.

epigastric

if a client is in cardiac arrest, where should you check their pulse?

femoral site

what areas are specifically susceptible to frostbite?

fingers, toes, earlobes

A nurse is performing an eye assessment in an older adult. The older adult is unable to see near objects. Which conditions may be suspected in the older adult? Cataract Glaucoma Hyperopia Presbyopia Macular degeneration

hyperopia presbyopia

what indicates a heat stroke?

increased HR

A client with a history of hypothyroidism reports giddiness, excessive thirst, and nausea. Which parameter assessed by the nurse confirms the diagnosis as heat stroke? Increased heart rate Increased blood pressure Decreased respiratory rate Increased circulatory damage

increased heart rate -b/c these are symptoms of a heat stroke, and a heat stroke is characterized by increased heart rate

paronychia?

inflammation of skin at base of nail

The trigeminal nerve provides sensory innervation to the facial skin and motor innervation to the muscles of the jaw. A client with a damaged trigeminal nerve will be unable to clench his teeth. The facial nerve provides sensory and motor innervations for facial expressions. The trochlear nerve is involved in downward and inward eye movements. The abducens nerve helps in the eyeball's lateral movement.

know all the nerves

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? Diplopia Skin rash Leg cramps Tachycardia Muscle weakness

leg cramps muscle weakness

A client suffers hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. What are the best sites to assess this condition? Lips Sclera Mouth Sacrum Nail beds Shoulders

lips mouth nail beds

unconscious pts should have their temperature taken where?

rectally

splinter hemorrhages?

red or brown linear streaks in nail bed

Three days after bariatric surgery, the client puts the call light on and states, "I felt a 'pop' in my belly after I had a coughing spell." The nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence? Loosening of the sutures Sharp increase in serosanguineous drainage Purplish color of the incision Protrusion of organs through an open incision

sharp increase in serosanguineous drainage

The _______ are safe and inexpensive sites of the body for temperature measurement. The oral route is an easily accessible site for temperature measurement but it may not be the safest route because of the exposure to body fluids. The rectal route may not be easily accessible and safe because a measurement via this route may increase the risk of body fluid exposure. The tympanic membrane is an easily accessible site for temperature measurement but care should be taken when used in neonates, infants, and children.

skin and axilla

how do you find cardiac output

the product of the heart rate and the stroke volume of the ventricle

Which statement is true for collaborative problems in a client receiving healthcare? They are the identification of a disease condition. They include problems treated primarily by nurses. They are identified by the primary healthcare provider. They are identified by the nurse during the nursing diagnosis stage.

they are identified by the nurse during the nursing diagnosis stage

how do you take temps for clients who abuse sedaatives or hypnotics?

thorax, forehead

-A client with a history of persistent cough, hemoptysis, unexplained weight loss, fatigue, night sweats, or fever may have a _______ -_________ are risks to be assessed in the client with a history of tobacco or marijuana use -________ may be present in a client with a persistent cough (productive or nonproductive), sputum streaked with blood, or voice changes

-HIV or tb -lung cancer or cerebrovascular disease -cardiopulmonary alterations

Which age-related change should the nurse consider when formulating a plan of care for an older adult? Difficulty in swallowing Increased sensitivity to heat Increased sensitivity to glare Diminished sensation of pain Heightened response to stimuli

-increased sensitivity to glare -diminished sensation of pain

-toddler heartbeat = -infant heartbeat = -preschooler heartbeat = -adolescent heartrate =

-toddler heartbeat = 90-140 -infant heartbeat = 120-160 -preschooler heartbeat = 80-110 -adolescent heartrate = 60-90

-Paronychia is an abnormality of the nail bed. The condition is marked by inflammation of the skin at the base of the nail; this condition may be caused by _____ or a _____ infection -_______ is associated with red or brown linear streaks in the nail bed -________ can cause changes in the angle between nail and nail base, which is a phenomenon known as clubbing -Koilonychia, a concave curvature of the nails, may occur as a result of ________

-trauma or local infection -trichinosis -pulmonary diseases -iron-deficiency

blood pressures of what ages? -110/65 -95/65 -105/65 -119/75

12 yr old 1 yr old 6 yr old 14-17 yr old

The nurse is performing a breast assessment. Which statement made by the client indicates the risk of breast cancer? "I had a late onset of menarche." "My first child was born when I was 32." "I noticed a slight discharge from a nipple." "I perform breast self-examinations frequently." "I consume two to four glasses of alcohol a day."

