HESI-assessment and analysis

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Which assessment finding in a client signifies a mild form of hypocalcemia? Seizures Hand spasms Severe muscle cramps Numbness around the mouth

A numbness or tingling sensation around the mouth or in the hands and feet indicates mild-to-moderate hypocalcemia. Seizures, hand spasms, and severe muscle cramps are associated with severe hypocalcemia.

The client is receiving high-flow intravenous (IV) fluid replacement therapy. Which nursing assessment findings are consistent with fluid volume overload? Select all that apply. Pulse quality Pulse pressure Bounding pulse Presence of dependent edema Neck vein distention in the upright position

Bounding pulse, presence of dependent edema, and neck vein distention in the upright position are all indicators of fluid overload, which should be reported by the nurse. Pulse quality and pulse pressure are indicators to monitor the client's response to fluid therapy.

During an assessment, the nurse shines a light into the client's eyes and observes that the pupil remains dilated. Which cranial nerve (CN) does the nurse suspect to be affected?

CN III is the oculomotor nerve, which is responsible for pupillary constriction and accommodation. Damage to this nerve may result in failure of the pupils to constrict; thus the pupils will remain dilated even upon exposure to a light source. CN V is the trigeminal nerve, which is responsible for chewing. CN VII is the facial nerve; asymmetrical facial movements indicate damage to this nerve. CN VIII is the vestibulocochlear nerve; decreased hearing acuity or hearing impairment or equilibrium impairment may indicate damage to CN

While performing a visual system assessment, the nurse observes that the client has a misalignment of the right eye. The client reports to the nurse, "I am having double vision." What may be the cause of this condition?

Having double vision indicates the client is experiencing diplopia. Abnormalities of extraocular muscle actions such as overaction or underaction of one or more extraocular muscles may result in double vision (diplopia) and misalignment or deviation of the eye position (strabismus). Myasthenia gravis may cause drooping of the upper lid margin (ptosis). Periorbital tumors may result in exophthalmos, which is manifested as a protrusion of the globe beyond its normal position within the bony orbit. If conjunctival blood vessels rupture, blood spots may appear on the sclera (subconjunctival hemorrhage). Test-Taking Tip: Misalignment or deviation of eye position is also called as strabismus.

The nurse is caring for a client who underwent surgery for a brain tumor. On assessment, the nurse suspects meningitis in the client. Which finding would help confirm the nurse's suspicion?

Meningitis may occur secondary to surgical procedures on the brain. It is highly probable when Kernig sign is positive. The Glasgow coma scale is used as a reliable way of recording the conscious state of the client, but it is not used to diagnose meningitis. A meningitis diagnosis is highly probable with a positive Brudzinski sign and the presence of nuchal rigidity (e.g., stiff neck). Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer.

A client underwent surgery and developed a wound without tissue loss. While caring for the client, the nurse detects abscess formation. Which assessments made by the nurse support the observation? Select all that apply. Necrosis of skin edges Swelling of the incision line Purulent drainage from the incision site Erythema of the incision line of more than 1 cm Localized fluctuance beneath the wound when palpated

Purulent drainage from the incision site's portion is detected during checks performed every 24 hours to detect abscess formation until sutures or staples are removed. Localized fluctuance and tenderness beneath a portion of the wound is palpated to detect abscess formation. Wound dehiscence is indicated by the presence of necrosis of skin edges. Swelling of the incision line or erythema of the incision line of more than 1 cm indicates cellulitis.

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Upon assessment of a client, the nurse discovers the following (see image). Which virus causes the condition indicated? Papillomavirus Epstein-Barr virus Varicella-zoster virus Herpesvirus 8 (HHV-8)

The condition represents Herpes zoster (shingles). This is caused by varicella-zoster virus. Clinically it is manifested as a linear distribution along a dermatome of grouped vesicles and pustules on an erythematous base. It resembles chickenpox. Papillomavirus causes verruca vulgaris (common wart). Epstein-Barr virus causes oral hairy leukoplakia. HHV-8 is associated with Kaposi sarcoma in immunosuppressed clients.

According to the emergency assessment protocol, which are the nursing actions for a client with a chest injury? Select all that apply. Palpating for bony crepitus Auscultating bowel sounds Examining the neck for stiffness Assessing for external signs of injury Observing the rate, depth, and effort of breathing

The priority nursing actions for a client with a chest injury include palpating for bony crepitus, assessing for external signs of injury, and observing the rate, depth, and effort of breathing. The nurse would auscultate the bowel sounds for a client with an abdominal injury. The nurse would examine the neck for stiffness for a client with a neck injury.

During chest assessment of a client with idiopathic pulmonary fibrosis, the nurse hears short, discontinuous, high-pitched sounds that sound like hair being rolled between the fingers just behind the ear in the bilateral lower lobes. Which respiratory disorders may also manifest these sounds as a pathophysiological sign? Select all that apply. 1. Croup 2. Atelectasis 3. Cystic fibrosis 4. Bronchospasm 5. Pulmonary edema

The short, discontinuous, high-pitched sounds that sound like hair being rolled between fingers just behind the ear in the bilateral lower lobes indicate fine crackles. These sounds may be auscultated in clients with pulmonary disorders such as idiopathic pulmonary fibrosis, atelectasis, and pulmonary edema. Croup is a respiratory disorder characterized by a continuous musical or a crowing sound of a constant pitch. Cystic fibrosis is characterized by continuous rumbling, snoring, and rattling sounds from secretions obstructing large airways. Bronchospasms are characterized by continuous high-pitched, squeaking, or musical sounds caused by rapid vibration of bronchial walls.

Which assessment finding is considered the earliest sign of decreased tissue oxygenation? Cyanosis Cool, clammy skin Unexplained restlessness Retraction of interspaces on inspiration

Unexplained restlessness is considered the earliest sign of decreased oxygenation. The other assessment findings, such as cyanosis, cool, clammy skin, and retraction of interspaces on inspiration, are considered late signs of decreased oxygenation.