Health Assessment Hesi

In a group therapy setting, one member is very demanding, repeatedly interrupting others and taking most of the group time. The nurse's best response would be what?

"Will you briefly summarize your point because others need time also?" This allows the client to focus his comments and allows him to make his point. "Your behavior is obnoxious and drains the group" is judgmental. "I am so frustrated with yuor behavior" does not facilitate communication. To ignore the behavior and allow him to vent focuses more on the nurse than the client's needs.

At what age is a toddler-age client physiologically and psychologically prepared for toilet training?

22 Months

Invulnerability

An adolescent who thinks that risky driving does not pose a threat: "Even if I drive my car at 120 km per hour, nothing will happen to me."

Polydipsia

Excessive thirst. One of the first signs of diabetes. Symptoms- persistent and unexplained thirst regardless of how much you drink; passing more than 5 liters of urine per day

Anuria

Occurs when kidneys aren't producing urine. A person may first experience oliguria which progresses to anuria.

What occurs during transduction (the first phase of nociceptive pain)?

Pain signals move from the site of origin to the spinal cord. Transduction is the first phase of nociceptive pain. During this phase, injured tissue releases chemicals that propagate the pain message; an action potential moves along an afferent fiber to the spinal cord. During transmission (second phase), the pain impulse moves from the level of the spinal cord to the brain. The third phase is perception; the person has conscious awareness of a painful sensation. In phase four, modulation, the neurons from the brainstem release neurotransmitters that block the pain impulse.

Nociceptors

Specialized nerve endings designed to detect painful sensations from the periphery and transmit them to the central nervous system.

Myopia

inability to see objects that are far away

Hyperopia

inability to visually accommodate near objects

Astigmatism

irregular corneal curvature

Fanning of toes when the sole of the foot is firmly stroked

= Positive Babinski reflex that is indicative of corticospinal pathology in an adult

Movement of eyes toward the opposite side when head is turned

= the oculocephalic or oculovestibular reflex (a normal finding)

Positive Romberg Test

A client is asked to close eyes when standing. If balance is lost after the client's eyes are closed, a positive Romberg test suggests that there is a sensory cause. Romberg test evaluates proprioception

Animism

A preschooler concerned about his or her doll: "My doll will cry if I will ignore her for too long."

Risk factors that may lead to skin disease and breakdown include:

Accumulating factors that place an aging person at risk for skin disease and breakdown include thinning of the skin, decrease in vascularity and nutrients, loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, social changes of aging, an increasingly sedentary lifestyle, and the chance of immobility. Aging results in the loss of protective cushioning of the subcutaneous layer of the skin. Aging results in decreased vascularity of the skin. Aging results in thinning of the skin.

What does the presence of ketones in the urine of a client with renal dysfunction indicate?

Anorexia nervosa The body of a client with anorexia nervosa produces ketones as an alternate source of fuel for muscles and organs. Increased RBCs in the urine indicate cystitis. Increased specific gravity of the urine indicates heart failure. The presence of casts in the urine indicates urinary calculi.

A client presents to the office with complaints of swelling in the legs, chills and shortness of breath. During auscultation of the chest, a heart murmur is heard. The client's blood culture reveals a microorganism in the blood. When a microorganism is found in the blood, this conditions is called

Bacteremia Bacteremia is the presence of bacteria in the blood. Clients with a heart murmur and bacteremia may have endocarditis. Endocarditis is inflammation of the lining of the heart and the valves of the heart. Manifestations of endocarditis includes fever, chills, heart murmur, fatigue, joints and muscles that ache, coughing, swelling in the extremities, shortness of breath and blood in the urine.

What is the source of deep somatic pain?

Bones and joints Deep somatic pain comes from the blood vessels, joints, tendons, muscles, and bones. Cutaneous pain is derived from skin surface and subcutaneous tissues. Visceral pain originates from the larger interior organs such as the pancreas. Visceral pain originates from the larger interior organs such as the intestine.

