HESI Practice

What should you consider on the part of your patient prior to a physical exam?

Comfort, Safety, and privacy

On inspection of a patient's dark skin, the nurse notes a blue-gray birthmark on the forehead and eye area. This assessment finding is called a. vitiligo. b. intertrigo. c. Nevus of Ota. d. telangiectasia.

c. Nevus of Ota.

During the physical examination of a patient's skin, the nurse would. a. use a flashlight in a poorly lit room. b. note cool, moist skin as a normal finding. c. pinch up a fold of skin to assess for turgor. d. perform a lesion-specific examination first and then a general inspection.

c. pinch up a fold of skin to assess for turgor. Turgor is the elasticity of the skin. The nurse should assess turgor by gently pinching an area of skin under the clavicle or on the back of the hand. Skin with good turgor should move easily when lifted and should immediately return to its original position when released.

When assessing the nutritional-metabolic pattern in relation to the skin, the nurse questions the patient regarding a. joint pain b. the use of moisturizing shampoo. c. recent changes in wound healing. d. self-care habits related to daily hygiene.

c. recent changes in wound healing. When assessing the nutritional-metabolic pattern, the nurse asks the following questions: "Describe any changes in the condition of your skin, hair, nails, and mucous membranes. Have you noticed any recent changes in the way sores or wounds heal? Have you had any weight loss or dietary changes, including supplemental vitamins and minerals?"

A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the PRIORITY nursing action for this client? 1.Assessment of vital signs 2.Completion of abdominal examination 3.Insertion of the prescribed nasogastric tube. 4.Thorough investigation of the precipitating events.

Assessment of Vital Signs

What does turgor mean?

It refers to the elasticity of skin. A nurse assesses this by pinching the skin on the top of the hand or under the clavical. It should move easily.

Persons with dark skin are more likely to develop a. keloids. b. wrinkles. c. skin rashes. d. skin cancer.

a. keloids. Persons with dark skin are predisposed to certain skin and hair conditions, such as keloids, which are overgrowths of collagenous tissue at the site of a skin injury.

To assess the skin for temperature and moisture, the most appropriate technique for the nurse to use is a. palpation. b. inspection. c. percussion. d. auscultation.

a. palpation. Using the back of your hand to palpate the patient's skin is the best way to assess the temperature of the skin.

The nurse assessed the patient's skin lesions as firm, edematous, irregularly shaped with a variable diameter. They would be called a. wheals. b. papules. c. pustules. d. plaques.

a. wheals. A wheal is a firm, edematous, irregularly shaped area with variable diameter. Examples include insect bites and urticaria.

Diagnostic testing is recommended for skin lesions when a. a health history cannot be obtained. b. a more definitive diagnosis is needed. c. percussion reveals an abnormal finding. d. treatment with prescribed medication has failed.

b. a more definitive diagnosis is needed. Biopsy is one of the most common diagnostic tests used in the evaluation of a skin lesion. A biopsy is indicated in all conditions in which a malignancy is suspected or a specific diagnosis is questionable.

Age-related changes in the hair and nails include (select all that apply) a. oily scalp b. scaly scalp c. thinner nails d. longitudinal nail ridging

b. scaly scalp c. thinner nails d. longitudinal nail ridging

What are the 4 different levels of sedation?

1. Awake and alert (Acceptable) 2. Slight drowsy (Acceptable) 3. Frequently drowsy. Drifts off to sleep during conversation. (Unacceptable) 4. minimal or no response to verbal or physical stimulation. (Unacceptable)

Which of the following techniques uses the sense of touch when assessing a patient? 1. Palpation 2. Inspection 3. Percussion 4. Auscultation

1. Palpation

Which technique of assessment is used to determine the presence of crepitus, swelling, and pulsations? 1. Palpation 2. Inspection 3. Percussion 4. Ausculation

1. Palpation

Which statement is true regarding the diaphragm of the stethoscope? 1. use the diaphragm to listen for high pitched sounds 2. use the diaphragm to listen for low pitched sounds. 3. Hold the diaphragm lightly against the person's skin to block out low-pitched sounds. 4. Hold the diaphragm lightly against the person's skin to listen for extra heart sounds and murmers.

1. use the diaphragm to listen for high pitched sounds

The nurse would use bimanual palpation technique in which situation. 1. palpating the thorax of an infant. 2. Palpating the kidneys and uterus 3. Assessing pulsations and vibrations 4. Assessing the presence of tenderness and pain.

2. Palpating the kidneys and uterus Bi means two Manual - hands

The inspection phase of the physical assessment: 1. Yields little information 2. Takes time and reveals a surprising amount of information 3. may be somewhat uncomfortable for the expert practitioner 4. requires a quick glance at the patient's body systems before proceeding on with palpation.

2. Takes time and reveals a surprising amount of information

Which of the following statements is true regarding the stethoscope and its use? 1. The slope of the earpieces should point posteriorly (toward the occiput) 2. The stethoscope does not magnify sound but does block out extraneous room noise. 3. The fit at quality of the stethoscope are not as important as its ability to magnify sound. 4. The ideal tubing length should be 22 inches long to dampen distortion of sound.