2, 3, 5

how do you find pulse pressure?

The difference between the systolic and diastolic pressure is called the pulse pressure

-loss of turgor -decreased night vision -______ rib mobility -______ sensitivity to odor

decreased, decreased; normal findings of older adults

-The 1:1 ratio of the anteroposterior diameter and transverse diameter of the chest indicates a barrel-shaped chest. This is a characteristic feature in an older adult who smokes and has chronic ____ disease. -In lordosis, there is an increase in lumbar curvature. -Osteoporosis is a systemic skeletal condition in which there is a decreased bone mass and deterioration of bone tissue.

lung

when is chronic illness the greatest (age)?

older adults

While performing a physical assessment in a client, the registered nurse (RN) notices reddish linear streaks in the nail bed. Which systemic condition can the registered nurse (RN) suspect in the client based on these assessment findings? Syphilis Iron deficiency anemia Subacute bacterial endocarditis Chronic obstructive pulmonary disease

subacute

(1) ________ nerve helps in lateral movement of the eyeballs; damage to this nerve limits lateral movement of the eyeball (2) Injury to the ______ nerve causes changes in visual acuity (3) injury to the ______ nerve results in loss of facial expressions and loss of taste perception from the anterior one third of the tongue (4) injury to the ______ nerve limits the extraocular movements and pupillary responses.

-abducens nerve (VI) -optic nerve -facial nerve -oculomotor

-______ is an excessive outward curvature of the spine that causes hunching of the back _______ is the excessive inward curvature of the lumbar part of the spine -_______ is the abnormal lateral curvature of the spine -______ is characterized by a loss of bone mass and a deterioration of bone tissues

-kyphosis -lordosis -scoliosis -osteoporosis

A registered nurse is teaching a nursing student about when a client with high blood pressure should follow up with the primary healthcare provider. Which statement made by the nursing student indicates effective learning? "I will advise a client with a blood pressure of 130/80 mm Hg to follow up in a year." "I will advise a client with a blood pressure of 110/70 mm Hg to follow up in a year." "I will advise a client with a blood pressure of 150/90 mm Hg to follow up in a month." "I will advise a client with a blood pressure of 185/115 mm Hg to follow up in a month." Eugene off target So close! A client with prehypertension tends to have a blood pressure (BP) between 120/80 and 139/89 mm Hg. These clients should be rechecked in a year. Clients with BP less than 120/80 mm Hg are considered normal. These clients should be rechecked in two years. Clients with stage 1 hypertension have a BP between 140/90 and 159/99 mm Hg. These clients should be rechecked in two months to confirm stage 1 hypertension. Clients with stage 2 hypertension have a BP greater than 160/100 mm Hg. These clients should be rechecked in one month. If a client's BP is greater than 180/110 mm Hg, then he or she should be treated immediately or within 1 week.

# 1

-inflating or deflating the cuff too slowly will yield false _____ readings -wrapping the cuff too loosely will result in false _____ values -applying the stethoscope too firmly will result in false ______ readings -repeating the assessment too quickly will result in false _____ readings

-high diastolic -high systolic and diastolic -low diastolic -high systolic

The registered nurse is teaching a nursing student about ways to minimize heat radiation. Which statements made by the nursing student indicate effective learning? Select all that apply. "I will apply an ice pack to the client." "I will cover the client with dark clothes." "I will instruct the client to remove extra clothes." "I will instruct the client to lie in the fetal position." "I will advise the client to wear sparsely woven clothes."

-apply ice pack -cover client w dark clothes -instruct client to fetal position

-In the given figure, the nurse is assessing the ulnar pulse of the client. This procedure helps to evaluate ______ insufficiency to the hand -The radial pulse is used to assess the ___________ -The popliteal artery, which is present behind the knee, may be assessed to evaluate ______ -The brachial pulse is used to note the _____

-arterial insufficiency -heart rate -aneurysms and PVS -blood pressure

-Clients experiencing ________ present with extremities that become pale when elevated and dusky red when lowered. Lower extremities may also be cool to touch, pulses may be absent or mild, and skin may be shiny and thin with decreased hair growth and thickened nails. -Clients with ________ often have normal-colored extremities, normal temperature, normal pulses, marked edema, and brown pigmentation around the ankles. -________ is an inflammation of a vein that occurs most often after trauma to the vessel wall, infection, and immobilization. -________ is swelling in one or more extremities that is a direct result of impaired flow of the lymphatic system.

