Nur 112 HESI review/practice questions

orthostatic hypotension

temporary fall in blood pressure associated with assuming an upright position; synonym for postural hypotension

systolic pressure

the highest pressure, created during ventricular contractions.

orthopnea

type of dyspnea in which breathing is easier when the patient sits or stands

hyperthermia

(high body temperature) if one is exposed to extremes of heat for long periods of time, hyperthermia may result.

hypothermia

(low body temperature) When one is exposed to extreme cold without adequate protective clothing, heat loss may be increased to the point of hypothermia.

prodromal stage

*A person is most infectious during the prodromal stage.* - Early signs and symptoms of disease are present, but these are often vague and nonspecific, ranging from fatigue and malaise to a low-grade fever. This period lasts from several hours to several days. During this phase, the patient often is unaware of being contagious. As a result, the infection spreads.

Assessment techniques

*general order of assessment not including abdomen* - inspection - palpation - percussion - auscultation

Rectal temperature

*insertion of thermometer into the rectum can slow heart rate by stimulating the vagus nerve.* - Do not take rectal temperature in patients with heart disease or after cardiac surgery

Factors affecting pulse

- Age and gender - physical activity - Fever and stress - medications - disease

Factors affecting blood pressure

- Age: the older adult has decreased elasticity of the arterial walls, which increases blood pressure - Circadian rhythm: normal fluctuations occur during the day. BP is usually lowest upon arising in the morning. - gender: women usually have lower bp than men until menopause - food: bp increases after eating - exercise: systolic pressure rises during periods of strenuous activity - weight: bp is higher in people who are obese - emotional state: anger, fear, and excitement may increase bp - body position: bp is lower in prone or supine position rather than standing or sitting. -Race: hypertension is more prevalent in african americans - drugs/medications: oral contraceptives cause a mild increase in systolic pressure in many women.

Fever and stress

- An elevated body temperature causes increased pulse rate due to increased metabolic demands and compensatory mechanisms to increase heat loss. - Increased levels of stress cause an increased pulse rate. Common sources of stress associated with increased pulse rate include pain, fear, and anxiety. (and nursing school)

Cutaneous pain Visceral Pain somatic pain

- Cutaneous: skin or subcutaneous tissue - visceral: organs, abdominal, thorax, cranium - somatic: ligaments, tendons, bones, blood vessels, nerves

Affective responses to pain

- Exaggerated weeping and restlessness - Withdrawal - Stoicism - Anxiety - Depression - Fear - Anger - Anorexia - Fatigue - Hopelessness - Powerlessness

Stages of infection

- Incubation period - Prodromal stage - Full stage of illness - Convalescent period

Subjective Data

Information given to you by the patient - Sensations/symptoms - Feelings - Perceptions - Desires - Preferences - Beliefs - Ideas - Values - Personal information

Gate control theory

It describes the transmission of painful stimuli and recognizes a relation between pain and emotions. The theory states that certain nerve fibers, those of small diameter, conduct excitatory pain stimuli toward the brain, but nerve fibers of a large diameter appear to inhibit the transmission of pain impulses from the spinal cord to the brain.

Cutaneous stimulation to relieve pain

- Massage (with or without analgesic ointments or liniments containing menthol) - Application of heat or cold, or both intermittently -Acupressure - Transcutaneous electrical nerve stimulation (TENS)

Ongoing/partial Assessment

- Mini-overview - Holistic health patterns - Determines deterioration/improvement - Detects new problems

Apnea

periods where there is no breathing

nociceptors (A-delta fibers and C-fibers)

peripheral nerve endings, which transmit the sensations to the CNS

airborne precautions

- Place patient in a private room that has monitored negative air pressure in relation to surrounding areas. - Wear a mask or respirator when entering room of patient with known or suspected tuberculosis. - Transport patient out of room only when necessary and place a surgical mask on the patient if possible.

Contact Precautions

- Place the patient in a private room, if available. - Wear PPE whenever you enter the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient's environment. - Limit movement of the patient out of the room. - Avoid sharing patient-care equipment.

Initial Comprehensive Assessment

- Subjective Data - Objective Data - Past medical history - Family History - Lifestyle/Health practices

Normal Ranges for vital signs

- Temp: 37.0 degrees C; 98.6 degrees F - pulse rate: 60-100 bpm - respirations: 12-20 - BP: 120/80

Droplet precautions

- Use a private room, if available. Door may remain open. - Wear PPE upon entry into the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient's environment. - Transport patient out of room only when necessary and place a surgical mask on the patient if possible. - Keep visitors 3 feet from the infected person.

Age and gender

- Women on average have slightly higher pulse rates than men. - Pulse rate decreases as a person ages due to decreased metabolic rate.

