246 HESI Review
What type of scale is used to measure pressure ulcers?
*The Braden Scale uses a scores from less than or equal to 9 to as high as 23. The lower the number, the higher the risk for developing an acquired ulcer/injury. *19-23 = no risk *15-18 = mild risk *13-14 = moderate risk *less than 9 = severe risk
A client with an acute respiratory infection is admitted to the hospital with a diagnosis of sinus tachycardia. Which nursing action should be included in the client's plan of care? 1.Limiting oral and intravenous fluids 2.Measuring the client's pulse each shift 3.Providing the client with short, frequent walks 4.Eliminating sources of caffeine from meal trays
4.Eliminating sources of caffeine from meal trays
*While assessing the legs of a female client, the nurse observes leathery-looking skin. The client reports aching tired legs that swell if she stands for long periods of time. To screen for venous insufficiency, the nurse should ask the client if she has experienced which subject finding? A. Decreased pain when legs are elevated. B. Deep, continuous pain in the calf muscles. C. Cool, pale skin below the knees. D. Painful symptoms alleviated by warmth.
A. Decreased pain when legs are elevated.
*The nurse is obtaining a health history for a client during an annual physical examination. When evaluating the client for menopausal symptoms, which finding indicates the client is perimenopausal? A. Drenching night sweats. B. Excessive vaginal moisture. C. Increase in sexual desire. D. Cessation of menstruation.
A. Drenching night sweats.
Which is an example of data a nurse collects during a physical examination? A. The patient's lack of hair and shiny skin over both shins B. The patient's stated concern about lack of money for prescriptions C. The patient's complaints of tingling sensations in the feet D. The patient's mother's statements that the patient is very nervous lately
A. The patient's lack of hair and shiny skin over both shins
*A client presents with "cough." Which question by the nurse is likely to elicit the most information regarding a client's use of medications? A. What medications are you currently taking? B. Have you tried any generic brands of cough syrup? C. Have you been prescribed any medications for your cough? D. What medications have you used for your cough?
A. What medications are you currently taking?
*A patient reports smoking 1 pack of cigarettes per day for 30 years. The nurse reports this as: a.15 pack years b.30 pack years c.365 pack years d.10,950 pack years
B. 30 pack years multiple # PPD x number years smoked
*A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I have lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this body-wracking dry cough that has been hanging around for the last six weeks." Which computer documentation of this client's concerns should the nurse enter? *A. Presents with a hacking non-productive cough of 6 weeks duration. B. Describe having a "body-wracking dry cough" of 6 weeks duration. C. Expresses concern of "lung cancer" symptoms for last 6 weeks. D. Young adult male presents with fears that he has "lung cancer"
B. Describe having a "body-wracking dry cough" of 6 weeks duration.
*The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? (Select all that apply) A. Osteopenia. B. Kyphosis. C. Atrophy. D. Contracture. E. Crepitus
B. Kyphosis. C. Atrophy. D. Contracture.
* A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a muffled voice. Which complication should the nurse suspect? A. Foreign body obstruction. B. Laryngeal polyps. C. Peritonsillar abscess. D. Nasal polyps
C. Peritonsillar abscess.
*A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds? A. Use the bell of the stethoscope to listen to the lung fields over lower lobes. B. Have the client lay flat while listening to the anterior surface of the chest. C. Press the stethoscope's diaphragm firmly on the skin over each lung field. D. Shave all chest hair that may distort sounds heard through the diaphragm.
C. Press the stethoscope's diaphragm firmly on the skin over each lung field.
Leading questions may initiate untrue or inaccurate responses because such questions: A.Encourage short or vague answers B.Require an educational level the patient may not possess C.Prompt the patient to try to give a particular answer D.Confuse the patient
C.Prompt the patient to try to give a particular answer
A patient comes to the emergency department and tells the triage nurse that he is "having a heart attack." What is the nurse's top priority at this time? A. Determine the patient's personal data and insurance coverage. B. Ask the patient to take a seat in the waiting room until his name is called. C. Request that a nurse collect data for a comprehensive history. D. Ask a nurse to start a focused assessment of this patient now.