-arterial insufficiency -venous insufficiency -phlebitis -lymphedema

order them (diagnostic reasoning process)

-assess pt's health status -validate data with other sources -interpret and analyze meaning of data -cluster data -look for defining characteristics -identify pt needs -formulate nursing dx

While assessing a client, a nurse finds that the ratio of the anteroposterior diameter and transverse diameter of the chest is 1:1. What is indicated by this finding? Select all that apply. Client has lordosis. Client is an older adult. Client has osteoporosis. Client has a history of smoking. Client has chronic lung disease.

-client has lordosis -client has osteoporosis -client has a history of smoking

The nurse is gathering a client's health history. Which information does should the nurse classify as biographical information? Symptoms Client's age Family structure Type of insurance Occupation status

-client's age -type of insurance -occupation status

(1) identified by the nurse; if the client's health problem requires treatment by other disciplines such as medical or physical therapy, the client has a ______ (2) a _______ is the identification of a disease condition; problems that require treatment by the nurse are referred to as ______ diagnoses. A medical diagnosis is identified by the primary healthcare provider based on the results of diagnostic tests

-collaborative problems -medical diagnosis -nursing diagnoses

-a delayed immune response that occurs 12 to 48 hours after exposure -skin condition that can be worsened with excessive drying -immediate allergic reaction that occurs due to chemicals that are used to make gloves. -immediate allergic reaction that occurs due to natural rubber latex

-contact dermatitis -eczema -hypersensitivity -anaphylactic shock

-The client is experiencing a relapse while attempting to make behavioral changes to his or her lifestyle. When relapse occurs, the client returns to the _______ stage before attempting to change again. -The ______ stage lasts for up to six months during which the client is actively engaged in strategies to change behavior -During the ________ stage, the client begins to believe that advantages outweigh disadvantages of behavior change -the ________ stage begins six months after the change has started and continues indefinitely.

-contemplation or precontemplation -action -preparation -maintenance

-A client with _______ has a sweet, fruity odor to the breath -_______ is marked by halitosis - stale urine smell indicates ________ -An infection _______ is accompanied by a musty odor of the casted body part.

-diabetic acidosis -gum disease -uremic acidosis -infection inside cast

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult, the nurse recalls what expected sensory losses associated with aging? Select all that apply. Difficulty in swallowing Diminished sensation of pain Heightened response to stimuli Impaired hearing of high frequency sounds Increased ability to tolerate environmental hea

-diminished sensation of pain -impaired hearing of high frequency sounds

Which site should be monitored for a pulse to assess the status of circulation to the foot? Carotid artery Femoral artery Popliteal artery Dorsalis pedis artery Posterior tibial artery

-dorsalis pedis artery -posterior tibial artery

A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? Dry cerumen Tears in the tympanic membrane Difficulty hearing high pitched voices Decrease of hair in the auditory canal Overgrowth of the epithelial auditory lining

-dry cerumen -difficulty hearing high pitched voices

-Developing and participating in meaningful activities and satisfaction with past accomplishments increase feelings of self-worth. -Achievement of a personal philosophy is a task of _______ -Adaptation to the children leaving home is a task of ________ -Adjustment to life in an assisted-living facility is not a developmental task of older adults; not all older adults live in assisted-living facilities.

-early adulthood -middle adulthood

-_______ diseases such as hirsutism will result in excessive hair growth on the upper lip, chin, and cheeks. -Aging and poor nutrition will result in decreased hair growth. -_______ insufficiency will result in decreased hair growth due to compromised blood supply.

