HESI Health Assessment
The correct method for measuring blood pressure includes deflating at what speed to identify the systolic pressure reading? 6-8 mmHg/second 15-20 mmHg/second 25-30 mmHg/second 2 to 3 mmHg/second
D
The nurse is assessing an elderly client with presbycusis. While gathering subjective data, it would be important for the nurse to: Ask how the hearing loss is impacting his daily life. Speak very loudly and slowly so the patient can hear the questions. Check for obstruction of the auditory canal as a possible cause. Assess for otitis media as a possible cause.
A
The nurse is assessing a client who recently suffered a stroke. Speech is impaired, although comprehension is intact. This finding reflects which type of aphasia? Global. Dysphonic. Wernicke's. Broca's.
D
A 28 year-old is brought to the emergency department. He is disoriented and hallucinating, and vital signs are elevated. The nurse suspects that the patient is experiencing withdrawal symptoms from which substance? Alcohol. Cocaine. Cannabis. Opiates.
A- hallucinations and delirium are commonly seen w alcohol withdrawal
During a skin assessment, the nurse notes these lesions on a client's leg. The client says they are "itchy" and they appeared 2 days ago after a hike. What should the nurse document? *picture looked like hives* Papules. Urticaria. Vesicles. Macules.
B
During a thyroid examination of a client presenting with "fatigue", the nurse observes no obvious enlargement. What should the nurse do next? Assume no abnormalities and document "no enlargement." Palpate the gland using a posterior approach. Auscultate the area for a bruit. Percuss the area for dullness.
B
An elderly client with chronic obstructive pulmonary disease (COPD) and lung cancer has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding as a result of these disorders? Cherry red color to the oral mucosa. Taut skin turgor. Nail base angle >180 degrees. Scleral icterus.
C
During an assessment of a 4 month-old presenting with "vomiting and diarrhea", the nurse notes that the fontanels are markedly concave. Based on this assessment finding, what should the nurse do next? Palpate for pitting edema over the wrist area. Pinch skin on the abdomen and assess for recoil. Document this expected finding. Perform an ophthalmic exam to assess for papilledema.
B
During a general survey of a 20 year-old patient presenting with "ear pain", the nurse observes ptosis and drooling from the left side of the mouth. The nurse suspects dysfunction of which cranial nerve (CN)? CN II. CN IV. CN VII. CN V.
C
An elderly client with pneumonia is being treated in the intensive care unit (ICU). He is acutely agitated, restless, and disoriented. The nurse documents his level of consciousness as: Manic. Demented. Drowsy. Delirious.
D
During an examination of a 70 year-old client presenting with "rash", the nurse notices small grouped vesicles along the left side of the client's chest. The client says it started earlier in the week and it is "very painful." The nurse suspects: Kaposi Sarcoma. Herpes zoster. Candidiasis. Allergic drug reaction.
B
During an eye assessment of a black patient, the nurse would consider which of these an expected finding? Yellow nodules covering the cornea. Gray-blue tint to the sclera. Asymmetry of the palpebral fissures. Pale conjunctivae.
B
The RN is gathering the vital signs of an adult athlete and finds the following: temperature-36.9° C; pulse-48 beats per minute; respirations-12 breaths per minute; blood pressure-104/58 mm Hg. What should the nurse do next? Continue with the exam; these are normal vitals for a healthy, athletic adult. Document "bradypnea" in the client's chart. Notify the physician of the pulse and blood pressure. Recheck all vital signs to confirm the findings.
A
The nurse is assessing an 88-year-old male patient. Which of the following assessment findings are expected in older adults? Additional fat deposits on the abdomen. Presence of lordosis and a narrow stance. Body changes including a longer trunk and shorter extremities. Increase in muscle mass from his younger years.
A
An elderly woman is brought to the hospital after her children found her confused and lying on the floor at home. Which examination finding is is most suggestive of dehydration in this client? Parched skin on the hands and legs. Sagging skin. Brittle, coarse hair. Dry mucous membranes.
D
During a general survey of a post-operative patient, the nurse notes that the patient's eyes are closed but they temporarily open with loud verbal stimulus and a gentle shake to the shoulder. The nurse documents his level of consciousness as: Alert. Somnolent. Stuporous. Obtunded.
