Health Assessment Hesi

A clients tells the nurse about not being able to sleep for several nights. What will the nurse most likely assess in this client?

Slurred speech, flat facial affect, red conjunctiva

a maladaptive response to the Generativity vs. Stagnation psychosocial developmental stage results in a nursing diagnosis of what?

Social Isolation. rationale: the client has likely distanced from others and isolated from society.

When assessing a child with meningitis, which finding would indicate the presence of Kernig's sign?

The inability of the child to extend the legs fully when lying supine.

The nurse is preparing to test the sensory function of cranial nerve V in a client. The nurse should obtain which item to test the sensory function of this nerve?

Trigeminal nerve (V) use a whisp of cotton to softly run along the cheek and see if the client can feel it equally on both sides

a client with elevated BP (145/90) on 3 different occasions is diagnosed with hypertension. What other test is indicated for the client at this time?

Urinalysis

The number one MOST effective way to lower blood pressure is what?

Weight loss

whispered pectoriloquy

a whispered phrase heard through the stethoscope that sounds faint and inaudible over normal lung tissue. can be heard over areas of consolidation.

egophony

abnormal change in tone of voice that is heard when auscultating the lungs by saying "E". Over consolidated tissue the "E" will be heard with a nasal quality, like a goats bleating.

The nurse assesses a client with hepatic encephalopathy for the presence of asterixis. what would the nurse do to appropriately test for asterixis?

asterixis is a rapid, nonrhythmic, abnormal muscle tremor of he wrists and fingers commonly referred to as "liver flap" have the patient extend the wrists and fingers to test for it.

A tuning fork would be used to assess

cranial nerve VIII (the acoustic nerve).

The nurse should ask a client to take which action when testing the function of the spinal accessory nerve (CN XI)?

elevate the shoulders

the nurse is monitoring the neuro status on a client with dementia and assessing the limbic system. Which would the nurse assess to yield the best info about this area of functioning?

emotions. feelings and emotions are part of the role of the limbic system.

when do we expect to hear Cheyne-Strokes respirations

end-of-life, brain injuries, congestive heart failure, carbon monoxide poisoning.

when a client has an upper respiratory infection, it is most likely that their lymph nodes will be:

enlarged and soft submandibular lymph nodes. Enlarged and tender anterior cervical lymph nodes.

Glasgow Coma Scale

eyes: open spontaneously (4 pts) opens in response to voice (3) Opens in response to pain (2) does not open eyes (1) Verbal: oriented and participates in spontaneous conversation (5) speaks but confused and disoriented (4) single words (3) makes sounds (2) no sounds (1) Motor: obeys commands (6) localizes to pain (5) withdrawls in response to pain (4) abnormal flexion in response to pain (3) abnormal extension in response to pain (2) no response to pain (1)

signs of chronice pancreatitis

flatulence, dull skin, brittle nails, hair loss, recurrent epigastric pain that radiates to the left lumbar

brudzinski's sign

flexion of the hips when the neck is flexed from a supine position. (Common in meningitis)

manifestations of hypothyroidism

hair loss, slow heart rate, dry skin, cold extremities

assessment of ular nerve

have client spread all fingers wide and resist pressure.

assessment of the radial nerve

move the thumb toward the palm and back

eupnea

normal breathing pattern

loss of sensation where would indicate postential nutritional deficiencies?

over the lower extremities

symptom of vasculitis

palpable red spots that do not blanch when pressure is applied (petechiae or purpura)

signs of hypoparathyroidism?

presents with symptoms of hypocalcemia (parkinsonism, carpal spasm when assessing bp)

assessment of cutaneous nerve

raise the forearm above the head assesses the flexion of the biceps and determines the status of the cutaneous nerve.

borborgmi

rumbling or gurgling noises produced by the movement of gas, fluid, or both in the gastrointestinal tract

cranial nerve XII test

stick out the tongue (Hypoglossal)

How does Toxoplasmosis occur?

through ingestion of raw meat or contact with contaminated cat feces.