-endocrine -arterial insufficiency

(1) a condition that responds to nursing interventions (2) describes the essence of the client's response to health conditions (3) describes the characteristics of the client's response to health conditions (4) identified from the client's assessment data and associated with the dx

-etiology of a nursing dx -diagnostic label -NANDA-1 approved diagnoses -related factor of a nursing dx

sxs of orthostatic hypotension

-fainting -lightheaded -weakness

What are the benefits of using standard formal nursing diagnostic statements? Fosters development of nursing knowledge Allows nurses to communicate with the client Provides precise definition of the client's problem Distinguishes the nurse's role from that of other care providers Enables the primary healthcare provider to deliver effective health care

-fosters development of nursing knowledge -provides precise definition of the client's problem -distinguishes the nurse's role from that of other care providers

-Inflating or deflating the cuff too slowly will yield false _____ -Wrapping the cuff too loosely will result in false _____ -Applying the stethoscope too firmly will result in false _____ -Repeating the assessment too quickly will result in false ______

-high diastolic -high systolic and diastolic -low diastolic -high systolic

-bulging eyes may indicate ________ -_______ are characterized by abnormal eye protrusions -______ can be revealed by the coarseness of the hair of the eyebrows and the failure of the eyebrows to extend beyond the temporal canthus -crossed eyes or strabismus may result from _______ injury or inherited abnormalities.

-hyperthyroidism -tumors -hypothyroidism -NM injury

-______ controls the body temperature; damage may cause abnormalities in the body temperature values during a physical assessment -_______ is responsible for maintaining level of consciousness -_______ controls heart rate and breathing -_______ performs motor and sensory functions.

-hypothalamus -pons -medulla -thalamus

While assessing a client's hair, a nurse notices that the client has head lice. The nurse teaches the client about hair hygiene and lice control. Which statements made by the client indicates an understanding of the teaching? "I will clean my comb in ammonia water." "I should use lindane-containing shampoo." "I should shampoo my hair in a tub or shower." "I should use a dilute vinegar solution to loosen the nits." "I should use a shampoo treatment once every 24 hours."

-i will clean my comb in ammonia water -i should use a dilute vinegar solution to loosen the nits -i should use a shampoo treatment once every 24 hours

(1) alteration in breathing process characterized by increased and abnormal deep/regular rate of respiration (2) abnormally low respiratory rate and the depth of ventilation is depressed (3) respirations are abnormally shallow for 2 or 3 breaths, followed by irregular periods of apnea (4) an irregular respiratory rate and depth characterized by alternating periods of apnea and hyperventilation (5) normal rate and depth of respiration is interrupted while singing

-kussmaul's respiration -hypoventilation -biot's respiration -cheyne-stokes respiration -eupnea

-position is used to assess heart function; client with asthma or other respiratory problems may not tolerate it -position is used to assess the heart, thorax, and lungs; this position should be avoided in physically weakened clients. -position is used to assess the heart, abdomen, extremities, and pulses. -position is used for an abdominal assessment and to assess the head, neck, and lungs.

-lateral recumbent -sitting -supine -dorsal recumbent

Which sites would the nurse prefer while assessing for turgor in an older adult? Back of the neck Back of the hand Palm of the hand On the sternal area Back of the fore arm

-on the sternal area -back of the fore arm

-Red and dry skin is associated with ______ abuse -A client with _______ abuse will have burns on the skin -Vasculitis is associated with ______ abuse -Diaphoresis is associated with chronic abuse of _________.

-phencyclidine abuse -alcohol abuse -cocaine abuse -sedative hypnotics

*sleep deprivation symptoms:* Ptosis and blurred vision Agitation and hyperactivity Confusion and disorientation Increased sensitivity to pain Decreased auditory alertness

-ptosis and blurred vision -decreased auditory alertness

-fever spikes and falls without returning to normal temperature levels. -periods of febrile episodes coupled with periods of acceptable temperature values are called _______ -constant body temperature continuously above 38° C (100.4° F) with little fluctuation refers to a ______ -fever spikes are interspersed with normal temperature levels.

-remittent pattern -relapsing pattern -sustained pattern -intermittent patter

-A client with _______ will experience severe diarrhea, abdominal cramps, and vomiting; these symptoms last as long as 5 days after the intake of contaminated food; the causative organism is usually present in such foods as eggs, salad dressings, and sandwich fillings. -A client with _______ will experience severe diarrhea, fever, headache, pneumonia, meningitis, and endocarditis 3 to 21 days after infection. -The symptoms of _______ range from cramps and diarrhea to a fatal dysentery that lasts for 3 to 14 days. -Pain, vomiting, diarrhea, perspiration, headache, fever, and prostration lasting for 1 or 2 days are the symptoms of a ______

-salmonella -listerosis -shigellosis -staph infection

(1) pinpoint red dots that indicate areas of bleeding under the skin (2) vascular birthmark; often fades over time (3) patchy loss of skin pigmentation

petechiae red birthmark vitiligo

A nurse is teaching a client about measures to promote health. Which statements made by the client indicate effective learning? "I will assess my own pulse rate after exercising." "I will follow my hypertension treatment plan consistently." "I will recalibrate my aneroid sphygmomanometer once a year." "I will perform a self-assessment of my heart rate using the carotid pulse." "I will ask my caretaker to check my blood pressure at a different time every day."