D
A 12 year-old child presents to the clinic complaining of "ear pain". The mother accompanies the child. The nurse utilizes which technique? While inserting the otoscope, the nurse pulls the pinna up and back. The nurse examines the middle ear with the child in the prone position. The nurse percusses the mastoid process for dullness. The nurse pulls the pinna straight down and inspects the tympanic membrane with the penlight.
A
A 46-year-old male presents to the Emergency Department with syncope. He says his cardiologist recently placed him on a new medication for his blood pressure (BP). What should the nurse do first? Obtain orthostatic vital signs. Educate the patient on homeopathic methods to control his BP. Administer a fluid bolus. Advise the patient to stop taking this medication.
A
A 5-year-old boy is brought to the emergency department by his mother. He points to his stomach and says, "Owie." Which pain assessment tool would be the best choice when assessing this child's pain? Wong-Baker FACES Pain Scale The nurse should use only objective data to assess for pain. Numeric rating scale Descriptor Scale
A
A 50 year-old patient is in the intensive care unit (ICU) with septic shock. The nurse receives an order to notify the provider if the patient's mean arterial pressure (MAP) is <60 mmHg. What does the nurse understand to be true? A MAP >60 is needed to maintain adequate tissue perfusion. MAP can only be obtained by using a noninvasive blood pressure (NIBP) monitor. MAP is the average of the systolic and diastolic pressures. A MAP of 40-60 mmHg indicates that the stroke volume is adequate.
A
A client presents with an acute strep throat infection. Upon examination of the lymph nodes, the nurse expects to palpate: Enlarged and tender submandibular nodes. Hard and immobile preauricular nodes. Atrophied and firm occipital nodes. No change in the lymph nodes.
A
A man is at the clinic for a complete physical exam. He states that he is "very anxious". What steps can the nurse take to make him more comfortable? Appear confident and unhurried during the exam. Measure vital signs at the end to allow the patient sufficient time to relax. Let him leave his clothes on during the examination. Obtain another nurse to examine the patient.
A
A neonatal nurse is performing morning assessments. Which finding does the nurse prioritize reporting to the physician? Appearance of a blue tint to the face during feeding in a 4-hour old infant. Yellow sclera in a 2 day-old infant. Generalized red rash in a 4 day-old infant. Small white papules on the face in a 2 week-old infant.
A
An adolescent male has been brought into the emergency department after a motorized scooter accident. How should the nurse begin the mental status examination? Assess the patient's level of consciousness. Assess the patient's judgment. Assess the patient's recent memory. Determine if the patient has suicidal thoughts.
A
An adolescent presents to the emergency department after getting into a fist fight at school. He has significant swelling around his eye. What other symptom leads the nurse to suspect retinal detachment? Loss of vision in one quadrant of the eye. Bilateral loss of central vision. Clear rhinorrhea and facial pain. Photosensitivity and a nonreactive pupil.
A
An adult client with liver failure has deep pitting edema all over his body. Based on this finding, the nurse documents: Anasarca. Scleroderma. Jaundice. Erythema.
A
As a mandatory reporter, the nurse notifies the authorities with which of the following? Suspicion of child or elder abuse/neglect. Proof of substance abuse in minors. Any bruising on a child or older adult. Proof of intimate partner violence.
A
During an examination of a toddler presenting for a well check, the nurse performs an otoscopic examination to assess the tympanic membrane (TM). Which assessment finding is normal? TM is slightly retracted with a pearly gray color. TM appears amber-colored with absence of cerumen. TM appears light pink and slightly convex. TM is mobile and appears reddish-orange .
A
The nurse is caring for a client with an acute traumatic injury to their arm. Which assessment is the quickest and most reliable way to assess for the status of peripheral circulation? Press on the nail bed and count how long it takes for color to return. Check the angle of the fingernail base. Assess for unequal hair distribution on the forearms. Depress firmly over the wrist to check for pitting. Capillary refill is a quick and accurate assessment
A
The nurse is caring for a client with cirrhosis. Which technique should the nurse use first to monitor for the early onset of ascites in this hospitalized client? Measure abdominal girth on a routine basis. Test for a fluid wave on the abdomen. Percuss for shifting dullness. Palpate deeply to assess for rebound tenderness
A
The nurse is caring for a patient with chronic lower back pain. The nurse knows that the most reliable indicator of pain in this client is: The patient is reporting "6/10" pain. The patient is refusing to get out of bed. The patient is refusing to eat breakfast. The patient's heart rate is 90 beats per minute.