D. Ask a nurse to start a focused assessment of this patient now.
A client reports to the healthcare provider's office for a routine post-surgical evaluation six weeks after a hysterectomy. Which history-taking approach should the nurse use to gather the needed information? A. Conduct a comprehensive review of systems. B. Perform a head-to-toe physical assessment. C. Prepare to collect a vaginal specimen for Papanicolaou smear. D. Collect information about the client's activities since surgery.
D. Collect information about the client's activities since surgery.
The nursing process offers a framework to identify needs, create a plan of care, and determine the effectiveness of interventions. Which of the following stages of the nursing process involves the assessment of which interventions were successful and which ones were not? a.Assessment b.Diagnosis c.Planning d.Evaluation
D. Evaluation
*The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating the spleen? * A. Pain notes when palpating McBurney's point. B. Nontender mass palpable in the RUQ. C. Rebound tenderness with compression over right lower quadrant. D. Firm mass palpated at bottom of left rib cage.
D. Firm mass palpated at bottom of left rib cage.
*A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response. Which interpretation of this finding is accurate? *A. A normal reflex response. B. Absent or sluggish response consistent with a lower motor neuron lesion. C. Flaccid paralysis. D. Hyperactive response consistent with an upper motor neuron disorder.
D. Hyperactive response consistent with an upper motor neuron disorder.
*The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or arterial insufficiency. Which assessment technique should the nurse use to differentiate the pathophysiology causing the ulcer? A. Measure the degree of join range of motion in the extremity. B. Compare the skin turgor of the client's upper and lower leg. C. Observe the specific location and appearance of the ulceration. D. Note any change in the color of the ulcer when the leg is moved
D. Note any change in the color of the ulcer when the leg is moved
*The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. What action should the nurse implement? *A. Offer to administer a laxative prescribed for PRN use. B. Obtain a prescription to catheterize the client's bladder. C. Instruct the client in distraction and relation techniques. D. Notify the healthcare provider of the rebound tenderness.
D. Notify the healthcare provider of the rebound tenderness.
A 24-year-old male patient tells the nurse he has had no energy for 2 weeks. He has no trouble falling asleep; in fact, he sleeps deeply about 12 hours every night. He states that he has gained 10 lb in the past 2 months and has no friends. The nurse associates these manifestations with which mental health disorder? a) Depression b) Schizophrenia c) Bipolar disorder d) Anxiety disorder
Depression
What is used to assess eyes?
Snellen Chart
Which description of pain from the patient makes a nurse suspect the patient's pain is originating from a muscle? a) "Crampy" b) "Dull and deep" c) "Boring and intense" d) "Sharp upon movement"
a) "Crampy"
While assessing a man during a physical examination for work, the nurse suspects alcohol use. Which assessment tool is appropriate in this situation? a) AUDIT screening tool b) Rapid eye test c) Mental status examination d) Holmes Social Readjustment Rating Scale
a) AUDIT screening tool
A patient reports having difficulty swallowing. Based on this information, how does the nurse assess the appropriate cranial nerve? a) Ask the patient to stick out the tongue and move it in all directions. b) Ask the patient to move the head to the right and left. c) Observe the symmetry of the face when the patient talks. d) Assess for taste on the anterior part of the tongue.
a) Ask the patient to stick out the tongue and move it in all directions.
