HESI Module #2 Health Promotion and Disease Prevention

A Mexican-American client with epilepsy is being seen at the clinic for an initial examination. What is the primary purpose of including cultural information in the health assessment? a. determine what the client believes has caused the epilepsy b. confirm the medical diagnosis c. identify any hereditary traits related to the epilepsy d. make accurate nursing diagnoses

a

A nurse conducting an interview with a client collects subjective data. During the interview, which action should the nurse take? a. takes minimal notes to avoid impeding observation of the client's nonverbal behaviors b. Takes notes because this allows the nurse to break eye contact with the client, which may increase the client's level of comfort c. take notes to allow the nurse to shift attention away from the client, which may make the nurse more comfortable d. Takes a great deal of notes to allow the client to continue at his or her own pace as the nurse records what he or she is saying

a

A nurse has collected subjective and objective data from an African-American client who is at risk for cardiovascular disease. The client tells the nurse that he is a cigarette smoker, drinks "a beer or two" every day, and enjoys sitting around watching sports on television. Which piece of data does the nurse identify as an unmodifiable risk factor? a. the client is African American b. the client is a cigarette smoker c. the client drinks beer every day d. the client sits around watching television

a

A nurse is observing a new nurse employee performs an abdominal assessment. The nurse determines the new nurse employee requires additional instruction if which action is performed? a. uses the bell end of the stethoscope b. listens for 5 minutes before determining that bowel sounds are absent c. holds the stethoscope lightly against the skin d. auscultates prior to using the palpation technique

a

A nurse is performing a throat assessment on an assigned client. On asking the client to stick his tongue out, the nurse notes that it protrudes in the midline. Which of the following cranial nerves is the nurse testing? a. cranial nerve XII b. cranial nerve V c. cranial nerve X d. cranial nerve IX

a

A nurse is preparing to test cranial nerve 1. Which item does the nurse obtain to test this nerve? a. coffee b. a wisp of cotton c. a tuning fork d. an ophthalmoscope

a

A nurse is supervising a student in preparing the physical environment for an interview with a client. Which action by the student is correct? a. setting the room temperature at a comfortable level b. setting up seating so that the client and nurse are not at eye level c. providing seating for the client so that the client faces a strong light d. placing a chair for the client across from the nurse's desk

a

A nurse palpates a client's radial pulse, noting the rate, rhythm, and force, and concludes that the client's pulse is normal. Which notation would the nurse make in the client's record to document the force of the client's pulse? a. 2+ b. 4+ c. 1+ d. 3+

a

A nurse performing a skin assessment notes that the client's skin is very dry. How should the nurse document this finding? a. Xerosis b. Pruritus c. Actinic Keratoses d. Seborrhea

a

A nurse sees documentation in the client's record indicating that the nurse on a previous shift has noted the presence of adventitious breath sounds. The nurse interprets this information in which manner? a. these are abnormal sounds that should not be heard in the lungs of a health client b. these sounds are normally heard in the lungs c. rustling sounds heard over the peripheral lung fields are associated with bronchitis d. hollow sounds heard over the trachea and larynx indicate pneumonia

a

An adult client tells the clinic nurse that he is susceptible to middle ear infections. About which risk factor related to infection of the ears does the nurse question this client? a. exposure to cigarette smoke b. use of power tools c. loud music d. occupational noise

a

During a neurological assessment, the nurse asks the client to close the jaws tightly, after which the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of which cranial nerve? a. trigeminal nerve b. trochlear nerve c. oculomotor nerve d. abducens nerve

a

The nurse has demonstrated the technique for a surgical wound dressing change to the wife of a client who will be discharged after hip replacement surgery. Which action should the nurse take to best confirm that the wife understands the procedure? a. asking the wife to perform the dressing change b. asking the wife whether she has any questions about the procedure c. asking the wife whether she feels comfortable performing the procedure d. asking the wife whether she understands what items need to be obtained from the surgical supply store

a

The nurse is counseling the parents of a 5-year-old about environmental hazards. Which statement by the parent indicates the *need for further information* to prevent injury? a. "We have our water heater's temperature set at 140 F." b. "We always place our child in a safety car seat when we ride in the care." c. "We frequently check the smoke detectors in our home to be sure that they work." d. "I've taught my child about the importance of wearing a helmet when riding a bicycle."