The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis?

tongue, nail bed, mucus membranes

altruism

unselfish regard for the welfare of others

Deficiency in which nutrients can cause anemia?

Iron, Vit B9, Vit B12, Vit E.

A clients nails are thin, depressed and concaved. How would the nurse document this finding?

Koilonychia

Elevated ST wave and crushing chest pain would indicate?

MI

Murphy's sign

Pain with palpation of gall bladder (seen with cholecystitis) Sudden stop of inhalation in the middle of a breath during deep palpation of URQ

The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How should the nurse best determine the presence of erythema?

Palpate for increased skin temperature around the wound edges.

An older male client experiences difficulty with extending the 4th and 5th finger of the left hand. What should the nurse do to obtain more info about this clients condition?

Palpate the clients palm to assess for nodules and thickening. rationale: Dupuytren contracture is a connective tissue disorder that results in fibrosis of the palmar fascia. Typically affecting older males of european descent, clients will have difficulty extending the 4th and 5th finger.

Which assessment technique would the nurse use when determining lung border changes during respiration

Percussion of the lower posterior lung fields.

What is the best methos for assessing a client for a pericardial friction rub?

Place the diaphragm of the stethoscope over the left sternal border

Conversion

when a psychiatric problem is expressed as physical symptoms. Ex. a client develops arm paralysis after a stressful event.

Cranial nerve I

(the olfactory nerve) is assessed by testing the sense of smell (using a non-noxious aromatic substance such as coffee beans) in a client who reports the loss of smell

sublimation (defense mechanism)

- Rechanneling of drives or impulses that are personally or socially unacceptable into activities that are constructive. EX: Mom of son killed by drunk driver, president of MADD.

Undoing: Defense Mechanism

- Symbolically negating or canceling out an experience that one finds intolerable. EX: Joe is nervous about his new job and yells at his wife. On his way home he stops and buys her flowers.

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply. 1. Set the room temperature at a comfortable level. 2.Remove distracting objects from the interviewing area. 3.Place a chair for the client across from the nurse's desk. 4.Ensure comfortable seating at eye level for the client and nurse. 5.Provide seating for the client so that the client faces a strong light. 6.Ensure that the distance between the client and nurse is at least 7 ft (2.1 meters).

1, 2, 4 When preparing the physical environment for an interview, the nurse should set the room temperature at a comfortable level. The nurse should provide sufficient lighting for the client and nurse to see each other. The nurse should avoid having the client face a strong light because the client would have to squint into the full light. Distracting objects and equipment should be removed from the interview area. The nurse should arrange seating so that the nurse and client are seated comfortably at eye level, and the nurse avoids facing the client across a desk or table because this creates a barrier. The distance between the nurse and the client should be set by the nurse at 4 to 5 ft (1.2 to 1.5 meters).

The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems? Select all that apply. 1.Allergy to pollen 2.History of headaches 3.Previous back injury 4.History of hypertension 5.History of diabetes mellitus

2, 3, 4, 5 Previous neurological problems such as headache or back injury place the client at greater risk for development of a neurological disorder. Chronic diseases such as hypertension and diabetes mellitus also place the client at greater risk. Assessment for allergies is a routine part of the health history, regardless of the nature of the client's problem.

The emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion? 1.Poor hygiene 2.Difficulty walking 3.Fear of the parents 4.Bald spots on the scalp

2. Abuse is the nonaccidental physical injury or the nonaccidental act of omission of care by a parent or person responsible for a child. It includes neglect and physical, sexual, or emotional maltreatment. Sexual abuse can involve incest, molestation, exhibitionism, pornography, prostitution, or pedophilia. Many times the findings associated with sexual abuse may not be easily apparent in the child. The most likely assessment findings in sexual abuse include difficulty walking or sitting; torn, stained, or bloody underclothing; pain, swelling, or itching of the genitals; and bruises, bleeding, or lacerations in the genital or anal area.

After a sprain, how long should we apply ice and not heat to the injury?

24 hrs.