1, 2, 4

he nurse recognizes that which are important components of a neurovascular assessment? Orientation Capillary refill Pupillary response Respiratory rate Pulse and skin temperature Movement and sensation

2, 5, 6 (others are for neurologic assessment)

pulse chart: (1) strong pulse (2) bounding pulse (3) normal/expected (4) diminished/barely palpable

3+ 4+ 2+ 1+

calculate BMI

Body mass index (BMI) can be calculated by dividing the client's weight in kilograms by the height in meters squared.

A registered nurse is teaching a nursing student about the third heart sound (S 3). Which statement given by the nursing student indicates a need for further education? "S 3 is heard in clients with heart failure." "S 3 is normal in pregnant women." "S 3 is abnormal in adults over 31 years of age." "S 3 is normal in children and young adults."

S3 is normal in pregnant women (false)

A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client? Alkalosis Renal failure Hypervolemia Pulmonary edema

pulmonary edema

What clinical finding indicates to the nurse that a client may have hypokalemia? Edema Muscle spasms Kussmaul breathing Abdominal distention Eugene off target So close! Hypokalemia diminishes the magnitude of the neuronal and muscle cell resting potentials. Abdominal distention results from flaccidity of intestinal and abdominal musculature. Edema is a sign of sodium excess. Muscle spasms are a sign of hypocalcemia. Kussmaul breathing is a sign of metabolic acidosis.

abdominal distension

A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin; decreased hair growth; and thickened toenails. What might this indicate? Venous insufficiency Arterial insufficiency Phlebitis Lymphedema

arterial insufficiency

-Symptoms of _______ include a shiny and taut appearance of the abdominal skin -Cyanosis occurs when there is a bluish discoloration of the skin -Accidental injury and different types of bleeding disorders are characterized by bruises or needle marks on the skin.

ascites

-A client with severe malabsorption disorder requires _______ nutrition -Clients with a neoplasm, anorexia nervosa, or inflammatory bowel disease will require ______ nutrition.

parenteral enteral

initial sign of hypocalcemia?

paresthesias

The nurse has just arrived in the unit for her shift at the healthcare facility. There are two new clients admitted to the unit. What should the nurse do first to collect the first set of information about the clients assigned to his or her care? Meet the clients' family. Read the clients' medical reports. Participate in the bedside rounds. Visit the clients and introduce self.

participate in bedside rounds

A client with severe bleeding due to a motor vehicle accident was admitted to the emergency department. The nurse assessed that the client was unconscious and the healthcare provider diagnosed the client with a hand fracture. The client is receiving oxygen therapy as well as intravenous fluids through the antecubital fossa. Which sites should be used to obtain the client's pulse rate? Apical Carotid Brachial Femoral Popliteal Eugene off target So close! Clients with severe bleeding may develop hypovolemic shock. The carotid and femoral pulses are easily accessible sites to measure pulses in clients with hypovolemic shock. The apical pulse may not be palpable in a client with hypovolemic shock. Because the client is diagnosed with a hand fracture and is receiving intravenous fluids through the antecubital fossa, the brachial artery cannot be accessed to measure the pulse rate. The popliteal site is used to assess the status of the circulation in the lower leg.

carotid, femoral

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful? Correct1 Clear breath sounds 2 Positive pedal pulses Incorrect3 Normal potassium level 4 Decreased urine specific gravity

clear breath sounds

Softening of the nail bed and enlarged finger tips with flattened nails are signs of ______

clubbing

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

contact dermatitis

While assessing a neonate's temperature, the nurse observes a drop in the body temperature. What is the most appropriate reason for this temperature drop? Increased basal metabolic rate Decreased involuntary shivering Increased voluntary movements Decreased nonshivering thermogenesis

decreased nonshivering thermogenesis

A nursing student under the supervision of a registered nurse is performing a pulse assessment. While preparing to assess the client, the registered nurse asks the nursing student to check the apical pulse after assessing the radial pulse. What could be the reason behind for this change? The client may have a dysrhythmia The client may have physiologic shock The client underwent surgery earlier in the day The cient may have peripheral artery disease

dysrhythmias

If the client's arm is unsupported, or if the arm is below the heart level, the resulting outcome is a _________ reading. Application of the stethoscope too firmly against antecubital fossa will result in a _______ reading. Repeated assessments of blood pressure too often result in a ______ reading. Deflating the cuff too slowly results in a _________ reading.