a

A nurse at a health fair is conducting teaching sessions on dietary measures to help prevent cancer. Which foods should the nurse encourage clients attending the teaching sessions to eat as a means of preventing cancer? *Select all that apply* a. fruits b. red meats c. vegetables d. foods low in fiber e. high-nitrate foods

a and c

The nurse is participating in a planning session for public health services that promote primary prevention. The nurse should guide the group into selecting to focus on which aspects? *Select all that apply* a. immunizations b. pollution control c. an exercise regimen d. cardiac rehabilitation e. self-examination practices f. diabetes mellitus management

a, b and c

The nurse is admitting a client to the hospital. Which should be included in a discussion of the client's personal history? *Select all that apply* a. recent hospitalizations b. cause of parents' death c. health of the client's siblings d. previous history of bipolar disorder e. hypersensitivity reactions to medications

a, d, and e

Health promotion includes

activities directed at developing a client's resources for maintaining or enhancing well-being as a protection against illness.

Factors that affect a person's physiological, psychological, sociological or spiritual well-being

alter the level of wellness of the patient

A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment? a. complete (total) b. follow-up c. emergency d. problem-centered

b

A nurse conducting a peripheral vascular assessment performs the Allen test. The nurse understands that this test is used to determine the patency of which structures? a. pedal pulses b. radial and ulnar arteries c. capillaries d. femoral arteries

b

A nurse has provided information to a client about measure to prevent cardiovascular disease. Which statement by the client indicates a *need for further information*? a. "I need to reduce my salt intake." b. "I need to cut down on my smoking." c. "I need to start a regular exercise program." d. "I need to watch my weight and cut down on my saturated fat."

b

A nurse inspecting a client's throat touches the posterior wall with a tongue blade and elicits the gag reflex. The nurse documents normal function of which nerve? a. cranial nerve V b. Cranial nerves IX and X c. Cranial nerve XII d. Cranial nerves I and II

b

A nurse is auscultating for vesicular breath sounds in a client. Of which quality would the nurse expect these normal breath sounds to be? a. hollow b. rustling c. harsh d. tubular

b

A nurse is preparing to assist the HCP in performing an internal gynecological examination of a client. In which of the following positions does the nurse place the client for this examination? a. left side-lying b. lithotomy c. prone d. sims

b

A nurse is preparing to auscultate for the presence of bowel sounds in a client who has undergone surgery. The nurse places the stethoscope in which abdominal quadrant first? a. RUQ b. RLQ c. LLQ d. LUQ

b

A nurse listening to a client's chest to determine the quality of vocal resonance asks the client to repeat the word "ninety-nine" as the nurse listens through the stethoscope. As the client says the word, the nurse is able to hear the word clearly. The nurse documents this assessment finding which way? a. abnormal vesicular breath sounds b. abnormal bronchophony c. normal whispered pectoriloquy d. normal egophony

b

A nurse provides information to a client about measure to prevent infection with West Nile virus. Which statement by the client indicates a *need for further information*? a. "I need to avoid wooded or swampy areas when I'm outdoors." b. "I don't need to use insect repellent if my clothes are covering my skin." c. "I should wear clothing that covers all of my skin, and I should wear a har." d. "I should stay indoors at dusk and dawn, when mosquitos are most active."

b

A nurse reviewing a client's record notes that the result of the client's latest Snellen chart vision test was 20/80. How should the nurse interpret this data? a. the client has normal vision b. the client can read at a distance of 20 feet what a client with normal vision can read at 20 feet. c. the client is legally blind d. The client can read at a distance of 80 feet what a client with normal vision can read at 20

b

A nurse suspects that a client has a distended bladder. On percussing the client's bladder, which finding does the nurse expects to not if the bladder if full? a. hypoactive bowel sounds b. dull sounds c. an absence of bowel sounds d. hyper-resonance sounds

b

While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which finding does the nurse expect to note when auscultating the client's bowel sounds? a. ab absence of bowel sounds b. hyperactive bowel sounds c. hypoactive bowel sounds d. low-pitched bowel sounds