A nurse assesses a patient with a head injury who has slowing intellectual functioning, personality changes, and emotional lability. The nurse correlates these findings with which area of the brain? a) Frontal lobe b) Parietal lobe c) Thalamus d) Temporal lobe
a) Frontal lobe
which client is at greatest risk for committing suicide? a. a client with metastatic cancer b. a client with a newly diagnosed cardiac disorder c. a client who just had an argument with the fiance d. a newly divorced client who states has custody of the children
a. a client with metastatic cancer
a client with a history of panic disorder comes to the ED and states to the nurse "please help me. i think i am having a heart attack" what is the priority nursing action? a. assess the client's vital signs b. identify the clients acitivity during the pain c. assess for signs related to a panic disorder d. determine the client's use of relaxation techniques
a. assess the client's vital signs
the nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. which assessment findings would the nurse expect to note? SATA a. dental decay b. moist, oily skin c. loss of tooth enamel d. electrolyte imbalances e. body weight well below ideal range
a. dental decay c. loss of tooth enamel d. electrolyte imbalances
the nurse is conducting a health history of a client with a primary diagnosis of heart failure. which conditions reported by the client could play a role in exacerbating the heart failure? SATA a. emotional stress b. AFIB c. nutrtional anemia d. peptic ulcer disease e. recent upper resp. infection
a. emotional stress b. AFIB c. nutrtional anemia e. recent upper resp. infection
the nurse in postanesthia care unit is monitoring a client for signs of bleeding after a rhinoplasty. which observation indicates to the nurse that bleeding may be occuring? a. frequent swallowing b. client complaints of discomfort c. ecchymosis around the client's eyes d. blood on the external nasal dressing
a. frequent swallowing
the nurse is performing an assessment on a client with a fiagnosis of left side heart failure, which assessmnet component would elicit specfic information regarding the clients left sided heart function? a. listening to lung sounds b. palpating for organomegaly c. assessing for JVD d. assessing for peripheral and sacral edema
a. listening to lung sounds
the home care nurse is visting an older client whose spouse died six months ago. which behaviors by the client indicate effective coping? SATA a. looking at old photographs of family b. participating in a senior citizens program c. neglecting personal grooming d. visiting the spouse's grave once a month e. decorating a wall with the spouses's pictures and awards received
a. looking at old photographs of family b. participating in a senior citizens program d. visiting the spouse's grave once a month e. decorating a wall with the spouses's pictures and awards received
the nurse is preparing to care for a burn client schedueld for an escahrotomy procedure being perofmed for a third degree dcircumferential arm burn. the nurse understand that which finding is the anticipated therapeutic outcome of the escharotomy? a. return of distal pulses b. brisk bleeding from the site c. decreasing edema formation d. formation of granulation tissue
a. return of distal pulses
the nurse is performing an assessment on a client with dementia. which piece of data gathered during the assessment indicates a manifestation associated with dementia? a. use of confabulation b. improvement in sleeping c. absence in sundown syndrome d. presence of personal hygenic care
a. use of confabulation
Which of the following characteristics are true regarding changes in the respiratory system of an older adult? a.Costal cartilages become calcified b.Thoracic expansion is increased c.Increase in the number of alveoli d.Increased residual volume e.Decreased vital capacity
a.Costal cartilages become calcified d.Increased residual volume e.Decreased vital capacity *Rationale: The costal cartilages become more calcified à the thorax is less mobile. The lungs are more rigid. Alveoli close off, which causes a decreased vital capacity (the max amount of air a person can expel from lungs) and an increased residual volume (amount of air remaining in lungs after a forceful expiration)
When assessing a patient's level of consciousness, what should the nurse assess first? a.Level of alertness b.Orientation to person c.Orientation to place d.Orientation to time
a.Level of alertness
Which findings does the nurse expect when assessing the mouth of a healthy adult? Select all that apply. a.Lips appear pink, smooth, moist, and symmetric b.Teeth are white, yellow, or gray, with smooth edges c.Slight roughness on the dorsum of the tongue d.Hard palate appears smooth, pale, and immovable e.Mucous membranes are dry and intact
a.Lips appear pink, smooth, moist, and symmetric b.Teeth are white, yellow, or gray, with smooth edges c.Slight roughness on the dorsum of the tongue d.Hard palate appears smooth, pale, and immovable
A nurse informs a patient that her blood pressure is 128/78. The patient asks what the number 128 means. What is the nurse's appropriate response? "The 128 represents the pressure in your blood vessels when: a) "The ventricles relax and the aortic and pulmonic valves open." b) "The ventricles contract and the mitral and tricuspid valves close." c) "The ventricles contract and the mitral and tricuspid valves open." d) "The ventricles relax and the aortic and pulmonic valves close."
b) "The ventricles contract and the mitral and tricuspid valves close.
