HESI

Which Korotkoff sound represents the diastolic pressure in children?

Fourth

The nurse is assessing four infants. Which infant does the nurse anticipate to be of abnormal weight?

Infant 2 age = 5 months weight at birth = 3.3 kg current weight = 8.5 kg

A client is admitted to the hospital after an accident. The nurse uses the Glasgow Coma Scale (GCS) with the client. The client is alert and opens his or her eyes when there is a sound or when someone talks. When questions are asked, the client answers in a confused manner. The client obeys commands, such as being asked to move a leg. What would be the client's total score? Record your answer using a whole number. ___________

13

Which questions should the nurse ask the client when obtaining the health history? Select all that apply

"Tell me about your food habits." "Do you use alcohol or tobacco?" "Have you ever experienced any allergic reactions?"

Which nursing intervention is employed to encourage the client to fully reveal the nature of their health problem?

2 The nurse leans forward attentively during the discussion.

A nurse is assessing several clients. Which client will require parenteral nutrition?

4 A client with severe malabsorption disorder Clients with a brain neoplasm, anorexia nervosa, or inflammatory bowel disease will require enteral nutrition.

A nurse is assessing four different clients. Which findings depict that the client is at risk for heart disease?

client 2

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?

Arterial Insufficiency

Which sites would the nurse prefer while assessing for turgor in an older adult?

On the sternal area Back of the fore arm

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?

oral

A nurse is teaching a client about measures to promote health. Which statements made by the client indicate effective learning? Select all that apply.

"I will assess my own pulse rate after exercising." "I will follow my hypertension treatment plan consistently." I will perform a self-assessment of my heart rate using the carotid pulse.

with different levels of impaired vision are given below: Which client is expected to be diagnosed with macular degeneration? 1. Client A: impaired near vision 2. Client B: loss of central vision 3. Client C: cross appearance of eyes 4. Client D: inability to see distant objects

2. Client B: loss of central vision Client B's loss of central vision is caused by macular degeneration. Impaired near vision in client A is due to presbyopia or hyperopia. Strabismus is a congenital condition in which both eyes do not focus on an object simultaneously; this results in the cross appearance of eyes, as seen in client C. Client D's inability to see distant objects is caused by myopia.

Which site should be monitored for a pulse to assess the status of circulation to the foot? Select all that apply.

Dorsalis pedis artery Posterior tibial artery

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?

Diminished sensation of pain Impaired hearing of high frequency sounds

Which finding is inferred from a grade 4 intensity of heart murmurs?

Loud murmur associated with thrill Grade 4 indicates loud murmurs with an associated thrill. A thrill is a fine vibration that is felt by palpation. A grade 5 intensity is characterized by an easily palpable thrill. A grade 2 intensity is characterized by quiet and clearly audible murmurs. A moderately loud murmur without a thrill is noted as grade 3.

A 50-year-old client with a 30-year history of smoking reports a chronic cough and shortness of breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen saturation of 80%. Which vital signs obtained by the nurse during the therapy indicates a positive outcome? Select all that apply.

Respiratory rate: 14 Blood pressure: 110/70 Oxygen saturation: 92% The respiratory rate ranges in older adults from 12 to 20 breaths/min and this range may be elevated in clients with chronic obstructive pulmonary disease (COPD). Thus a rate decrease to 14 breaths/min indicates a positive outcome. COPD may also cause high blood pressure. Thus, a blood pressure of 110/70 obtained during therapy indicates a positive outcome. The normal oxygen saturation rate should be 95 to 100%. An oxygen saturation increase from 88% to 92% indicates a positive outcome of the therapy. The radial pulse indicates a positive outcome of the therapy if the client has a history of heart disease. A body temperature reading of 36.8 °C is considered normal and not a sign of COPD.

A registered nurse is teaching a nursing student how to assess for edema. Which statement made by the student indicates the need for further education?

4 "If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given

While auscultating the heart, a healthcare provider notices S3 heart sounds in four clients. Which client is at more risk for heart failure?