The nurse is conducting a neurological assessment, including a health history, on a client with a neurological disorder. The nurse observes that the client is having difficulty answering the questions and should perform which action? 1.Ask a second nurse to be present during the interview. 2.Defer both the health history and the neurological examination. 3.Defer the health history and proceed with the neurological examination. 4.Ask the client to give permission for a family member to stay during the interview.

4 The health history and physical assessment for a client with a neurological problem are very similar to those for any other client, with perhaps a more intense neurological examination. If the client is confused or agitated or has difficulty hearing or speaking, the nurse should ask the client to give permission for a family member or significant other to stay with him or her during the history taking to ensure accurate data. Deferring the health history and/or neurological examination will not obtain the assessment data. Having a second nurse present is of no benefit.

When assessing the client for influenza, how should the nurse collect a specimen for culture?

Insert the swab into a nare quickly running parallel to the palate to reach a depth of 8cm, then rotate.

the best time to preform a self breast exam is?

5-7 days after the end of your period.

what is a T-tube and where is it located?

A biliary drain inserted following a cholecystectomy. used to insert contrast into the biliary tract during surgery and typically 5-10 days following surgery. So the surgeon can evaluate for stenosis or obstruction of the common bile duct, fistulas, leaking, or remaining calculi.

A client with a history of type 2 diabetes mellitus is admitted with weight loss, malaise, and lethargy. Which assessment findings indicate that the client is experiencing hyperosmolor hyperglycemic state (HHS)? a. blood glucose 700 mg/dL b. resp rate 28 c. urine ketones 3+ d. pH 7.21 e. Serum osmolality 395 mOsm/Kg

A, E Blood glucose 700 mg/dL and Serum Osmolality 395 mOsm/Kg

an older male client reports mild aching pain and occasional swelling in the groin area. What is the next step in the assessment of this client?

Ask the client to strain while holding his breath. Rationale: these are manifestations of an inguinal hernia. Asking the client to perform the Valsalva maneuver will produce a visible bulge.

Cheyne-Stokes

Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia

Ptosis

Drooping eye.

What is the cauda equina syndrome?

Due to injury of lumbosacral nerve roots in spinal canal. Leads to areflexic bladder, bowel, and lower limbs.

A client is admitted for evaluation of painless puple lesions over the arms, legs, and face. What lab test would be indicated first for this client?

HIV rapid antibody test because these are signs of Kaposi sarcoma

during an examination of a client's respiratory system, the nurse asks the client to state repeatedly the number 99. what is the nurse assessing with this technique?

bronchophony. rationale: the clients voice will be heard clearly over areas of consolidation (absess, pleural effusion, pneumonia) q

when assessing client for compartment syndrome the nurse should assess for this

cap refill less than 3 seconds

A client with otitis media reports feeling something "pop" inside the ear. What does this information suggest to the nurse?

clients eustachian tubes collapsed

chest pain located at the sternal border that intensifies when palpating?

costochondritis. Give Ibuprofen

onychomycosis

fungal infection of the nail

Assessment of the medial nerve

have the client grasp the nurses hand and assess the strength of the first two fingers.

the nurse interprets which observation is related to the dysfunction of cranial nerve III?

Ptosis of the eyelid is caused by pressure on and the dysfunction of cranial nerve III, the oculomotor nerve.

The nurse prepares to take the blood pressure of a school-age child. To obtain an accurate measurement, how should the nurse position the blood pressure cuff?

Two thirds of the distance between the antecubital fossa and the shoulder

Sleep apnea is often accompanied by metabolic syndrome with causes

high blood sugars

Apraxia

inability to perform particular purposive actions, as a result of brain damage.

What is Orchitis?

inflammation of one or both testicles that can be caused by bacterial (moth common is Neisseria gonorrhoeae) in men. Or mumps. Tx = supportive care and antibiotics if bacterial orchitis.

what is tangential lighting?

lighting shined laterally to the surface. This technique casts a shadow.

The nurse is assessing for the presence of pallor in a dark-skinned client. What finding should the nurse look for?

loss of normal red tones in the skin

Flaky, crusty, erythematous skin around the areola can be what?

mammary Paget disease. can be an underlying sign of breast cancer.