A
The nurse observes excess body hair on the upper lip and cheeks of a client with Cushing's syndrome. The nurse documents: "Hirsutism" "Anasarca" "Alopecia" "Milia"
A
The nurse obtains which piece of data during the general survey? Client is alert and calm. Client's heart rate is 80 beats per minute. Client's body mass index (BMI) is 30. Client's lung sounds are "clear" to auscultation.
A
Which assessment finding is most consistent with psoriasis? Pink/red plaques covered with silvery scales. Unilateral vesicles on the shoulder area. Fast growing pink, scaly patches on sun-exposed areas such as the face and hands. Red nonblanching intact skin on the sacrum and heels.
A
Which statement is true regarding head and chest circumference in infants and children? The newborn head circumference is usually about 2cm larger than the chest circumference. The nurse only needs to check a head circumference in premature infants. The head and chest circumference will even out at 3 months. Chest circumference should be greater than head circumference at birth.
A
While reviewing a patient's past medical history, the nurse notes that the patient has been diagnosed with orthostatic hypotension. What does the nurse understand to be true? Patients with documented orthostatic hypotension should be taught to get up slowly. Orthostatic hypotension is more often seen in young children. Anyone with orthostatic hypotension should have their blood pressure measured on their lower extremities. Patients with orthostatic hypotension experience a drop in heart rate of at least 20 bpm with position change.
A
An 18 year-old presents to the emergency department with "headache." Which of these assessment findings alerts the nurse to recent opioid use? Pupillary constriction Hallucinations. Fever. Tachypnea.
A- constricted pupils are a sign of recent opioid use, the rest are withdrawals
A college student is brought to the emergency department with a "severe headache". The nurse assesses for what other sign associated with meningitis? Decreased range of motion in the neck. Loss of smell. Bulging fontanels. Hypothermia.
A- the acute onset of neck stiffness and pain along with headache and fever occurs with meningeal inflammation. A severe headache in an adult or child who has never had it before is a red flag. Head injury and cluster or migraine headaches are not associated with a fever or stiff neck.
The nurse is performing a head-to-toe assessment on a dark-skinned client presenting with "fatigue." To best assess for pallor, the nurse should check which of these areas? Conjunctivae. Sclera. Middle ear. Hair.
A-Pallor will be best seen in lesser pigmented areas such as the oral mucosa and conjunctivae, which are normally pink in color.
A nurse educator is leading a new graduate orientation class on pressure ulcers. Topics include pressure ulcer prevention and assessment. The nuse should include which of the following statements? Select all that apply. Common sites for pressure ulcers are the heels, sacrum, coccyx, and hips. Stage II pressure ulcers extend into the epidermis or dermis. Stage III pressure ulcers are deep, exposing muscle, bone, and tendon. Risk factors for pressure ulcers including impaired mobility, poor nutrition, and bowel and bladder incontinence. Stage I pressure ulcers appear as reddened areas that blanch with pressure. The best way to prevent pressure ulcers is to turn your immobile patients twice a day.
ABD
The nurse is examining a 92-year-old female during a check-up. The nurse concludes which findings to be normal age-associated changes? Select all that apply. Brown macules on the hands and arms. Vertical ridges on the nail beds. Tender vesicles on the left side of the face. Non blanching, red, intact skin over the coccyx bone. Bristly hairs on the chin and upper lip. Thin, loose skin with decreased turgor. 3mm pupils with a slightly sluggish pupillary light reflex.
ABEFG
A patient with a history of alcoholism has been admitted to the ICU after surgery. The nurse closely monitors him for symptoms of alcohol withdrawal, including which of the following? Select all that apply. Elevated vital signs. Constricted pupils. Muscle aches. Nausea and vomiting. Headache. Auditory hallucinations.
ADEF
During new grad orientation, the nurse teaches about normal changes that can be expected in older adults. What should the nurse include in the teaching? Older adults have a slower respiratory rate. Older adults often have a wider pulse pressure. Older adults normally have joint pain. Older adults have a higher core body temperature.
B
A Chinese family presents to the clinic with flu-like symptoms. Upon examination of the 8 year-old child, the nurse notices linear bruising covering the chest and back . What should the nurse do first? Notify Child Protective Services. Perform a cultural assessment. Take photographs of the bruises. Document the finding as suspected abuse.