An adult patient's pulse is 46 beats per minute. The term used to describe this rate is:

Bradycardia A HR less than 50 BMP in an adult is bradycardia. A HR grater than 90 BPM in an adult is tachycardia. Weak and thready describes the force of the pulse reflecting a decreased stroke volume. Sinus arrhythmia is a pulse that is irregular, the HR varies with the respiratory cycle.

A client who had a cesarean birth is unable to void 3 hours after the removal of an indwelling catheter. How would the nurse evaluate the client for bladder distension?

By palpating the client's suprapubic area gently. Palpation will indicate whether bladder distention is present. The increased intra-abdominal space available after birth can result in bladder distention without discomfort. Assessment should be done before interventions. Trauma to the area makes surrounding organs atonic; the client may have a full bladder and not feel the urge to void.

An adolescent with Duchenne muscular dystrophy has received care at the pediatric clinic since early childhood. Of which body system should the nurse perform a focused assessment to identify life-threatening complications as the child ages?

Cardiopulmonary As muscular degeneration advances in the adolescent, the diaphragm, auxiliary muscles or respiration, and heart are affected, resulting in life-threatening respiratory infections and heart failure. Central nervous system functioning is not affected by Duchenne muscular dystrophy. Nutritional problems are less of a priority then cardiopulmonary. Although the musculoskeletal system will exhibit marked degeneration, it is second in priority to the cardiopulmonary changes.

What is the priority nursing intervention for a school-aged child with lead poisoning who is undergoing chelation therapy?

Careful monitoring of intake and output. Kidney function must be adequate to excrete the lead; if it is not adequate, nephrotoxicity or kidney damage may result. Skin breakdown is not associated with chelation therapy. A high-protein diet is not necessary. Liver damage does not occur with chelation therapy

The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump?

Checking for residual stomach contents. Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. Aspiration can occur if a feeding is started with excessive residual. Checking for last bowel movement is important but not crucial as checking for gastric residual. Knowledge of last nausea medication is not necessary at this time. Clients receiving nasogastric tube feeding must have the head of their bed elevated to at least 30 degrees.

When a client who has had a mastectomy returns from surgery, a dressing and a portable wound drainage system to the axillary area are in place. The nurse notes an excessive amount of serosanguineous drainage on the mastectomy dressing. What is the nurse's next action?

Checking the function of the drainage system If the tubing is patent and negative pressure is present, the wound should be free of exudate. Drainage is to be expected; it is the nurse's responsibility to maintain the drainage system. Pressure drainings are not used with portable wound drainage systems because the systems are effective in removing interstitial fluid. Although elevating the arm may facilitate drainage, it is not the priority in relation to the data presented.

To determine if a dark-skinned patient is pale, the nurse should assess the color of the:

Conjunctivae or mucous membranes

Myexdema

Deficiency of thyroid hormone. If severe, the symptoms include nonpitting edema or myxedema, a puffy edematous face, especially around the eyes (periorbital edema); coarse facial features; dry skin; and dry coarse hair and eyebrows. ongenital hypothyroidism is a thyroid deficiency that occurs at an early age; characteristics include low hairline, hirsute forehead, swollen eyelids, narrow palpebral fissures, widely spaced eyes, depressed nasal bridge, puffy face, thick tongue protruding through an open mouth, and a dull expression. Scleroderma is a rare connective tissue disease characterized by chronic hardening and shrinking degenerative changes in the skin blood vessels, synovium, and skeletal muscles. Hashimoto thyroiditis is a condition with excess thyroid hormone production; symptoms include goiter, nervousness, fatigue, weight loss, muscle cramps, heat intolerance, tachycardia, shortness of breath, excessive sweating, fine muscle tremor, thin silky hair and skin, infrequent blinking, and a staring appearance.

Depression

Depression is characterized by feelings of hopelessness, helplessness, and despair, leaving little room for any pleasure; alteration in appetite (either decreased or increased) is common in depressed clients. Although there is a narrowing of perception, rigidity is uncommon with depression. Fatigue is continually present and does not alternate with a high energy level. There is a loss of interest in socialization and little participation in activities of daily living.