2. The stethoscope does not magnify sound but does block out extraneous room noise. *Stethoscope AMPLIFIES sound, does not magnify.

The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best asses the patient's skin temperature? 1. Use the fingertips because they are more sensitive to small changes in temperature. 2. Use the dorsal surface of the hand because the skin is thinner on the palms. 3. Use the ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity. 4. Use the palmar surface of the hand because it is most sensitive to temperature variations because of increased nerve supply in the area.

2. Use the dorsal surface of the hand because the skin is thinner on the palms.

How would you evaluate a patients quantity and quality of foods and fluids consumed?

24 Hour diet recall from the patient.

The nurse is preparing to percuss to assess the underlying: 1. Tissue turgor 2. Tissue Texture 3. Tissue density 4. Tissue Consistency

3. Tissue density

Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse will 1. Warm the endpiece of the stethoscope by placing it in warm water 2. leave the gown on so the patient does not get chilled during examination 3. make sure the bell side of the stethoscope is turned to the on position 4. Check the temperature of the room and offer blankets to the patient if he or she feels cold.

4. Check the temperature of the room and offer blankets to the patient if he or she feels cold.

The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed? 1. Avoid palpation of reported 'tender' areas because this may cause patient pain. 2. Quickly palpate the area to avoid any discomfort that the patient may experience. 3. Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths. 4. Start with light palpation to detect surface characteristics and to accustom the patient to being touched.

4. Start with light palpation to detect surface characteristics and to accustom the patient to being touched.

An examiner is using an optholmascope to examine a patient's eyes. The patient has astigmatism and is nearsighted. Which of the following techniques would indicate the examination is being performed correctly? 1. Using the large full circle of light when assessing pupils that are not dilated. 2. Rotating the lens selector dial to the black numbers to compensate for astigmatism. 3. using the grid on the lens aperture dial to visualize the external structures of the eye. 4. Rotating the lens selector dial to the red numbers to compensate for nearsightedness

4. Rotating the lens selector dial to the red numbers to compensate for nearsightedness

Which of the following statements is true regarding the otoscope? 1. the otoscope is often used to direct light onto the sinuses. 2. the otoscope uses a short broad speculum to visualize the ear. 3. The otoscope is used to examine the structures of the internal ear. 4. The otoscope directs light into the ear canal and onto the tympanic membrane.

4. The otoscope directs light into the ear canal and onto the tympanic membrane.

Which situation would require the nurse to obtain a focused assessment? Select all that apply: •A. A patient denies a current health problem •B. A patient reports a new symptom during rounds. •C. a previous identified problem needs reassessment •D. A baseline health maintenance exam is required. •E. an emergency problem is identified during physical Examination

B & C A focused assessment is an abbreviated health history and examination. It is used to evaluate the status of previously identified problems and monitor for signs and symptoms of new problems. It can be done when a specific problem (e.g., pneumonia) is identified. The patient's clinical manifestations should alert you to the appropriate focused assessment

Primary Function of the skin is A. insulation B. Protection C. Sensation D. Absorption

B. Protection The primary function of the skin is to protect the underlying tissues of the body by serving as a surface barrier to the external environment

An important nursing responsibility related to pain is to: A. leave the patient alone to rest. B. help the patient appear to not be in pain C. Believe what the patient says about the pain D. Assume responsibility for eliminating the patient's pain

B. help the patient appear to not be in pain •These definitions emphasize the subjective nature of pain, in which the patient's self-report is the most valid means of assessment.

The nurse hears bilateral louder, longer, and lower tones when percussing over the lungs of a 4 year old child. What should the nurse do next? 1. Palpate over the area for increased pain and tenderness. 2. Ask the child to take shallow breaths and percuss over the area again. 3. Refer the child immediately because of an increased amount of air in the lungs. 4. Consider this a normal finding for a child this age and proceed with the examination.

Consider this a normal finding for a child this age and proceed with exam.

When percussing over the ribs of a patient, the nurse notes a dull sound. The nurse would 1. Consider this a normal finding. 2. Palpate the area for an underlying mass 3. Reposition the hands and attempt to percuss this area again. 4. Consider this an abnormal finding and refer the patient for additional treatment.

Consider this a normal finding. Dull sound is what we expect over ribs. *Note the opposites in the answer options. Note the answer that suggested hurrying to further treatment without identifying what that treatment is. We can reposition, but we want to make sure we reposition over the same area and know what we are looking for as far as normal vs abnormal findings.

That is the diaphragm of the stethoscope more sensitive to?

High pitched sounds ex. bowel sounds.

The nurse is preparing to percuss the thorax of an adult. Which technique is correct? 1. Use the direct percussion technique. 2. Use the indirect percussion technique. 3. Use the ulnar surface of the hand to percuss the thorax. 4. Use the dorsal surface of the hand to percuss the thorax.

Indirect percussion should be used on the thorax. Tapping on two fingers.

What is Auscultation?

Listening to sounds produced by the body with a stethoscope to assess normal conditions and deviations from normal.

What is the bell of the stethoscope more sensitive to?