B
A father brings his 10 month-old child to the clinic for a check-up. General survey reveals a yellow-orange tint to the child's face and hands. Sclera is white. What should the nurse do next? Reassure the father that this is an expected finding from eating too many Vitamin C-rich foods. Obtain a nutritional history. Document "acrocyanosis" in the client's chart. Notify the provider about your concern for jaundice.
B
A patient with a body mass index (BMI) of 24 falls under which category? Obese. Healthy weight for height. Extreme obesity. Overall rweight.
B
An elderly client presents to the clinic complaining that her mouth and eyes have become "very dry" within the past few weeks, enough so that her taste and vision have been affected. What question or statement should the nurse use next? "This dryness is normal with age. You will adapt to these changes.' "Have you started any new medications?" "Let's refer you to an ophthalmologist to check your vision." "You aren't drinking alcohol, are you?"
B
An emergency department nurse is examining a client newly admitted with pneumonia. The nurse depresses the client's nail beds and notes that color return takes 4 seconds. The nurse's immediate response is to: Document "Brisk capillary refill" in the client's chart. Assess for other signs of poor perfusion. Understand this to be an expected finding in clients with pneumonia. Ask another nurse to assess the cap refill.
B
The nurse is assessing an 80 year-old client presenting for an annual check-up. As the nurse begins the mental status portion of the assessment, the nurse expects which finding? The patient will have no decrease in any of his abilities. Verbal responses may be slightly delayed. The patient may be disoriented to place. The patient may have mood swings and lapses in judgment.
B
The nurse is assessing an adult Black client presenting to the emergency department with gastrointestinal bleeding. Interview reveals that the patient is on blood thinners. The nurse knows to observe for petechiae in which area? Genitalia. Oral mucosa. Scalp. Middle ear.
B
The nurse is conducting a mental status assessment on an adult female recovering from alcohol withdrawal. Which question by the nurse would best assess a person's judgment? "What is the similarity between a watch and a ruler?" "What are your plans once you leave the hospital?" "What brought you into the hospital 7 days ago?" "Do you ever see or hear things that aren't really there?"
B
The nurse is preparing to perform brief head-to-toe assessments on assigned patients. Which technique is correct? The nurse uses the base of the fingers to assess pulsations. The nurse uses the ulnar surface of the hands to assess vibrations. The nurse uses the palmar surface of the hand to assess skin temperature. The nurse uses the dorsum of the hand to assess for crepitus.
B
The school nurse is conducting a pain assessment on an adolescent presenting with "back pain that started last week." What should the nurse ask first? "How have you treated it?" "What were you doing when this pain started?" "Why do you think you are having this pain?" "Is it affecting your daily life?"
B
When assessing a 70-year-old patient with heart failure, the nurse notes he is consistently leaning forward with arms on the bedside table. What does the nurse understand to be true? The patient is eager and interested in participating in the exam. This position is often used when a patient is having respiratory difficulties. This is suspicious for pain; a focused abdominal exam should be prioritized. The client is in respiratory distress and should be assisted to a prone position.
B
While examining the nares of an adult patient presenting with "cough and watery eyes" the nurse notices pale, swollen turbinates with clear nasal discharge. These findings are most consistent with which condition? Foreign object. Allergic rhinitis. Acute sinusitis. Epistaxis.
B
Which of the following actions should the nurse take to ensure an accurate blood pressure (BP) reading? Ensure the width of the BP cuff is equal to 80% of the arm circumference. Ensure the client's back is supported and feet are flat on the ground. Take two BP readings 20 seconds apart. Ensure that the patient's arm is above heart level.
B The patient's arm should be supported at heart level. Separate BP readings may need to be taken, but not one right after the other. The length of the BP bladder should equal 80% of the arm circumferen
Which of these situations could result in a falsely low blood pressure reading? Select all that apply. The cuff is loosely wrapped around the arm. The arm is held above the level of the heart. The person is sitting with his or her legs crossed.! The nurse does not inflate the cuff high enough. The blood pressure cuff is too small for the extremity.
B D
During a complete HEENT and cranial nerve examination of a 65 year-old female, the nurse notices that the tonsils are halfway to the uvula, pink, and covered with crypts. What should the nurse do next? Gently touch the oropharynx with the tongue blade to test CNs IX and X. Assess for CN XII by having the client say "ahhhhh." Refer the patient to an allergy specialist. Obtain a throat culture upon suspicion of Group A Strep infection.
B The assessment findings are normal, so a throat culture and referral are not needed. CN XII is assessed by having the client stick out their tongue.
