(HESI PREP) Basic Physical Assessment

To evaluate a client's cerebellar function, a nurse should ask

"Do you have any problems with balance?" To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination. The nurse asks about difficulty speaking or swallowing to assess the functions of cranial nerves IX, X, and XII. Questions about muscle strength help the nurse evaluate the client's motor system.

The charge nurse on a pediatric unit is making client assignments for the evening shift. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/VN)?

a 4-year-old with chronic graft-versus-host disease who is incontinent The LPN/VN's scope of practice includes care of clients with chronic and stable health problems, such as the client with chronic graft-versus host disease. Chemotherapy medications should be administered by an RN who has received additional education in chemotherapy administration. Platelets and other blood products should be administered by the RN. The 5-year-old client is exhibiting clinical manifestations of neutropenia and sepsis and should be assessed by the RN.

Why should an infant be quiet and seated in an upright position when the nurse assesses the fontanels?

Lying down and crying can cause the fontanels to bulge. Lying down and crying can cause the fontanels to bulge, making the nurse's assessment inaccurate. The nurse should sit the child upright and try to keep the baby calm and quiet. The fontanels should look almost flush with the scalp, and the nurse should observe slight pulsation. The fontanels should feel soft and either flat or slightly indented.

The nurse is working with a licensed practical nurse (LPN) and delegating the taking of vital signs for a preoperative client. Upon review of the chart as the client is leaving for the operating room, the nurse notes that the temperature is 101.1°F (38.4°C) and the pulse is 110 bpm. What are the nurse's initial actions?

Notify the surgeon and await the surgeon's decision; reinforce with the LPN the importance of reporting abnormal preoperative vital signs. The purpose of a registered nurse's signing off the chart is to ensure that the safety of the client has been assessed. Abnormal vital signs identify that priority systems indicate that a stressor or infection is present.

After a laminectomy, a client has a palpable bladder and reports lower abdominal discomfort with voiding 60 to 80 mL of urine every 4 hours. The vital signs are BP 110/88 mm Hg, HR 86 bpm, and RR of 20 breaths/min. What is the best nursing intervention?

Perform a bladder scan, and obtain an order for urinary catheterization. The client has overflow retention. A catheter relieves the discomfort by draining urine from the bladder. Permitting further distension could injure the bladder. Although an analgesic may relieve the discomfort, it will not resolve the primary cause. Nurses' self regulation practice can perform a bladder scan without an order. Other answers are incorrect because the client may have neurologic impairment and decreased sensation for voiding.

A client, age 75, is admitted to the hospital. Because of the client's age, how should the nurse modify the client's assessment?

allowing extra time for the assessment When assessing an older adult client, the nurse should allow extra time to compensate for aging-related physiologic changes, address the client respectfully rather than by first name, and give simple instructions. Speaking in a loud voice is demeaning and assumes that the client has difficulty hearing, which may not be the case.

A client is transferred to the acute stroke unit, and the nurse initiates a neurologic flow sheet to provide ongoing data about the recovery phase of care. The nurse is aware this information indicates what regarding a client's clinical status?

changes in level of consciousness or responsiveness as evidenced by movement and orientation to time, place, and person The nurse will track specific measurable data about the client's neurological status. The other choices are not complete neurologic assessments.

When auscultating a client's chest, a nurse assesses a second heart sound (S2). What would the nurse determine is the cause of this sound?

closing of the aortic and pulmonic valves The S2 results from closing of the aortic and pulmonic valves. The first heart sound (S1) occurs when the mitral and tricuspid valves close.

Which observation by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding?

formula in the client's mouth during the feeding, and increased cough Formula in the mouth and cough are indicators of aspiration. Passage of flatus reflects intestinal motility, which does not pose a potential problem. A passage of flatus is not reflected in tolerating a feeding, it is an indication of bowel function. A rapid flow should not be administered by a nurse, and gastric tenderness does not indicate tolerance of tube feed.

A nurse prepares to auscultate a client's carotid arteries for bruits. For this procedure, the nurse should

use the bell of the stethoscope. With the client holding their breath, the nurse uses the bell of the stethoscope to auscultate the carotid arteries for bruits. Having the client inhale would interfere with the nurse's ability to detect sound. Palpating the radial artery wouldn't yield significant information and could interfere with the nurse's ability to listen without interruptions or distractions. Palpating both carotid arteries simultaneously would stop blood flow to the brain.

Students in a health class are discussing birth control and prevention of sexually transmitted infection (STI). The school nurse would know that teaching regarding both goals has been effective if the students make which statement?

"Responsible sex involves using condoms and spermicides for protection and birth control." This comment indicates an understanding of ways to lessen the incidence of STIs through condom use; it also indicates an awareness that use of spermicide and a condom will help to prevent unwanted pregnancies. Safe sex not merely prevention of unwanted pregnancy; it is also the prevention of STIs. Since neither the IUD nor the rhythm method involves a barrier, neither will protect against STIs.

A client has just been transferred to the postanesthesia recovery room following a laparotomy. In addition to vital signs, what are the most important initial assessments that need to be completed?