b

A clinic nurse about to meet a new client and plans to gather subjective data regarding the client's health history. Which actions should the nurse take to help ensure the success of the interview? *Select all that apply* a. maintain a distance of 2 feet (60 cm) or closer between the nurse and client b. seeing that distracting objects are removed from the room c. switching on a dim light that will make the room cozier and help the client relax d. ensure that the room is private e. having the client sit across a desk or table to give the client some personal space

b and d

A nurse has taught a young adult male client about testicular self-examination. Which statement indicates to the nurse that the teaching was effective? a. the client states he will perform the self-examination at least every two weeks b. the client indicates the need to use both hands and palpate both testes at the same time c. the client states that it is important to contact the HCP immediately if any lumps are felt d. the client states that he should always perform the self-examination just before getting into the shower

c

A nurse is assessing the carotid artery of a client with cardiovascular disease. The nurse performs this assessment in which manner? a. instructing the client to take slow, deep breaths while the nurse listens to the carotid artery b. palpating both arteries simultaneously to compare amplitude c. listening to the carotid artery, using the bell of the stethoscope to assess for bruits d. palpating the carotid artery in the upper third of the neck

c

A nurse is gathering subjective data from an adult client about the client's daily food intake. Which questions should the nurse ask the client first? a. "Do you do your own shopping?" b. "Have you ever heard of MyPlate?" c. "Can you tell me what you ate and drink over the last 24 hours?" d. "Do you have adequate income to purchase the foods you need?"

c

A nurse is performing an abdominal assessment on a client. On auscultation of the abdomen the nurse hears a brut over the abdominal aorta. Which action should the nurse take as a priority on the basis of this finding? a. percuss the abdomen to check the tympany b. palpate the area for a mass c. notify the healthcare provider d. document the finding

c

A nurse is preparing to administer the diphtheria/tetanus/acellular pertussis vaccine (DTaP) to a 6-month-old infant. Which action should the nurse take to minimize the potential for a local reaction to the vaccine? a. using a 1.5 inch needle for injection b. administering the injection in the deltoid muscle c. administering the injection in the vastus lateralis muscle d. changing the needle on the syringe after drawing up the vaccine

c

A nurse is preparing to assess a client for the presence of the Tinel sign. Which action does the nurse take to elicit this sign? a. asking the client to hold the hands back to back while flexing to wrist 90 degrees. b. checking for repetitive movements in the joints c. percussing at the location of the median nerve d. testing the strength of each muscle joint

c

A nurse is preparing to perform a Rinne test on a client who complains of hearing loss. In which area does the nurse first place an activated tuning fork? a. on the client's forehead b. on the client's teeth c. on the client's mastoid bone d. on the midline of the client's skull

c

A nurse conducting a physical examination of a Chinese-American client is gathering subjective data about the client's health care practices. What is the nurse's *primary* reason for asking the client about the use of herbal products and dietary supplements? a. to determine whether these are acceptable forms of treatment b. to determine whether the client's HCP approves of their use c. to determine whether they have been approved by the U.S. Food and Drug Administration d. to determine whether they will interact adversely with medications being prescribed for the client

d

A nurse is administering the hep B vaccine to a newborn. Which anatomic site should the nurse select for the infections? a. deltoid b. dorsogluteal c. Rectus femoris d. vastus lateralis

d

A nurse is making an initial home visit to a client with chronic obstructive pulmonary disease who was recently discharged from the hospital. Which type of database does the nurse use to obtain information from the client? a. episodic b. follow-up c. emergency d. complete

d

A nurse is preparing to listen to a client's breath sounds. The nurse should use which technique? a. listen to the right lung, then the left lung b. ask the client to take shallow rapid breaths through the mouth c. ask the client to lie down d. use the diaphragm of the stethoscope, holding it firmly against the client's chest

d

A nurse is preparing to screen a client's vision with the use of Snellen chart. Which action should the nurse take? a. assesses both eyes together, then assesses the right and left eyes separately b. asks the client to stand 40 feet (12 meters) from the chart and read the largest line on the chart c. asks the client to stand 40 feet (12 meters) from the chart and read the line that can be read 200 feet (60 meters) away by someone with unimpaired vision. d. tests the right eye, then test the left eye, and finally both eyes together