The nurse is performing a physical examination on a child with strabismus and expects to assess: Ptosis. Asymmetrical corneal light reflex. Absence of a red reflex. Nystagmus
B- Asymmetric corneal light reflex and an abnormal cover test are found with strabismus. Absence of red reflex is consistent with cataract. Poor peripheral vision describes glaucoma. Unequal palpebral fissures describes ptosis.
Which error may result in a falsely low blood pressure (BP) reading? The patient has a full bladder. The arm is held above the level of the heart. The cuff size is too small for the client. The BP cuff is wrapped loosely around the arm.
B- at heart level
A mother brings her toddler in for a "runny nose" that "started suddenly this morning". The nurse notes a purulent, serosanguinous drainage coming from the right nare. The child's vital signs are within normal limits. What should the nurse do next? Refer to the provider for an antibiotic prescription. Inspect the right nare with the otoscope. Obtain a throat culture for possible strep infection. Tell the mother that this drainage is normal for a toddler.
B-Children are prone to put an object up the nose, producing unilateral purulent drainage with a foul odor. Because some risk for aspiration exists, removal should be prompt.
The nurse is examining a patient with Grave's disease. What findings are consistent with an overactive thyroid? Select All That Apply. Unintentional weight gain. Diaphoresis Exophthalmos. Swelling of the hands and face. Tremors. Decreased heart rate.
BCE
A 40 year-old patient with hypertension (HTN) presents to the internal medicine clinic for an initial visit. When obtaining the patient's blood pressure (BP), how should the nurse proceed? Cuff should be inflated to the exact point at which the palpated pulse disappeared. Cuff should be inflated to about 200 mmHg and then slowly deflated. Cuff should be inflated about 20-30 mmHg above the palpated systolic BP. Cuff should be inflated 30 mm Hg above the patient's pulse rate.
C
A father brings his 13 month-old child in for "fever" and he reports that the child has been "pulling on his left ear". Upon entering the exam room, the child is asleep in the father's arms. The nurse should perform which assessment first? Use the otoscope to look inside the ear. Use a penlight to check the eyes and nose. Auscultate the lungs, heart, and abdomen. Assess gross motor skills using the Denver II screening tool.
C
During an integumentary exam, the nurse notices a lesion that is suspicious of basal cell carcinoma. What data leads the nurse to this conclusion? A raised pink, scaly patch on a sun-exposed area. A nevus with color variation and irregular borders. A non healing pearly papule with a central red ulcer. A flat brown macule on the forearm.
C
The neonatal nurse notices that an infant's head looks enlarged compared to the previous shift. The nurse assesses for what other sign of hydrocephalus? Upward palpebral slant. Depressed fontanels. Downcast eyes. Lymph node enlargement.
C
The nurse is assessing a newborn infant. How should the nurse measure the heart rate (HR)? Palpate the radial pulse for 15 seconds and multiply by four. Palpate the brachial pulse for 30 seconds and multiply by two. Auscultate the apical site for 60 seconds. Apply a pulse oximeter to obtain both the HR and SpO2.
C
The nurse is assessing an adult client recovering from abdominal surgery. Which finding causes the nurse to suspect acute hypoxia in this client? barrel chest. clubbing of distal phalanx. sudden anxiety and restlessness. respiratory rate 20 breaths per minute.
C
The nurse is assessing an elderly client presenting for an annual check-up. What question would be best for the nurse to use to assess cognitive function in this client? "Do you ever feel like people are watching you?" "What are your health goals?" "What have you eaten in the last 24 hours?" "Are you in any pain?"
C
The nurse is caring for a client with a severe deficiency of thyroid hormone. Examination reveals decreased vital signs, weakness, and nonpitting edema on the face. The nurse documents: exophthalmos. anasarca. myxedema. scleroderma.
C
The nurse is examining a 68 year-old male with a "hearing problem." The client says it started suddenly last week, is worse in the left ear, and it sounds like everyone is mumbling and whispering but it helps when they talk louder. Based on subjective data, what should the nurse do first? Assess his mood and ask how the hearing loss is affecting his life. Assume the client is developing presbycusis and refer for audiometric testing. Perform an otoscopic examination of the external and middle ear. Suspect a sensorineural loss and assess the functions of the inner ear.
C
The nurse is examining a client with cataracts. What does the nurse expect to find during the examination? Blurred margins of the optic disk. Eye pain. Cloudy appearance to the lens. Gradual loss of peripheral vision.