3 Older adult client The S3 is the third heart sound heard after the normal "lub-dub." It is indicative of congestive heart failure in adults over 30 years old. In young, pregnant, and under 30 year old clients, the third heart sound is often considered to be a normal parameter.

The community nurse is assessing an elderly client who lives alone at home. The nurse finds that the client refrains from physical activity for fear of falling when walking. Which interventions by the nurse are most beneficial to promote a healthy lifestyle? Select all that apply. 1 Instruct the client to apply bed side rails. 2 Encourage the client to wear nonskid shoes. 3 Suggest that the client use an assistive device. 4 Ask the client to install hand rails in the bathroom. 5 Help the client rearrange furniture in the house.

2 Encourage the client to wear nonskid shoes. 3 Suggest that the client use an assistive device. 5 Help the client rearrange furniture in the house.

A registered nurse is teaching a nursing student about the third heart sound (S3). Which statement given by the nursing student indicates a need for further education? 1 "S3 is heard in clients with heart failure." 2 "S3 is normal in pregnant women." 3 "S3 is abnormal in adults over 31 years of age." 4 "S3 is normal in children and young adults."

2 The third heart sound (S3) can be heard when the heart attempts to fill an already distended ventricle. This sound may be common and normal in the last stages of pregnancy, but not in all stages. This sound may be heard in heart failure clients. The S3 sound is abnormal in adults over the age of 31. This sound is normally heard in children and young adults.

The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The nurse should monitor for what complication associated with this type of surgery?

3 Expectoration of blood

The nurse is caring for a client who has lost an arm in a motor vehicle accident. Which reaction made by the client leads the nurse to realize that the client is in the withdrawal phase of adjusting to the change in body image?

4 The client recognizes the reality and becomes anxious

The nurse administers a pneumococcal vaccine to a 70-year-old client. The client asks "Will I have to get this every year like I do with the flu shot?" How should the nurse respond?

4. "It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose."

While performing a physical assessment of a client, a nurse notices patchy areas with loss of pigmentation on the skin, hands, and arms. What is the probable etiology for this condition? 1. Anemia 2. Pregnancy 3. Lung disease 4. Autoimmune disease

4. Autoimmune disease Patchy areas with loss of pigmentation on skin, hands, and arms are due to vitiligo, which is caused by an autoimmune or congenital disease. Anemia results in pallor due to a reduced amount of oxyhemoglobin. A tan-brown color of the skin is noticed in pregnancy due to an increased amount of melanin. Lung disease or heart failure can cause cyanosis due to an increased amount of deoxygenated hemoglobin.

A 78-year-old client who has hypertension is beginning treatment with furosemide. Considering the client's age, what should the nurse teach the client to do?

Change positions slowly

A mother is worried about the sudden behavioral changes in her child. The child has suddenly developed a fear of certain people and places. The child's school performance is declining rapidly, and the child has developed poor relationships with his or her peers. After assessing the physical findings of the child, the nurse suspects child abuse. Which physical findings might have led the nurse to this suspicion?

Foreign bodies in the rectum, urethra, or vagina.

A client develops an allergic reaction when a student nurse is performing a physical assessment. Which statement made by the student nurse in response to this incident indicates the need for further teaching?

The client's first exposure to latex will cause a type IV allergic reaction.

The nurse is assessing a client who reports breathlessness. Which activity best ensures that the nurse obtains accurate and complete data to prevent a nursing diagnostic error? Assess the client's lungs. Assess the client for pain. Obtain details of smoking habits. Ask about the onset of breathlessness.

assess the client's lungs The nurse should assess the client's lungs to gather objective data that will support subjective data provided by the client. The nurse can obtain objective data for this client by auscultating for lung sounds, assessing the respiratory rate, and measuring the client's chest excursion. The nurse should review the data for accuracy and completeness before grouping the data into clusters. The nurse may also assess the client for pain, which is subjective data. The client may provide details about smoking habits, which is also subjective data. It is important for the nurse to identify what causes breathlessness; however, the client's statement is subjective data. All subjective data must be supported by measurable objective data.

