NU271 EAQ Evolve Elsevier NU271 HESI Prep: Fundamentals - Health and Physical Assessment

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

o Attainment of a sense of worth as a person · 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 early adulthood. Adaptation to the children leaving home is a task of middle adulthood. 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.

A client suffers hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. Which is/are the best site(s) to assess this condition? Select all that apply. One, some, or all responses may be correct. o Lips o Sclera o Mouth o Sacrum o Nail beds o Shoulders

o Lips o Mouth o Nail beds · Prolonged hypoxia resulting in increased amounts of deoxygenated blood causes cyanosis, which can be best evaluated in lips, mouth, nail beds, and skin (in extreme conditions). Sclera is the site of assessment for jaundice, whereas shoulders are assessed to confirm the condition of erythema.

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

o Percussion · Percussion is the process of tapping the body parts with the fingers or hands to determine the consistency and borders of the body organs. Palpation is the act of feeling with the hand by applying pressure to the body surface to determine the condition of the skin and underlying tissues. Inspection is the process of visual observation of the body during physical examination. Auscultation means to listen to the internal sounds of the body.

The nurse suspects that a client has interacted with poison ivy because assessment findings reveal vesicles on the arms and legs. Which is the description of a vesicle? o A lesion filled with purulent drainage o An erosion into the dermis o A solid mass of fibrous tissue o A lesion filled with serous fluid

o A lesion filled with serous fluid · A vesicle is a small blister like elevation on the skin containing serous fluid. Vesicles are usually transparent. Common causes of vesicles include herpes, herpes zoster, and dermatitis associated with poison oak or ivy. A lesion filled with purulent drainage is known as a pustule, an erosion into the dermis is known as an excoriation or ulcer, and a solid mass of fibrous tissue is known as a papule.

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

o Increased heart rate · Prolonged exposure to the sun or a high environmental temperature overwhelms the body's heat-loss mechanisms. These conditions cause heat stroke, which manifests as giddiness, excessive thirst, and nausea. An increased heart rate (HR) characterizes a heat stroke. A low blood pressure (BP), increased respiratory rate, and increased circulatory and tissue damage are not indicators of heat stroke.

The nurse is performing a skin assessment. Which illustration may represent a tumor?

· A solid mass that extends deep through the subcutaneous tissue may indicate a skin tumor called an epithelioma (as seen in the first figure). A palpable, circumscribed, solid elevation in the skin indicates the formation of a papule (as seen in the second figure). An elevated solid mass that is deeper and firmer than a papule indicates the formation of a nodule (as seen in the third figure). A circumscribed elevation of the skin that is similar to a vesicle but filled with pus indicates a pustule (as seen in the fourth figure).

The 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 a result of which? o A food allergy o Noncompliance with medications o Side effects from medications o A nutritional deficiency

o A nutritional deficiency · All of the signs listed are classic for a poor nutritional state lacking in basic nutrients such as vitamins and protein. A specific food allergy or medication is not described; therefore there is not enough information to assume the signs and symptoms are related to either or to noncompliance with medications.

The student nurse prepares a concept map while caring for a client. Which would be the first step that the student nurse would take when preparing the concept map? o Assess the client and gather information. o Arrange cues into clusters that form patterns. o Identify patterns reflecting the client's problem. o Identify specific nursing diagnoses for the client.

o Arrange cues into clusters that form patterns. · A concept map is a visual representation of the connection between the client's many health problems. The first step is to arrange all the cues into clusters that form patterns. This helps the nurse identify specific nursing diagnoses for the client. During the assessment stage, the nurse assesses the client and gathers information. This step is performed before preparing the concept map. After placing all cues into clusters, the nurse begins to identify patterns reflecting the client's problem. The concept map helps the nurse obtain a holistic view of the client's needs. The next step is to identify specific diagnoses so that appropriate nursing interventions can be provided.

Which activity by the community nurse is an illness prevention strategy? o Encouraging the client to exercise daily o Arranging an immunization program for chicken pox o Teaching the community about stress management o Teaching the client about maintaining a nutritious diet

o Arranging an immunization program for chicken pox · An illness prevention program protects people from actual or potential threats to health. A chickenpox immunization program is an illness prevention program. It motivates the community to prevent a decline in health or functional levels. A health promotion program encourages the client to maintain his or her present levels of health. The nurse promotes the health of the client by encouraging the client to exercise daily. Wellness education teaches people how to care for themselves in a healthy manner. The nurse provides wellness education by teaching about stress management. The nurse promotes the health of the client by teaching the client to maintain a nutritious diet.

