BSN 246 week1 HESI Prep

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply. A.Set the room temperature at a comfortable level. B.Remove distracting objects from the interviewing area. C.Place a chair for the client across from the nurse's desk. D.Ensure comfortable seating at eye level for the client and nurse. E.Provide seating for the so that the faces a strong light. F.Ensure that the distance between the client and the nurse is at least 7 feet.

- Set the room temperature at a comfortable level. - Remove distracting objects from the interviewing area. - Ensure comfortable seating at eye level for the client and nurse.

A confrontation test is prescribed for a client seen in the eye and ear clinic. How would the nurse perform this test? Arrange the actions in the order that they would be performed. All options must be used. 1.Asks the client to cover one eye 2.Examiner covers eye opposite to the eye covered by the client. 3.Asks the client to report when object is first noted 4.Stands 2 to 3 ft (60 to 90 cm) in front of client and faces the client 5.The examiner brings in an object gradually from periphery

- Stands 2 to 3 ft (60 to 90 cm) in front of client and faces the client - Examiner covers eye opposite to the eye covered by the client. - Asks the client to cover one eye - The examiner brings in an object gradually from periphery - Asks the client to cover one eye

The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation? A. An involuntary rhythmic, rapid twitching of the eyeballs. B. A dorsiflexion of the ankle and great toe with fanning of the other toes. C. A significant sway when the client stands erect with feet together, arms at the side and the eyes closed. D. A lack of sense of position when the client is unable to return extended fingers to a point of reference.

A significant sway when the client stands erect with feet together, arms at the side and the eyes closed.

The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data? A.Turn the flashlight on directly in front of the eye and watch for a response. B.Check pupil size, and then ask the client to alternate looking at the flashlight and the examiners finger. C.Instruct the client to look straight ahead, and then shine the flashlight from the temporal area to the eye. D.Ask the client to follow the flashlight through the six cardinal positions of gaze

Ask the client to follow the flashlight through the six cardinal positions of gaze

The nurse is caring for a client with a new diagnosis of hypothyroidism. Which clinical manifestations might the nurse expect to note on examination of this client? Select all that apply. A.Irritability B.Periorbital edema C.Coarse, brittle hair D.Slow or slurred speech E.Abdominal distention F.Soft, silky, thinning hair

B. Periorbital edema C.Coarse, brittle hair D.Slow or slurred speech E.Abdominal distention

A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client monitors the status of breath sounds in that area by placing the stethoscope at which location? A.Near the lateral 12th rib B.Just under the left clavicle C.In the fifth intercostal space Posteriorly under the left scapula

Just under the left clavicle

The nurse is testing a client for astereognosis. The nurse would ask the client to close the eyes and perform which action? A.Identify three numbers or letters traced in the client's palm. B.Identify an object in the client's hand. C.State whether one or two pinpricks are felt when the skin is pricked bilaterally in the same place. D.Identify the smallest distance between two detectable pinpricks, made with two pins held at various lengths.

Identify an object in the client's hand.

The nurse is assessing a client who presents with right upper quadrant pain, which of the following organs would the nurse palpate for based on the client's complaint. A.Gallbladder B.Liver C.Pancreas D.Apex of the stomach

Liver

A nursing student is performing a respiratory assessment on an adult client and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching? A.Palpating over the lung apices in the supraclavicular area B.Asking the client to repeat the word ninety-nine during palpation C.Palpating over the breast tissue to assess and compare vibrations from one side to the other D.Comparing vibrations from one side to the other as the client repeats the word ninety-nine

Palpating over the breast tissue to assess and compare vibrations from one side to the other

A client with pneumonia is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history? A.Focus only on the physical assessment. B.Obtain all history information from the family members. C.Plan short sessions with the client to obtain data. D.Use the primary healthcare provider's medical history.

Plan short sessions with the client to obtain data.

The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique would the nurse implement to test the motor function of this nerve? A.Ask the client to puff out the cheeks. B.Separate the client's jaw by pushing down on the chin. C.Place a small amount of sugar on the client's tongue and ask them to identify the taste. D.Ask the client to rotate the head forcibly against resistance applied to the side of his or her chin.

Separate the client's jaw by pushing down on the chin.

The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? A.The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. B.The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. C.The client passively flexes his hip and knee in response to neck flexion and reports pain in the vertebral column. D.The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

The client passively flexes his hip and knee in response to neck flexion and reports pain in the vertebral column.

The nurse is monitoring a client for signs of hypocalcemia after thyroidectomy. Which sign or symptom, if noted in the client, would most likely indicate the presence of hypocalcemia? A. Bradycardia B. Flaccid paralysis C. Tingling around the mouth D. Absence of Chvostek's sign

Tingling around the mouth

After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse would expect to note which finding? A.Waves of loud gurgles auscultated in all four quadrants. B.Low-pitched swishing auscultated in one or two quadrants. C.Relatively high-pitched clicks or gurgles auscultated in one or two quadrants. D.Very high pitched, loud rushes auscultated in especially in one or two quadrants.

Waves of loud gurgles auscultated in all four quadrants.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds would the nurse expect to hear when performing a respiratory assessment on this client? A.Stridor B.Crackles C.Wheezes Diminished

Wheezes