A patient reports having abdominal distention. The nurse observes that the patient's sclerae are yellow. Which abnormal finding does the nurse anticipate on examination of this patient's abdomen? a) Decreased bowel sounds in all quadrants b) Glistening or taut skin of the abdomen c) Bulge in the abdomen when coughing d) Bruit around the umbilicus
b) Glistening or taut skin of the abdomen
A nurse is auscultating the lungs of a healthy male patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding? a) Make sure the bell of the stethoscope is used, rather than the diaphragm. b) Hold stethoscope firmly to prevent movement when placed over chest hair. c) Ask the patient not to talk while the nurse is listening to the lungs. Change the patient's position to ensure accurate sounds.
b) Hold stethoscope firmly to prevent movement when placed over chest hair.
When inspecting a patient's posterior wall of the pharynx and tonsils, a nurse documents which finding as abnormal? a) Both tonsils have a smooth surface. b) Left and right tonsils meet at the midline. c) Left and right tonsils extend beyond the posterior pillars. d) Both tonsils have a glistening appearance.
b) Left and right tonsils meet at the midline.
What is the most important nursing action to reduce transmission of microorganisms during a physical assessment? a) Clean the bell and diaphragm of the stethoscope between patients. b) Perform hand hygiene. c) Wear gloves when anticipating exposure to body fluids. d) Wear eye protection when anticipating spatter of body fluids.
b) Perform hand hygiene.
As a patient is walking down the hall, the nurse notices the patient's staggering, unsteady gait and suspects a cerebellar problem. What findings does the nurse anticipate on the neurologic examination? a) When the patient stands with feet together, eyes open and then closed, an upright posture is maintained. b) When the patient touches the end of each finger to the thumb of the same hand, a tremor is observed in the fingers. c) When the patient is giving a history to the nurse, a tremor is noticed as the patient's hands rest in the lap. d) When lying supine, the patient is able to move the heel of one foot down the shin of the other leg.
b) When the patient touches the end of each finger to the thumb of the same hand, a tremor is observed in the fingers.
A nurse assessing a patient with liver disease expects to find which manifestation during the examination? a) Yellowish color in the axilla and groin b) Yellow pigmentation in the sclera c) Very pale skin on the palms d) Ashen-gray color in the oral mucous membranes
b) Yellow pigmentation in the sclera
A patient tells the nurse, "I've been having gnawing pain in my upper belly for several weeks that is worse on an empty stomach." The nurse suspects: a)Gastroesophageal reflux disease b)Peptic ulcer disease c)Appendicitis d)Cholecystitis
b)Peptic ulcer disease
the nurse is performing an admission assessment on a client at high risk for suicide. which assessment question will best elicit data related to this risk? a. "what are you feeling right now?" b. "do you have a plan to commit suicide?" c. "how many times have you attemped suicide int he past?" d. "why were your attemps at suicide unsuccessful in the past?"
b. "do you have a plan to commit suicide?"
a 56 year old client with heart failure is taking digoxin for treatment of the health problem. the nurse ausculatates the clients apical HR before admin, digoxin and the HR is 52 bpm. the nurse would interpret this as? a. normal, because of age b. abnormal, requiring further assessment c. normal, as a result of digoxin d. normal, bc this is the reason he is getting digoxin
b. abnormal, requiring further assessment
a client with severe coronary artery disease who had cardiac surgeyr 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. the client received a single blous of 500 mL of IV fluid. urine output for the subsequent hour was 25 mL. daily lab results indicate that the BUN level is 45 mg/dL and the serum creatnine level is 2.2 mg/dL. on the basis of these findings, the nurse would anticipate that the client is at risk for which problem? a. hypovolemia b. acute kidney injury c. glomerulonephritis d. heart failure
b. acute kidney injury BUN levels 10-20 normal
Based on the picture, what is an appropriate nursing diagnosis for this client? a.Infection b.Fluid Volume Deficit c.Decreased Cardiac Output d.Acute Pain
b.Fluid Volume Deficit
A patient asks, "Why is touching my toes necessary? This is a sports physical examination, not exercise class." What is the most appropriate response by the nurse? a) "This is the best way to check for symmetry of your arms." b) "I am looking at the stretch of your ham strings." c) "This allows me to see how straight your spinal column is." d) "I am assessing the rotation of your spine."