While assessing a neonate's temperature, the nurse observes a drop in the body temperature. Which would be the reason for this temperature drop? o Increased basal metabolic rate o Decreased involuntary shivering o Increased voluntary movements o Decreased nonshivering thermogenesis

o Decreased nonshivering thermogenesis · Neonates are susceptible to heat loss or cold stress. Nonshivering thermogenesis is a natural mechanism of heat production that occurs to minimize heat loss in a neonate. This mechanism's failure may lead to a drop in body temperature. The basal metabolic rate (BMR) accounts for heat production; an increased BMR may raise the body temperature. Shivering is an involuntary movement that produces heat, which may not be seen in neonates. Voluntary movements cause increases in body temperature.

While assessing the client's skin, the nurse notices a skin condition. The nurse realizes the pathophysiology involves increased visibility of oxyhemoglobin caused by an increased blood flow due to capillary dilation. Which skin condition is associated with this client? o Pallor o Vitiligo o Cyanosis o Erythema

o Erythema · Erythema occurs due to an increased visibility of oxyhemoglobin, which is caused by increased blood flow. Pallor is caused by a reduced amount of oxyhemoglobin or a reduced visibility of oxyhemoglobin. Vitiligo is a pigmentation disorder caused by autoimmune diseases. Cyanosis is a bluish discoloration of the skin around the lips; this occurs due to an increased amount of deoxygenated hemoglobin in the blood.

Which would the nurse do when the defining characteristics of assessment data for a client can apply to more than one diagnosis? Select all that apply. One, some, or all responses may be correct. o Reassess the client. o Reject all diagnoses. o Gather more information. o Identify related factors. o Review all defining characteristics

o Gather more information. o Identify related factors. o Review all defining characteristics · The nurse must gather more information to clarify interpretations of assessment data. The correct interpretation of information allows the nurse to select the proper diagnosis that applies to the client. A related factor is a condition or etiology that gives a context for the defining characteristics. The nurse would identify related factors to individualize a nursing diagnosis for the client. The nurse would review all of the defining characteristics, eliminate irrelevant ones, and confirm the relevant ones. The nurse must interpret the data to form data clusters only after reassessing and validating them. At this stage, the nurse would have only validated assessment data in the database. The nurse need not reject all of the diagnoses. The nurse would review all of the defining characteristics to support or eliminate the irrelevant ones.

A client has a history of a persistent cough, hemoptysis, unexplained weight loss, fatigue, night sweats, and fever. Which risk would be assessed? o Lung cancer o Cerebrovascular disease o Cardiopulmonary alterations o Human immunodeficiency virus (HIV) infection

o Human immunodeficiency virus (HIV) infection · A client with a history of persistent cough, hemoptysis, unexplained weight loss, fatigue, night sweats, or fever may have a human immunodeficiency virus (HIV) infection or tuberculosis. Lung cancer and cerebrovascular disease are risks to be assessed in the client with a history of tobacco or marijuana use. Cardiopulmonary alterations may be present in a client with a persistent cough (productive or nonproductive), sputum streaked with blood, or voice changes.

Which food would the nurse recommend to a client when instructing to increase potassium intake? Select all that apply. One, some, or all responses may be correct. o Onion o Celery o Orange o Cheese o Oatmeal

o Orange · Oranges and other citrus fruits contain potassium. Onions, celery, cheese, and oatmeal do not contain potassium in any significant amounts.

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

o Percuss and palpate in the hypogastric region. · To detect a distended bladder, percussion and palpation should be performed over the hypogastric region of the abdomen. Percussion of a distended bladder would produce a dull sound and feel firm on palpation. Inspecting and palpating in the epigastric region, auscultating and percussing in the inguinal areas, or percussing and palpating bilaterally in the lumbar areas are all inaccurate procedures to assess for a distended bladder.

Arrange the hierarchy of needs in ascending order beginning with the highest priority needs as defined by Maslow. o Physiological needs o Safety and security o Love and belonging needs o Self-esteem o Self-actualization

o Physiological needs o Safety and security o Love and belonging needs o Self-esteem o Self-actualization · Maslow's hierarchy of needs helps the nurse understand the interrelationships of basic human needs. These basic needs are a major factor in determining a person's level of health. The first level includes basic physiological needs such as oxygen, fluids, nutrition, body temperature, elimination, shelter, and sex. The second level is safety and security needs, which involve physical and psychological security. The third level is the need of love and belonging. The fourth level encompasses self-esteem needs. The fifth level is the need for self-actualization. It is the highest expression of one's individual potential and allows for continual discovery of self.