Level of consciousness, pain level, and wound dressing Postoperatively vital signs are taken to ensure that vital systems are returning to normal after anesthesia. It is also important to check the level of consciousness, particularly postanesthesia and postanalgesia. Pain levels need to be monitored. Dressings need to be checked to detect abnormal increase in bleeding. The nurse would not check metabolic rate and reflexes, emotional response, or social support systems as an initial assessment after surgery.

A tornado strikes a community, resulting in multiple trauma victims. What is the most appropriate action of the nurse working in an acute care unit of the receiving facility in implementing the disaster preparedness plan?

Follow the formal written plan of action for coordinating the response of the hospital staff. When a disaster occurs, a formal written plan of action is put into place. All nurses will follow the formal plan of action. Nurses will be notified via telephone if not on duty and will be asked to come in. Those working in the hospital will be sent to the various designated areas within the hospital to care for clients who will be brought in. This plan needs to identify how areas will be used so there is not indecision at the time of the disaster. These are important components of a disaster preparedness plan. A formal fan-out contact list would be in place. Nurses need to commit to the disaster, not just have a volunteer plan. The disaster plan will focus on having health professionals and supplies available.

The nurse is caring for an infant on phototherapy that has had an unstable temperature. Morning assessment reveals that the infant also has had diarrhea, decreased urinary output (UOP), and a capillary refill time (CRT) of 4 seconds. Place the nursing actions in order of priority for this infant. All options must be used.

1. Administer IV fluids 2. Assess temperature 3. Apply protective ointment to the diaper area 4. Cluster care 5. Allow parents to assist with care 6. Document care provided Due to the side effects of phototherapy, the most important nursing intervention is to assure that the infant is hydrated. This helps to decrease bilirubin levels and counteract the side effect of dehydration from the phototherapy. This infant is dehydrated with a CRT of 4 seconds and therefore needs IV fluids first. The scenario states that the infant has had an unstable temperature, so the temperature should be assessed, but this can be done after IV fluids are administered. Skin care should be the next intervention because the infant is naked under phototherapy lights; the eyes and skin need to be monitored. The diaper area needs to be monitored because loose stools are also a side effect. Comfort and parent/infant bonding are not physiological in nature and should be lower on the priority list. The infant's comfort should be next because it reflects the client's outcomes, saving bonding for last.

A client has just been transferred to the postanesthesia recovery room following a laparotomy. The nurse has completed assessing vital signs. What other important initial assessments would the nurse make?

level of consciousness, pain level, and wound dressing Postoperatively, vital signs are taken to ensure that vital systems are returning to normal after anesthesia. It is also important to check the level of consciousness, particularly postanesthesia and postanalgesia. Pain levels need to be monitored. Dressings need to be checked to detect abnormal increase in bleeding. The nurse would not check metabolic rate and reflexes, emotional response, or social support systems as an initial assessment after surgery.

A client has a 10-year history of rheumatoid arthritis and is concerned now that the client's child is experiencing some morning stiffness and pain. What would be the most appropriate response by the nurse?

"There is some evidence that a genetic basis for the disease may exist, so you might want to have your child evaluated." Some research has indicated that a genetic link may be present. Suggesting that the child take aspirin is incorrect because that is offering medical advice and is out of scope of practice of a nurse. Reassuring the client is providing false reassurance.

A client who underwent a mastectomy has been admitted to the surgical care unit after discharge from the postanesthesia care unit. What is the nurse's priority assessment?

Assess the vital signs and oxygen saturation levels. The correct response is based on the principle of prioritizing assessment of airway, breathing, and circulation (ABC) for every client. Assessing vital signs and oxygen saturation, therefore, is the priority. The return of urinary function after anesthesia usually takes 6 or more hours, so this assessment is not a priority upon return from the postanesthesia care unit. Checking the dressing and level of pain are both important but not the priority.

A cloth chest restraint has been prescribed for a client who is restless and combative due to alcohol intoxication. What is an appropriate nursing intervention for this client?

Check the extremities for circulation based on hospital protocols. Assessment of extremities is essential for distal blood flow. Professional responsibility is to follow policies and procedures by the hospital. Family presence can lessen confusion, tied knots do not allow for quick release in an emergency situation, and documentation of a client in this acute state needs to occur more often than once per shift.

The nurse is observing a nursing student palpating a client's maxillary sinuses. The nurse observes that the student has correctly palpated the client's maxillary sinuses when the student palpates which area?

below the client's cheekbones To palpate the maxillary sinuses, the nurse would place hands on either side of the client's nose, below the cheekbone (zygomatic bone). To palpate the frontal sinuses, the nurse places their thumb just above the client's eye, under the bony ridge of the orbit. No sinuses are located on the bridge of the nose or in the temporal area.

The nurse is caring for a client that had surgery this morning. What assessment finding would the nurse notify the health care provider about?

urinary output of 20 mL/hr over 2 hours Urine output is maintained at a minimum of 30 mL/hr in adults. Less than this for 2 consecutive hours should be reported to the health care provider. A low-grade fever is expected in healing and is the natural inflammatory response to surgery. Moderate drainage can be observed, and the blood pressure is still within normal parameters.