c) "This allows me to see how straight your spinal column is."
When auscultating the heart of a patient with pericarditis, the nurse expects to hear which sound? a) A systolic murmur b) An S3 heart sound c) A friction rub d) An S4 heart sound
c) A friction rub
A patient complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what of the following findings will suggest that the cause of this patient's dyspnea is due to heart disease rather than respiratory disease? a) Increased anteroposterior diameter b) Clubbing of the fingers c) Bilateral peripheral edema d) Increased tactile fremitus
c) Bilateral peripheral edema
A nurse is assessing a patient's peripheral circulation. Which finding indicates venous insufficiency of this patient's legs? a) Paresthesias and weak, thin peripheral pulses b) Leg pain that is worsened by walking c) Edema that is worse at the end of the day d) Leg pain that decreases when the legs are lowered
c) Edema that is worse at the end of the day
Which nurse is performing the technique of light palpation appropriately? a) Nurse A applies the bimanual technique to determine size and location of the patient's heart. b) Nurse B uses the fingertips to feel for temperature differences on the patient's legs. c) Nurse C places the ulnar surface of the hands on the patient's thorax to detect vibrations. d)Nurse D depresses the patient's abdomen approximately 4 cm to assess pulsations.
c) Nurse C places the ulnar surface of the hands on the patient's thorax to detect vibrations.
A nurse is using the finger pads to palpate a patient's dorsalis pedis pulses and is unable to feel any pulses. Which action is appropriate for the nurse to perform next? a) Document that the dorsalis pedis pulses are not palpable. b) Have the patient stand and try again to palpate the pulses. c) Use a Doppler to detect the presence of the pulses. d) Palpate the dorsalis pedis pulses using the ulnar surface of the hand.
c) Use a Doppler to detect the presence of the pulses.
which piece of subjective data obtained during assessment of a severely anxious client would indicate the possibility of PTSD? a. "im always crying" b. "im afraid to go outside" c. "i keep reliving the abuse" d. " i keep washing my hands over and over"
c. "i keep reliving the abuse"
the nurse notes documentation that a newly admitted client experiences flashbacks. what diagnosis would this notation support? a. anxiety b. agoraphobia c. PTSD d. schizophrenia
c. PTSD
the nurse is assessing a client who has been admitted to the coronary care unit. the client seems to flucutate in the ability to focus during the day. on the basis of this assessment, which client problem would the nurse suspect? a. dementia as a result of isolation b. dementia as a result of substance intoxication c. acute confusion as a result of hopsital induced psychosis d. interruption in the family as a result of alcohol withdrawal
c. acute confusion as a result of hopsital induced psychosis
the nurse notes that a clients cardiac rhythm shows absent P waves, no PR interval, and an irregular rhythm. how would the nure interpret this rhythm? a. bradycardia b. tachycardia c. atrial fibrillation d. normal sinus rhythm (NSR)
c. atrial fibrillation
the nurse is caring for a client after the application of a plaster cast for a fractured left radius, the nurse would suspect umpairment with the neurovascular status of the client casted extremity if which findings are noted? SATA a. capillary refill less than 3 seconds b. pulses present and with swollen, pink fingers c. client report of severe, deep, unrelenting pain d. client report of pain as nurse assess finger movement e. client report of numbness and tingling sensation in the fingers
c. client report of severe, deep, unrelenting pain d. client report of pain as nurse assess finger movement e. client report of numbness and tingling sensation in the fingers
the nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. the nurse would assign priority to which assessment finding? a. tearful, self-isolated b. affect bland, withdrawn c. fist clenched, pounding table, fearful d. temperature 98.4, respirations 18 breaths/min
c. fist clenched, pounding table, fearful