Which clinical manifestation would cause the nurse to suspect that a toddler-age client ingested a corrosive agent, such as bleach?

Drooling is often associated with the ingestion of a corrosive agent, such as bleach. Choking, gagging, and vomiting are clinical manifestations associated with the ingestion of hydrocarbons, not corrosive agents

When taking the health history, the patient complains of pruritus. What is a common cause of this symptom?

Drug reactions Drug reactions can lead to pruritus or itching. Excessive bruising can occur in response to a traumatic event or a coagulation abnormality. It is associated with erythema, not pruritus. Hyperpigmentation is related to color changes. Melasma (also known as chloasma or the mask of pregnancy) is a facial skin discoloration related to hormones of pregnancy.

A client has a kidney transplant. The nurse should monitor for which assessment findings associated with rejection of the transplant?

Fever is a characteristic of the systemic inflammatory response to the antigen (transplanted kidney). Oliguria or anuria occurs when the transplanted kidney is rejected and fails to function. Weight gain can occur from fluid retention when the transplanted kidney fails to function or as a result of steroid therapy; this response must be assessed further. Jaundice is unrelated to rejection. Polydipsia is associated with diabetes mellitus; it is not a clinical manifestation of rejection.

A young pregnant adolescent reports bleeding and abdominal pain and is diagnosed with an ectopic pregnancy. Which risk factors should the nurse look for in the client? Select all that apply.

Habit of smoking, Damage to the Fallopian tubes, history of pelvic inflammatory disease. Adolescents who smoke experience a higher risk for ectopic pregnancy. Inflammation of the fallopian tubes and ovaries and a history of pelvic inflammatory disease are risk factors. The use of contraceptive pills and a history of irregular menses are not associated with ectopic pregnancy.

Inspiratory and expiratory stridor may be heard in a client who what?

Has aspirated a piece of meat. Inspiratory and expiratory stridor is a low pitched crowning sound heard in clients who have a foreign body obstructing the trachea or main stem bronchi. Acute asthmatic attacks are characterized by wheezing. Goiter attacks and sever laryngtracheitis are associated with inspiratory stridor only.

An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 105° F. Which condition does the nurse suspect in the client?

Heat stroke Older adults are more at risk of heat stroke. Symptoms of heat stroke include giddiness, excessive thirst, nausea, and increased body temperature. Heat exhaustion is indicated by a fluid volume deficient. Heat exhaustion occurs when profuse diaphoresis results in excess water and electrolyte loss. Accidental hypothermia usually develops gradually and goes unnoticed for several hours. When the skin temperature drops below 95 degrees F, the client suffers from uncontrolled shivering, memory loss, depression, and poor judgment. Malignant hyperthermia is an adverse effect of inhalation anesthesia that is indicated by a sudden rise in body temperature in intraoperative or postoperative clients.

Which behavior noted by the nurse when observing a preschool-age client indicates the end of the Oedipus or Electra complex?

Identification with same-sex parent

Neuropathic pain

Implies an abnormal processing of the pain message. Neuropathic pain results from abnormal processing of the pain message. Neuropathic pain does not adhere to the typical and predictable phases inherent in nociceptive pain.

You are assisting the doctor with a sterile procedure. You notice that the doctor's hand touches one of a non-sterile area for a moment. What should you do?

Inform the doctor immediately of the break in sterile procedure & Provide the doctor with new sterile gloves. Patient's well-being is most important. To prevent infection the break in sterile procedure must be addressed immediately. There is no way to prevent infection if the incident is reported after the procedure is complete.

Back channeling

Involves the use of active listening prompts such as "Go on...", "all right", and "uh-huh." Such prompts encourage the client to complete the full story.

Endogenous obesity

Is caused by excess adrenocorticotropin production by the pituitary gland Adrenocorticotropin stimulates the adrenal cortex to secrete excess cortisol and causes Cushing syndrome, which is characterized by weight gain and edema with central trunk and cervical obesity. Excessive catabolism causes muscle wasting with thin arms and legs. Body fat is evenly distributed in exogenous obesity because of excessive caloric intake. Acromegaly is caused by an excessive secretion of growth hormone in adulthood.