false high? false high diastolic? false high systolic false high diastolic

While assessing a client with dehydration, the nurse notices diminished skin elasticity. Which portion of the hand is used to perform this assessment? Correct1 Fingertips 2 Pads of fingertips Incorrect3 Ulnar surface of hand 4 Palmer surface of finger pads

fingertips

which feature is a characteristic of a risk nursing diagnosis?

has NO related factors

headaches and SOB = ____ sxs

hypertension

The nurse recognizes that a common conflict experienced by older adults is the conflict between what? Youth and old age Retirement and work Independence and dependence Wishing to die and wishing to live

independence and dependence

what can cause concave nail curvature?

iron deficiency anemia or syphilis

A nurse is discussing weight loss with an obese individual with Ménière disease. Which suggestion by the nurse is most important? Limit intake to 900 calories per day. Enroll in an exercise class. Get involved in diversionary activities when there is an urge to eat. Keep a diary of all foods eaten each day.

keep a diary of all foods eaten each day

The nurse is performing a skin assessment of a client. Which findings in the client may indicate a risk of skin cancer? Lesion Lumps Rashes Bruising Dryness

lesion, lumps, rashes

After recovery from a modified neck dissection for oropharyngeal cancer, the client receives external radiation to the operative site. For which most critical reaction to the radiation should the nurse assess the client? Dry mouth Skin reactions Mucosal edema Bone marrow suppression

mucosal edema (effect of radiation)

sxs of ____: -brittle hair -flaky skin -beefy red tongue -bleeding gums

nutritional deficiency

-_______ is a condition defined by rapid, involuntary, rhythmical oscillation of the eyes. This condition is caused by local injury to the eye muscles and supporting structures. -A cataract is a condition in which the opacity of the lens will be increased; this disorder is commonly related to age. -Glaucoma is intraocular structural damage resulting from elevated intraocular pressure. -Strabismus is a congenital condition in which both eyes do not focus on an object simultaneously. In this condition, the eyes appear crossed.

nystagmus

Nurses care for clients in a variety of age groups. In which age group is the occurrence of chronic illness the greatest? Older adults Adolescents Young children Middle-aged adults

older adults

A registered nurse (RN) is instructed to assess the body temperature of a neonate. Which site for placing the thermometer is contraindicated in these clients? 1 Axilla Correct2 Oral cavity 3 Temporal artery

oral cavity

-Receptive and expressive aphasia are the two types of aphasia. A client with receptive is unable to understand written or verbal speech. A client with expressive aphasia understands written and verbal speech but cannot write or speak appropriately. -A client with aphasia may not have the mental ability to give feedback; asking for feedback is ineffective. -Asking the client to read simple sentences aloud is an effective way of dealing with this client. -Pointing to a familiar object and asking the client to name it is also effective. -A client with aphasia can understand simple verbal commands.

read over

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? Skeletal and nervous Circulatory and urinary Respiratory and urinary Muscular and endocrine

respiratory and urinary

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock? Respirations of 10 Urine output of 30 mL/hour Lethargy Restlessness

restlessness

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? Spoon-shaped nails Transverse depressions in nails Softening of nail beds and flat nails Red or brown linear streaks in nail bed

softening of nail beds and flat nails

-client may have cochlea deterioration -thickening of tympanic membrane -inability to hear high-frequency sounds -inability to differentiate b/w consonants

someone receiving aminoglycoside therapy

how do you find apical pulse if you know radial and pulse deficit?

the difference b/w the two

beau lines?

transverse depressions in nails indicating a temporary disturbance of nail growth

(1) small blisterlike elevation on skin with serous fluid (2) lesion filled with purulent drainage (3) erosion into dermis (4) solid mass of fibrous tissue

vesicle pustule excoriation/ulcer papule