d

A nurse performing a neurological assessment is preparing to assess the optic nerve. The nurse performs this examination by which method? a. inspecting the eyelid for ptosis b. assessing pupil constriction c. assessing ocular movements d. assessing visual acuity

d

A nurse performing an assessment of a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. How should the nurse document this finding? a. Increased vascularity of the skin tissue b. unilateral edema c. ecchymosis d. Anasarca

d

A nurse preparing to examine a client's eyes plans to perform a confrontation test. The nurse tells the client that this test measures which aspect of vision? a. distant vision b. color vision c. near vision d. peripheral vision

d

A nurse preparing to perform an abdominal assessment asks the client to void and the assists the client into a supine position. Which primary finding does the nurse expect to not on percussing all 4 quadrants of the abdominal cavity? a. borborygmus b. dullness c. hyperresonance d. tympany

d

A nurse reviewing the healthcare record of a client notes documentation of grade 4 muscle strength. The nurse makes which determination regarding this client's range of motion? a. full ROM against gravity with full resistance b. full range of motion (ROM) with gravity c. full ROM with gravity eliminated (passive motion) d. full ROM against gravity with some resistance

d

A nurse teaches a client about healthy dietary measures and explains the MyPlate food plan. The nurse determines that the client understands the information if the client says how many of his grains should be whole grains? a. 2/3 b. 1/3 c. 1/4 d. 1/2

d

Performing an abdominal assessment, a nurse notes tenderness while lightly palpating a client's right lower quadrant. The nurse determines that this finding is most likely associated with which disorder? a. spleen rupture b. liver cirrhosis c. pancreatic dysfunction d. inflammation of the appendix

d

The clinic nurse, performing a physical examination of an adult client, is gathering subjective data about the client's lifestyle. When asked about alcohol, the client tells the nurse that he does drink on a daily basis. Based on this finding, which question should the nurse ask next? a. "What type of alcohol do you drink?" b. "Have you ever passed out after drinking alcohol?" c. "Does your drinking affect your work or home life?" d. "How frequently do you drink, and how much alcohol do you consume?"

d

The nurse is observing a new nurse employee who is examining the peripheral vision of a client using the confrontation test. The nurse determines the new nurse is using correct technique if the nurse performs which action? a. asks the client to discriminate numbers on a chart composed of colored dots b. has both the client and nurse cover the right eye, stare at each other's uncovered eye, and bring a small object into the visual field, then repeat the test with the left eye c. darkens the room and asks the client to identify colored blocks and shapes that appear in the visual field d. sits at eye level with the client, covers one eye, and has the client cover the eye directly opposite the nurse's, after which each stares at the other's uncovered eye and the nurse brings a small object into the visual field

d

The nurse reviews a client's medical records and notes that vesicular breath sounds were auscultated. The nurse determines this was assessed to determine presence of an abnormality in which area? a. major bronchi b. the trachea and larynx c. the xiphoid process d. the peripheral lung fields

d

For moderate or severe anaphylactic reactions/distress we need to do the following

establish an airway; perform cardiopulmonary resuscitation if the client is not breathing; place client in a head-elevated position; administer epinephrine, fluids, and vasopressors; and monitor VS and urine output.

Breast and testicular self-examinations should be performed

every month

For mild anaphylactic reactions with no evidence of respiratory distress or cardiovascular compromise we would

give a subcutaneous injection of epinephrine, an intramuscular injections of antihistamine such as diphenhydramine, or a combination of both is indicated.

Physical assessment includes

inspection, palpation, percussion, and auscultation; these skills are performed on at a time in this order, except for the abdominal assessment

Abdominal assessment includes

inspections, auscultation, percussion, and palpation in this order

Actinic Keratoses

localized thickening of the skin caused by excessive exposure to sunlight, a known precursor to cancer

The nurse should evaluate a client's learning by

observing the client's performance of the behavior or activitity

seborrhea

oily discharge

normal tympanic membrane

pearly gray, shiny, translucent

a client's perception of health status is his or her

perceived level of health and well-being and includes personal practices for maintaining health.

The nurse must determine the client's

readiness and motivation to learn and the client's learning needs.

pruritus

severe itching

The goals of treatment during an anaphylactic reactions are

to provide ventilation, restore adequate circulation, and prevent further exposure to the antigen.