A nurse is assessing an older adult during a regular checkup. Which findings during the assessment are normal?

Loss of turgor, Decreased night vision, Decreased mobility of ribs. In older adults, the skin loses its turgor or elasticity and there is fat loss in the extremities. Visual acuity declines with age; therefore, decreased night vision is a normal finding in older adults due to cartilage. Diminished sensitivity to odor is often found. Urinary incontinence is an abnormal finding in older adults.

A dispersion consists of a solute dispersed through a dispersing vehicle. Which of the following dispersions is a liquid for topical application that contains insoluble solids or liquids?

Lotion A lotion is a liquid for topical application that contains insoluble solids or liquids. An ointment is a semisolid dosage form for topical application. A paste is similar to an ointment that contains more solid materials. A gel is a two-phase system that has a semisolid form.

Which is an independent nursing action that should be included in the plan of care for a client after an episode of ketoacidosis?

Monitoring for signs of hypoglycemia resulting from treatment. During treatment for acidosis, hypoglycemia may develop. Careful observation for this complication would be made by the nurse. Withholding all glucose may cause insulin coma. Whole milk and fruit juices are high in carbohydrates, which are contraindicated immediately following ketoacidosis. The regulation of insulin depends on the prescription for coverage- the prescription usually depends on the client's blood glucose level rather than ketones in the urine.

A student nurse has been assigned to teach fourth graders about hygiene. While preparing, the student nurse adds information about the sweat glands. Which of the following should be included while discussing this topic?

Newborn infants' eccrine glands do not secrete sweat in response to heat until the first few months of life; newborn temperature regulation is ineffective. There are two types of sweat glands: eccrine glands and apocrine glands. The evaporation of sweat reduces body temperature. The apocrine glands produce a thick, milky secretion and open into the hair follicles; they are located mainly in the axillae, anogenital area, nipples, and navel.

A nurse is caring for a child with newly diagnosed acute lymphoblastic leukemia. What clinical findings does the nurse anticipate when assessing the child?

Pallor, fatigue, and multiple bruises. Pallor is the result of anemia associated with leukemia. Fatigue is the result of anemia associated with leukemia. Multiple bruises are the result of thrombocytopenia associated with leukemia. Jaundice usually indicates liver damage or excessive hemolysis and is not an early sign of leukemia. Edema is not a manifestation of the disease because the pathophysiology does not involve transport of fluids.

A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity is scheduled for a femoral angiogram. What would be appropriate for the nurse to include in the postprocedure plan of care?

Perform a neurovascular assessment every 2 hours. Because of the trauma associated with the insertion of the catheter during the procedure, the involved extremity should be assessed for sensation, motor ability, and arterial perfusion; hemorrhage or an arterial embolus can occur. The client has an arterial problem, and perfusion (passage of fluid through the circulatory system or lymphatic system to an organ or tissue) is promoted by keeping the legs ar the level of or lower than the heart. A general anesthetic is not used; therefore voiding is not a concern. Keeping the client in high-Fowlers is unsafe; this position increases pressure in the groin area, which can dislodge the clot at the catheter insertion site, resulting in bleeding. It also impedes arterial perfusion and venous return.

The general survey consists of four distinct areas. They include:

Physical appearance, body structure, mobility, and behavior. The general survey is a study of the whole person, covering the general health state and obvious physical characteristics. The general survey does not include assessment of mental status and physical condition.

A flat macular hemorrhage is called a(n):

Purpura Purpura is a flat, macular, red-to-purple hemorrhage that is a confluent and extensive patch of petechiae and ecchymoses greater than 3 mm. An ecchymosis is a hemorrhage that is greater than 3 mm. Petechiae are tiny punctate hemorrhages that are 1 to 3 mm; round and discrete; and dark red, purple, or brown caused by bleeding from superficial capillaries. Hemangiomas are vascular lesions caused by a benign proliferation of blood vessels in the dermis.