a moderately depressed client who was hopsitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. the client says to the nurse "I'm finally cured." how would the nurse interpret this behavior as a cue to modify the treatment plan? a. suggesting a reduction in medication b. allowed increased "in room" activities c. increasing the level of suicide precautions d. allowing the client off-unit privileges as needed
c. increasing the level of suicide precautions
the nurse is caring for a client just admitted to the mental health unit the client is displaying immobile and mute behaviors and is withdrawn. the client is lying on the bed in a fetal position. which is the most appropriate nursing interventions? a. ask direct questions to encourage talking b. leave the client alone so as to minimize external stimuli c. sit beside the client in silence with occasional open ended questions d. take the client into the dayroom with other clients so that they can help watch the client
c. sit beside the client in silence with occasional open ended questions
the clinic nurse is performing an assessment on a client with a diagnosis of RA: the nurse checks for which assessment finding that is associated with RA? a. age of onset is generally 65 years of age or older b. complaint of pain that is more severe after activity c. system symptoms such as fatigue,a norexia, and weight loss d. joint pain as assymetrical and associated with past injuries to the joint
c. system symptoms such as fatigue,a norexia, and weight loss
*A client with a history of HIV comes to the outpatient clinic complaining of cough and chest pain with breathing. The nurse should first: a.Inspect for chest expansion and accessory muscle use. b.Retrieve a sputum sample to evaluate for hemoptysis c.Obtain data relating to a History of Present Illness d.Check CD4 count
c.Obtain data relating to a History of Present Illness
A 45-year-old woman tells the nurse she is distressed by the presence of dark, coarse hair on her face that has recently developed. What is the nurse's most appropriate response to this patient? a) "This is simple vellus hair and it will decrease in amount over time." b) "Some women in your cultural group normally have dark hair on their faces." c) "This is unusual; female hair distribution should be limited to arms, legs, and pubis." d) "Coarse dark hair could result from hormonal changes such as from menopause."
d) "Coarse dark hair could result from hormonal changes such as from menopause."
During a symptom analysis, a patient describes his productive cough and states his sputum is thick and yellow. Based on these data, the nurse suspects which factor as the cause of these symptoms? a) Virus b) Allergy c) Fungus d) Bacteria
d) Bacteria
A nurse is completing a symptom analysis with a patient complaining of chest pain. When asked what makes the chest pain worse, the patient reports that coughing and sneezing increase the chest pain. Based on these data, what does the nurse suspect as the cause of this patient's chest pain? a) Stable angina b) Esophageal reflux disease c) Mitral valve prolapse d) Costochondritis
d) Costochondritis
While taking a history, a nurse learns that this patient experiences shortness of breath (dyspnea). If the cause of the dyspnea is a cardiovascular problem, the nurse expects which abnormal finding on examination? a) Flat jugular neck veins b) Red, shiny skin on the legs c) Absent peripheral pulses d) Edema of the feet and ankles
d) Edema of the feet and ankles
What sound does a nurse expect to hear when using the bell of the stethoscope over the epigastric area of the abdomen of a healthy patient? a) Bowel sounds b) Venous hum c) Soft, low-pitched murmur d) No sounds
d) No sounds
During the history, a 65-year-old male patient reports smoking two packs of cigarettes a day for more than 40 years. With this knowledge, what should the nurse look for during the examination of this patient's mouth? a) Cracks and erythema in the corners of the mouth b) Slightly rough papillae on the dorsal surface of the tongue c) Smooth or beefy, red-colored, edematous tongue d) Painless, non-healing mouth ulcers
d) Painless, non-healing mouth ulcers
The nurse is assessing a patient's abdomen and suspects ascites. Which technique is used to confirm the presence of abdominal ascites? a) Auscultation of fluid movement within the abdominal cavity b) Palpation of rebound tenderness c) Palpation of pitting edema of the abdomen d) Percussion of dullness over dependent areas of the abdomen