Low pitched sounds ex. Heart murmurs

What drug is used in an opioid overdose?

Naloxone

Which cultural group consider silence as essential for thinking and consider it a way of carefully responding?

Native Americans

What does PQRST stand for?

P- Precipitate - Patients attempts to alleviate or treat the symptom. Q- Quality -Patients own words. Their description R- Radiate - Region of body - local, radiating superficial or deep S- Severity - Pain rating T- Timing - Time of onset, duration, periodicity and frequency.

While palpating, you observe the skin is cold. What is this a sign of?

Shock, circulatory problems, chilling or may have an infection.

Dysfunctional Health Patterns result in nursing diagnoses. T or F

True

•The nurse is preparing to examine a patient's abdomen. Identify the proper order of the steps in the assessment of the abdomen, using the numbers 1-4 with 1: first technique, 4: last technique. •__ Inspection •__ Palpation •__ Percussion •__ Auscultation

•1, 4, 3, 2 •Inspection •Auscultation •Percussion •Palpation •The techniques are usually performed in this sequence, except for the abdominal examination (inspection, auscultation, percussion, and palpation). Performing percussion and palpation of the abdomen before auscultation can alter bowel sounds and produce false findings. Not every assessment area requires the use of all four assessment techniques (e.g., musculoskeletal system requires only inspection and palpation).

•Which statement most accurately describes cultural factors that may affect health? •A. Diabetes and cancer rates differ by cultural/ethnic groups •B. Most patients find that religious rituals help them during times of illness •C. There are limited ethnic variations in phsychologic responses to medications •D. Silence during a nurse-patient interaction usually means the patient understands the instructions.

•A. Diabetes and cancer rates differ by cultural/ethnic groups People living in rural areas have higher rates of cancer, heart disease, diabetes, depression, and injury-related deaths than people living in urban areas. For example, in rural Appalachia the rates of lung, colon, cervical, and colorectal cancer are higher than the national average. Rural populations tend to be older than urban populations. Many rural areas have higher rates of obesity and chronic disease. The impact of social and physical environment on health choices can be illustrated by the problem of intimate partner violence in rural communities.8

•The nurse would place information about the patient's concern that his illness is threatening his job security in which functional health pattern •A. Role-relationship •B. Cognitive-Perceptual •C. Coping-stress tolerance •D. Health Perception-Health Management

•A. Role-relationship •This pattern reveals the patient's roles and relationships, including major responsibilities. Ask the patient to describe family, social, and work roles and relationships and to rate his or her performance of the expected behaviors related to these. Determine whether patterns in these roles and relationships are satisfactory or whether strain is evident. Note the patient's feelings about how the present condition affects his or her roles and relationships.

•When communicating with a patient who speaks a language that the nurse does not understand, it is important to FIRST attempt to •A. have a family member interpret •B. Use a trained medical interpreter •C. use specific medical terminology so there will be no mistakes •D. Focus on the translation rather than nonverbal communication

•B. Use a trained medical interpreter

•As part of the nursing process, cultural assessment is BEST accomplished by •A. Judging the patient's cultural values based on observations •B. Using a cultural assessment guide as part of the nursing process •C. Seeking guidance from a nurse from the patient's cultural background •D. Relying on the nurse's previous experience with patients from that cultural group

•B. Using a cultural assessment guide as part of the nursing process.

•Pain is best described as •A. a creation of a person's imagination •B. an unpleasant, subjective experience •C. a maladaptive response to a stimulus •D. a neurologic event resulting form activation of nociceptors

•B. an unpleasant, subjective experience •Pain - "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."1

•Which words are MOST likely to be used to describe neuropathic pain? Select all that apply: •A. Dull •B. Mild •C. Burning •D. Shooting •E. Shock-like

•C. Burning •D. Shooting •E. Shock-like Neuropathic pain is caused by damage to peripheral nerves or structures in the CNS. While neuropathic pain is commonly associated with diabetic neuropathy and other neuropathic pain syndromes, approximately 8% of the general population has pain with neuropathic characteristics.10 Typically described as numbing, hot, burning, shooting, stabbing, sharp, or electric shock-like, neuropathic pain can be sudden, intense, short lived, or lingering.

•A patient is receiving a PCA infusion after surgery to repair a hip fracture. She is sleeping soundly but awakens when the nurse speaks to her in a normal tone of voice. Her respirations are 8 breaths a minute. The MOST appropriate nursing action in this situation is to: •A. Stop the PCA infusion •B. Obtain an oxygen saturation level •C. Continue to closely monitor the patient •D. Administer naloxone and contact the physician.

•C. Continue to closely monitor the patient If the patients respirations fall below 8 or 10 breaths you should try and keep the patient awake. If the patient becomes over sedated administer oxygen and the opioid dose should be reduced. In the case of this patient they are within good parameters.

•The patient health history and physical examination provides the nurse with information to primarily •A. diagnose a medical problem •B. investigate a patient's signs and symptoms •C. Classify subjective and objective patient data •D. Identify nursing diagnosis and collaborative problems

•D. Identify nursing diagnosis and collaborative problems Or rather, the question leads us to think about what is our end goal from the beginning.