A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is priority?

Respiratory exchange The respiratory center in the medulla oblongata can be affected with acute Guillain-Barre syndrome because the ascending paralysis can reach the diaphragm, leading to death from respiratory failure. Although urinary output, sensation to touch, and neurologic status are important, none of them are the priority.

What is the emergency care for a drowning client?

Safely rescuing the client The emergency care for a drowning client is focused on safe rescue of the victim. Oxygen is administered after the client is brought to a safe area. Gastric contents are prevented from aspiration after the client is safely removed from the water. Cardiopulmonary resuscitation is performed after the client is rescued.

The nurse is caring for four clients admitted at the same time under mass casualty conditions. Based on this data, which client should be given the highest priority for treatment? Massive head trauma Open fracture with a distal pulse Shock Strains and contusions

Shock Client C reporting with shock is identified with a red tag, indicating an immediate threat to life. The client with the massive head trauma is labeled with a black tag, which indicates the client is deceased or expected to die, so treatment will not be provided in order to maximize resources to save the most clients possible. The client reporting with an open fracture with distal pulse is triaged as class 3 where the treatment is considered urgent but less so than for a red-tagged client. Strains and contusions are minor injuries and are considered nonurgent- client D should be triaged as class III.

Physical appearance includes statements that compare appearance with:

Stated age Physical appearance includes statements that compare appearance with age, sex, level of consciousness, skin color, and facial features. Behavior is compared with mood and affect. Mobility is compared with gait. Body structure is compared with nutrition.

A client is admitted to the hospital for observation after an accident. The client is oriented to person, place, and time, and vital signs are within normal ranges. When performing an assessment, the nurse observes a clear, watery drainage oozing from the client's ear. What should be the nurse's first action?

Test the fluid for glucose and apply a sterile dressing. The presence of glucose indicates that the drainage is cerebrospinal fluid (CSF); a sterile dressing prevents microbial contamination. Positioning the client so that the unaffected ear is dependent may cause retention of CSF and increase intracranial pressure. attempts to clean the ear may cause microbial contamination; clean cotton balls are not sterile.

Best site to inspect on a client suspected to have jaundice

The sclera is the best site to inspect for jaundice. Because the skin may become pale due to anemia or jaundice, a skin inspection is not recommended. The palms and conjunctiva are inspected to assess pallor.

What disease is more commonly seen in preschoolers?

Toddlers and preschoolers are very prone to developing upper respiratory tract infections such as sinusitis. Lung cancer is seen commonly in young or middle-aged adults due to a smoking habit. Hypertension is commonly seen in middle-aged adults due to an unhealthy diet, lack of exercise, and stress. Angina also tends to affect young and middle-aged adults

Oliguria

Urine output that is less than 1 ml/kg/h in infants, 0.5 ml/kg/h in children, and 400 ml daily in adults. It is one of the clinical hallmark signs of renal failure an has been used as criteria to diagnose and stage acute kidney injury (aka acute renal failure)

An example of a primary lesion is a(n):

Urticaria is a primary lesion; a primary lesion is one that develops on previously unaltered skin. Erosions are secondary lesions; a secondary lesion is one that changes over time or changes because of a factor such as scratching or infection. Ulcers are secondary lesions; a secondary lesion is one that changes over time or changes because of a factor such as scratching or infection. A port-wine stain is a vascular lesion.

Probing

Using open-ended questions such as "What else is bothering you?" to obtain more information until the client has nothing more to say

Which of the following statements regarding cultural/racial differences in the treatment of pain is true?

White individuals receive more analgesic therapy than black or Hispanic individuals with similar symptoms.

Lovett score

Zero (0)- "No evidence of contractility." Trace (T)- "Evidence of slight contractility." Poor (P)- "Complete range of motion with gravity eliminated." Fair (F)- "Complete range of motion with gravity." Good (G)- "Complete range of motion against gravity with some resistance." Normal (N)- "Complete range of motion against gravity with full resistance."

Presbyopia

loss of accommodation associated with age