An older adult reporting a headache, nosebleed, and fatigue arrives at the hospital. The nurse instructs the nursing assistive personnel (NAP) to measure blood pressure using the one-step method. Arrange the sequence of events in order. o Place stethoscope earpieces in the ears and be sure the sounds are clear. o Relocate the brachial artery and place the bell or diaphragm chest piece of the stethoscope over it. o Close the pressure bulb value and quickly inflate the cuff to 30 mm Hg above the client's systolic pressure. o Slowly release the pressure bulb valve and allow the needle of manometer gauge to fall at a rate of 2 to 3 mm Hg/sec. o Note the point on the manometer when you hear first clear sound. o Continue to deflate the cuff, noting the point at which muffled or dampened sound appears.

o Place stethoscope earpieces in the ears and be sure the sounds are clear. o Relocate the brachial artery and place the bell or diaphragm chest piece of the stethoscope over it. o Close the pressure bulb value and quickly inflate the cuff to 30 mm Hg above the client's systolic pressure. o Slowly release the pressure bulb valve and allow the needle of manometer gauge to fall at a rate of 2 to 3 mm Hg/sec. o Note the point on the manometer when you hear first clear sound. o Continue to deflate the cuff, noting the point at which muffled or dampened sound appears. · During the one-step method, the stethoscope earpieces are placed in the ears, and the nursing assistive personnel (NAP) should be able to hear the sounds clearly. Then, the brachial artery is relocated, and the bell or diaphragm chest piece of the stethoscope is placed over it. The valve of the pressure bulb should be closed, and the cuff should be inflated quickly to 30 mm Hg above the client's systolic pressure. After inflation, the pressure bulb valve should be released slowly, and the needle of the manometer gauge is allowed to fall at a rate of 2 to 3 mm Hg/sec. Then the NAP should note the point on the manometer when the first clear sound is heard. The cuff should be further deflated, and the NAP should note the point when muffled or dampened sounds appear.

A client complains of pain in the ear. While examining the client, the nurse finds swelling in front of the left ear. Which lymph node would the nurse expect to be involved? o Mastoid o Occipital o Submental o Preauricular

o Preauricular · The preauricular lymph node is located in front of the ear and in this situation would be edematous. The mastoid or posterior auricular lymph node is present behind the ear. The occipital lymph nodes are located in the back of the head, near the occipital bone of the skull. Submental lymph nodes are located below the chin.

Where is the nurse positioned when performing a Romberg test? o Sitting next to the client o Standing behind the client o Standing in front of the client o Standing to the side of the client

o Standing to the side of the client · The nurse would be standing to the side of the client when performing a Romberg test because the client is most likely to sway side to side. Sitting does not safely position the nurse to rescue an unbalanced client. Standing behind or in front of the client is not optimal for safety because the client is most likely to sway side to side.

Which assessment would the nurse exclude when dealing with a client with receptive and expressive aphasia? o Ask the client to read simple sentences aloud. o Point to a familiar object and ask the client to name it. o Test the mental status by asking for feedback from the client. o Ask the client to respond to simple verbal commands such as "stand up."

o Test the mental status by asking for feedback from the client. · Receptive and expressive aphasia are the two types of aphasia. A client with receptive aphasia 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.

In which situation would the nurse consider family members as the primary source of information? Select all that apply. One, some, or all responses may be correct. o The client is an older adult. o The client is an infant or child. o The client is brought in as an emergency. o The client is critically ill and disoriented. o The client visits the outpatient department.

o The client is an infant or child. o The client is brought in as an emergency. o The client is critically ill and disoriented. · The nurse interviews the parents who care for the infant or child. Thus the parents become the primary source of information. A client who is brought to the emergency department may not be in a position to explain the circumstances that led to the visit. In this case the family or significant others who accompany the client become the primary source of information. The family becomes the primary source of information when the client is critically ill, disoriented, and unable to answer questions. Generally, the client is the primary source of information. The older adult who is conscious, alert, and able to answer the nurse's questions is the primary source of information. The client who visits the outpatient department is capable of providing accurate answers to the nurse's questions. This client is the primary source of information during assessment.

The nurse is caring for a client who has lost an arm in a motor vehicle accident. Which reaction cues the nurse to realize that the client is in the withdrawal phase of adjusting to the change in body image? o The client is going through a grieving period. o The client talks as if another person is affected. o The client is willing to learn techniques to adapt. o The client recognizes the reality and becomes anxious.

o The client recognizes the reality and becomes anxious. · The client with a change in body image after an injury recognizes the reality of the change, becomes anxious, and refuses to discuss it. This client uses withdrawal as an adaptive coping mechanism. During the acknowledgement phase, the client and family go through a grieving period as they acknowledge the change in physical appearance. At the end of the acknowledgement phase, they learn to accept the loss. Initially, the client is in a state of shock and depersonalizes the change. The client talks as if another person is affected by the change. The client in the rehabilitation stage is ready to learn how to adapt to the change in body image through use of prosthesis or changing lifestyles and goals.

The nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. Which type of pain would the client experience? o Visceral pain o Somatic pain o Referred pain o Intractable pain

o Visceral pain · Visceral pain arises from visceral organs such as the pancreas, which results from the stimulation of pain receptors in the abdominal cavity. Somatic pain arises from bone, joint, muscle, skin, or connective tissue and is usually aching or throbbing in quality and well localized. Referred pain is experienced in clients with tumors, in which pain is felt in a part of the body other than its actual source. Intractable pain is a neuropathic pain that is severe, constant pain that is not curable.