C
The nurse is examining a patient presenting with "severe headache." Which assessment finding leads the nurse to suspect increased intracranial pressure? Enlarged and tender occipital lymph nodes. Red, bulging tympanic membrane. Blurred margins of the optic disc. Pupils are 4mm and reactive.
C
The nurse is examining a patient undergoing withdrawal from opiates. The temperature is 102 degrees Fahrenheit. What other vital sign change does the nurse expect to find, in relation to the fever? Low oxygen saturation. Bradypnea. Elevated heart rate. Hypotension.
C
The nurse is teaching a pregnant client about changes she may experience during her pregnancy, including: Hard and fixed cervical lymph nodes. Moderate vision loss. Inflammation of the gums. Tender, enlarged thyroid gland.
C
Which statement is true regarding blood pressures (BP) obtained in the thigh? Thigh pressures are obtained in all clients with a history of mastectomy. Thigh BPs should be obtained in all clients to compare to the brachial BP. Systolic blood pressures in the thigh are higher compared to the arm. Thigh BPs are obtained with the client sitting.
C
While collecting the pulse on a 26 year-old client, the nurse notes that the heart rate seems to speed up and then slow down in accordance with respirations. The pulse is counted at 80 beats per minute. What should the nurse do next? Obtain orthostatic vital signs. Notify the physician. Document "sinus arrhythmia." Use a doppler to confirm the finding.
C
the nurse notes a patient's peripheral pulse is weak and barely palpable, the nurse document the pulse force? 0 3+ 1+ 2+
C
The nurse is assessing an adult male client presenting with "abdominal pain". Which finding is considered normal? Pulsatile, whooshing sounds heard during auscultation with the bell. Dark, tarry stools. Drumlike notes heard during percussion. Protuberant abdominal contour.
C tympany?
A 62 year-old female presents to the clinic with epistaxis lasting 6 hours. What is a priority question for the nurse to ask? "Do you smoke or drink alcohol?" "What have you eaten in the last 24 hours?" "Do you take any medications?" "Have you recently been on antibiotics?"
C- Epistaxis (bleeding from nose) can result from trauma, forceful blowing or picking, and anticoagulant medications. A reversal agent may be needed if it is due to medication.
A 40 year-old male with no significant past medical history presents to the clinic for his "annual check-up for work". How should the nurse conduct the mental status examination (MSE)? Defer the MSE, as the client has no concerns. Begin the MSE by assessing abstract reasoning and judgment. Start with a brief MSE by incorporating it into the interview. Integrate the Mini-Cog into the exam.
C- Integrating the MSE into the health history is sufficient for most people. You will collect ample data to be able to assess mental health strengths and coping skills and to screen for any dysfunction.
The nurse is performing a full cranial nerve (CN) examination on an adult client. Which assessments will be performed? Select all that apply. To test CN I (olfactory nerve), the nurse looks inside the nose with the otoscope. To test CN XII (hypoglossal nerve), the nurse assesses the gag reflex. To test CN XI (spinal accessory nerve), the nurse assess neck strength. To test CN VIII (vestibulocochlear nerve), the nurse observes facial symmetry. To test CN V (trigeminal nerve), the nurse assesses jaw strength. To test CN II (optic nerve), the nurse assesses extraocular movements
CE
General survey reveals pallor in a client presenting with "fatigue." What should the nurse do to further assess for signs/symptoms of an iron deficiency? Ask the client if they experience dry eyes. Observe the sclera. Examine the bones and joints. Inspect the nails.
D
A client presents to the clinic for a skin check. Which assessment finding is most suspicious for malignant melanoma? Tiny brown streaks on all of the nail beds. A 2 cm raised bright red papule on the chest. A 4 cm pink scaly patch on the forehead. An 8 mm asymmetrical nevus with purple coloration.
D
A mother brings her 6 year-old child in for "irritability." How should the nurse conduct the mental status exam? The nurse can defer the mental status exam, as irritability is normal in a 6 year-old child. The nurse should begin the exam by having the patient fill out the GAD-7 and PHQ-9. The mini-mental state exam (MMSE) should be used to obtain a baseline for cognitive ability. Appearance, behavior, cognition, and thought processes can be assessed with special consideration for developmental milestones.