A client who has been admitted to the hospital with chest pain complains of shortness of breath, weakness, and vomiting. The nurse suspects cardiac arrest. Which site is the most appropriate place to check the client's pulse rate?

femoral

The nurse is overseeing a nursing student who is conducting an assessment of a client who does not speak English. No interpreter is available. Which action requires further teaching? 1 Using medical terminology 2 Proceeding in an unhurried manner 3 Speaking in a low and moderate voice 4 Pantomiming words and simple actions while verbalizing them

1 Nurses should follow certain guidelines when interpreter is not available while assessing a client who does not understand English. Rather than using medical terminology, the nursing student should use simple, more well-known words, like "pain" instead of "discomfort." The nursing student's other actions are appropriate. Proceeding in an unhurried manner; speaking in a low, moderate voice; and pantomiming words and simple actions while verbalizing them promote effective communication.

Which clients suffer from impaired near vision? Select all that apply. 1 A client with myopia 2 A client with presbyopia 3 A client with hyperopia 4 A client with retinopathy 5 A client with macular degeneration

2 3 A loss of elasticity of the lens causes impaired near-vision in presbyopia. Light rays focusing behind the retina are the cause of impaired near vision in clients with hyperopia. Myopia is caused by a refractive error where the light rays focus in front of the retina. Retinopathy is a noninflammatory change in the retinal blood vessels. Macular degeneration is a blurring of central vision caused by progressive degeneration of the central retina.

Which parts of the body should be assessed for temperature in clients who abuse sedatives or hypnotics? Select all that apply. 1 Axillae 2 Thorax 3 Forehead 4 Oral cavity 5 Rectal area

2 3 Diaphoresis (excessive perspiration) is an abnormal condition noticed in clients as a result of the substance abuse of sedatives and hypnotics. For this case, the temperature should be primarily assessed in the forehead or upper thorax. The axillae, oral cavity, and rectal area are the regularly preferred site for assessing body temperature in those that do not abuse sedatives or hypnotics.

Which anatomic area is palpated if the nurse suspects aortic abnormalities?

4 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. The left second intercostal space is the pulmonic area. In this area, deeper palpation is required to feel the spaces in obese or heavily muscled clients. After the pulmonic area, the lower left sternal border of the third intercostal space is called the second pulmonic area. The tricuspid area is located at the fourth or fifth intercostal space along the sternum.

Cheyne-Stokes respiration?

In Cheyne-Stokes respiration, a client's breathing pattern is characterized by progressively deeper and faster breathing, that is, hyperventilation followed by apnea. Client 3 exhibits this type of respiration. Client 1's breathing pattern indicates bradypnea, while client 2 exhibits tachypnea. Client 4 is exhibiting Biot's respirations.

A pregnant woman in her second trimester arrived at the hospital for a general health checkup. The physician recommended a pelvic examination to the client. Which position is most suitable for assessing the client in this condition?

Lithotomy position provides maximum exposure to the female genitalia and easy examination of the region. Therefore this position is recommended for examining pregnant women. Sims position is indicated for rectal and vaginal examinations. Supine position is recommended for examining anterior thorax, lungs, breasts, axilla, heart abdomen, extremities, and pulse. Dorsal recumbent position is mainly indicated to examine the abdomen because it promotes abdominal relaxation.

A client is admitted to the hospital with severe diarrhea, abdominal cramps, and vomiting after eating. These symptoms have lasted 5 days. Upon further assessment, the primary healthcare provider finds that the symptoms occurred after the client ate eggs, salad dressings, and sandwich fillings. Which food borne disease would be suspected in this client?

Salmonellosis

While assessing a client's skin, a nurse notices that the skin is dry. What is the probable etiology of the condition? Select all that apply.

Use of hard soap Frequent bathing

Which position is used to assess the extension of the hip joint and buttocks?

prone