d) Percussion of dullness over dependent areas of the abdomen
A patient has been complaining of abdominal cramping and gas; the nurse notes that his abdomen is slightly distended. Which sound does the nurse expect to hear during percussion of this patient's abdomen? a) Flatness b) Dullness c) Resonance d) Tympany
d) Tympany
When performing a skin assessment of an adult patient, the nurse expects what finding? a) Reddened area does not blanch when gentle pressure is applied b) Indentation of the finger remains in the skin after palpation c) Flaking or scaling of the skin d)Return of skin to its original position when pinched
d)Return of skin to its original position when pinched
A client is admitted to the hospital with a diagnosis of BPH, and a trasnurethral resection of the prostate is performed. four hours after surgery, the nruse takes the cleitns vital signs and empties the urinary drainage bag. which assessment finding indicates the need to notify the PHCP? a. red, bloody urine b. pain rated as 4/10 c. urine output of 150 ml higher than intake d. BP: 100/50mm Hg: Pulse 130 bpm
d. BP: 100/50mm Hg: Pulse 130 bpm sign of excessive blood loss
a client recovering from an exacerbation of left sided heart failure is experiencing activity intolerance. which change in vitals during activity would be the best indicator that the client is tolerating mild excercise? a. oxygen saturation decreased from 96% to 91% b. pulse rate increased from 80 to 104 bpm c. bp decreased from 140/86 to 112/72 mm hG d. RR increased from 16 to 19 bpm
d. RR increased from 16 to 19 bpm
the nurse is conducting health screening for osteoporosis. which client is at greatest risk of developing this disorder? a. a 25 year old woman who runs b. a 36 year old man who has asthma c. a 70 year old man who consumes excess alcohol d. a sedentary 65 year old woman who smokes ciagarettes
d. a sedentary 65 year old woman who smokes ciagarettes
the nurse is caring for a client with resolved intenstinal obstruction who has a NG tube in place. the PCP has now prescribed that the NG tube be removed. what is the priority nursing assessment prior to removing the tube? a. checking for normal serum electrolyte levels b. checking for normal pH of the gastric aspirate c. checking for proper NG tube placement d. checking for proper NG tube placement
d. checking for proper NG tube placement
the nurse is monitoring a hopsitalized client who abuses alcohol. which findings would alert the nurse to the potential for alcohol withdrawal delirium? a. hypotension, ataxia, hunger b. stupor, lethargy, muscle rigidity c. hypotension, coarse hand tremors, lethargy d. hypertension, changes in level of consciousness, hallucinations
d. hypertension, changes in level of consciousness, hallucinations
when would the nurse determine that it will be safe to remove the restraints from a client who demonstrated violent behavior? a. administered medication has taken effect b. the client verbalizes the reasons for the violent behavior c. the client apologizes and tells the nurse that it will never happen again d. no aggressive behavior has been observe for 1 hour afrter the release of two of the extremity restraints
d. no aggressive behavior has been observe for 1 hour afrter the release of two of the extremity restraints
the nurse preparing to admit a client with a diagnosis of OCD to the mental health unit would expect to note which behaviors in the client? a. sad and tearful b. suspicous and hostile c. frightened and delusional d. rigidness in thought and inflexibility
d. rigidness in thought and inflexibility
the nurse is caring for a client diagnosed with alzheimer's disease who is demonstrating characteristics of agnosia. which client behavior supports the presence of this cognitive deficiency? a. the client has difficulty with balance when rising from the chair b. the client has lost the cognitive ability to fold their own clothes c. the client recognizes children but has difficulty calling them by name d. when asked to pick up the cup, the client consistently fails to identify the cup
d. when asked to pick up the cup, the client consistently fails to identify the cup apraxia- inability to perform familar skilled activites