D
A patient presents to the clinic with "abdominal pain." The nurse asks all of the following questions during a full pain assessment, except: "When did this pain begin?" "What does your pain feel like?" "Point to where it hurts the most." "How is your pain tolerance?"
D
An adult client presents with a "sore throat" that has "gotten so much worse over the past day". Upon examination, he is febrile, neck is swollen with decreased range of motion, and he is having a difficult time swallowing. These findings are most consistent with: Acute rhinitis. Oral malignancy. Viral sinusitis. Peritonsillar abscess.
D
An adult patient comes in with a 2-day history of nausea and vomiting. When assessing for dehydration, the most appropriate initial action by the nurse is to: Palpate the scalp for mobility. Check a urine sample. Assess for pitting edema over the tibia. Pinch skin on the forearm and assess for recoil.
D
An adult patient presents to the E.D. with "vaginal bleeding" and dizziness. Level of consciousness is decreased. The nurse prioritizes collecting which vital signs? Respiratory rate and temperature. Body mass index (BMI). Weight and oxygen saturation. Heart rate and blood pressure.
D
The nurse is assessing the intravenous (IV) line site in a dark-skinned client. The nurse utilizes which technique to best assess for localized inflammation? Checking cap refill on the nailbeds. Assessing for increased vital signs. Utilize a Wood's lamp in a dimly lit room. Palpating the skin for temperature changes and swelling.
D
The nurse is caring for an 8-year-old developmentally appropriate child who has several bruises of varying colors on the buttocks. What action should the nurse take next? Assume that the bruises were caused by spanking. Inform the child "You can tell me who did this to you and we will not allow them to see or hurt you again." Rely on the parents to provide information related to the cause of the bruising. When the child is alone, ask "How did you get these sore areas on your bottom?"
D
The nurse is examining a Black client who presents to the E.D. with nausea and vomiting. Upon examination, the client is tachycardic and tachypneic. Oxygen saturation is 98% on room air. Which assessment finding is most concerning in this patient? Yellow nodules underneath the eyelids. Thick, dark line along the gingival margin. Slight blue tint to the lips. Fruity breath odor.
D
The nurse is examining a patient with Hashimoto's disease. What sign or symptom is consistent with an underactive thyroid? Tremors. Diaphoresis. Tachycardia. Weight gain.
D
The nurse nurse is assessing a woman presenting with "headache" and identifies suspicious injuries upon skin examination. Which question or statement should the nurse use to further assess the situation? "I need to report this abuse to the authorities." "I can see you are a victim of domestic violence. Please tell me about this." "Why would somebody want to hurt you?" Correct! "These types of injuries can sometimes be caused by other people. Is anyone hurting you or frightening you?"
D
The nurse understands which statement to be true regarding pulse pressure? Pulse pressure is an indicator of tissue perfusion. Normal pulse pressure is 10-30 mmHg. Pulse pressure is often narrower in the aging adult. Pulse pressure is reflective of stroke volume.
D
The school nurse is preparing to assess the visual acuity of an adolescent. How should the nurse proceed? Test extraocular movements and nystagmus with the penlight. Observe the ocular fundus with the ophthalmoscope. Assess for pupillary constriction and convergence. Utilize the Snellen chart positioned 20 feet from the patient.
D
When evaluating the temperature of older adults, the nurse should remember which aspect about an older adult's body temperature? Fever is a reliable sign of infection in older adults. The older adult's body temperature varies widely because of the thinner subcutaneous layer. There are no differences in temperature between a young and old adult. Older adults body temperature runs lower than that of an adult.
D
Which method should the nurse use to assess for accommodation? Assess peripheral vision of the client using the confrontation test. Have the client follow an object upward, downward, obliquely, and horizontally. Touch the cornea lightly with a cotton wisp. Observe for pupil constriction and convergence with near vision.
D
During percussion of a patient's lungs, the nurse notes a clear, hollow sound. The nurse documents: Dullness. Flatness. Tympany. Resonance.
D Resonance is a clear, hollow sound normally heard over adult's lungs. Dullness is a muffled thud and if heard over the lungs, it would indicate increased density associated with consolidation (pneumonia), fluid, or a mass. Tympany is a musical, drumlike sound heard over the abdomen
A patient presents to urgent care with "excruciating" headache pain. The client reports the pain to be unilateral, occuring about twice a month, and the pain is accompanied by photophobia and nausea. These symptoms are most consistent with: Cluster headache. Sinus headache. Tension headache. Migraine headache.
D- unilateral