Standard precautions (tier 1)

- follow hand hygiene techniques - wear PPE - follow respiratory hygiene/ cough etiquette - avoid recapping used needles - use safe injection practices - facemask

Types of Asepsis

- medical - surgical

mechanisms of heat transfer

- radiation - convection - evaporation -conduction

Tachypnea and bradypnea

- tachypnea: increased respiratory rate - Bradypnea: decreased respiratory rate

Vital signs

- temperature - pulse - respiration - blood pressure - pain (known as the 5th vital sign)

physiological responses to pain

-Increased blood pressure* -Increased pulse and respiratory rates* - Pupil dilation - Muscle tension and rigidity - Pallor (peripheral vasoconstriction) - Increased adrenalin output - Increased blood glucose

behavioral responses to pain

-Moving away from painful stimuli -Grimacing, moaning, and crying -Restlessness -Protecting the painful area and refusing to move

bradycardia

-decreased pulse rate - below 60 beats/min

radiating pain referred pain phantom pain

-radiating: perceived both at the source and extending to other tissues. - referred: perceived in body areas away from the pain source - phantom: perceived in nerves left by a missing, amputated, or paralyzed body part.

Tachycardia

-rapid heart rate - an adult rapid pulse rate is considered 100-180 beats/min

Possible HESI question A nurse assesses an oral temperature for an adult patient. The patient's temperature is 37.5°C (99.5°F). What term would the nurse use to report this temperature? A) Febrile B) Hypothermia C)Hypertension D) Afebrile

ANS: Feedback: Afebrile means without fever. This temperature is within the normal range for an adult

Steps of Health Assessment

1. Collection of subjective data 2. Collection of objective data 3. Validation of data 4. Documentation of data

Types of Health Assessment

1. Initial Comprehensive Assessment 2. Ongoing or partial assessment 3. Focused/problem-oriented assessment 4. Emergency Assessment

Possible HESI Question: When a nurse picks up a client's contaminated tissue without gloves and fails to wash his hands sufficiently, the nurse provides for the client's organisms to be spread by which type of transmission? a) Contact b) Vehicle c) Vector d) Airborne

ANS: A

Possible HESI question: Which of the following statements made by a patient reflects that the patient understands the relationship between the gate control theory of pain and the use of meditation to relieve pain? A) "Meditation controls pain by blocking pain impulses from coming through the gate." B) "Meditation will help me sleep through the pain because it opens the gate." C) "Meditation stops the occurrence of pain stimuli." D) "Meditation alters the chemical composition of pain neuroregulators, which closes the gate."

ANS: A Feedback: The gate theory states that pain impulses cause pain when they get through gates that are open. Pain is blocked when the gates are closed. Nonpharmacologic pain relief measures, such as meditation, work by closing the gates, which keeps pain impulses from coming through.

Possible HESI question: A nurse is assessing the vital signs of patients who presented at the emergency department. Based on the knowledge of age-related variations in normal vital signs, which patients would the nurse document as having a normal vital sign? Select all that apply. A) A 4-month old infant whose temperature is 38.1°C (100.5°F) B) A 3-year old whose blood pressure is 118/80 C) A 9-year old whose temperature is 39°C (102.2°F) D) An adolescent whose pulse rate is 70 bpm E) An adult whose respiratory rate is 20 bpm F) A 72-year old whose pulse rate is 42 bpm

ANS: A, D, E, F Feedback: The normal temperature range for infants is 37.1°C to 38.1°C (98.7°F-100.5°F). The normal pulse rate for an adolescent is 55 to 105. The normal respiratory rate for an adult is 12 to 20 bpm and the normal pulse for an older adult is 40 to 100 bpm. The normal blood pressure for a toddler is 89/46 and the normal temperature for a child is 36.8°C to 37.8°C (98.2°F-100°F;

Possible HESI: A patient complains of severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessments? Select all that apply. A) An increase in the pulse rate B) A decrease in body temperature C) A decrease in blood pressure D) An increase in respiratory depth E) An increase in respiratory rate F) An increase in body temperature

ANS: A, E Feedback: The pulse often increases when a person is experiencing pain. Pain does not affect body temperature and may increase (not decrease) blood pressure. Acute pain may increase respiratory rate but decrease respiratory depth.

Possible HESI Question: The nurse knows that which technique is best for assessing pain in a child who is 4 years of age? A) Ask the parents if they think their child is in pain. B) Use the FACES scale. C) Ask the child to rate the level of pain on a 0 to 10 pain scale. D) Check to see what previous nurses have charted.

ANS: B Feedback: Assessing pain intensity in children requires special techniques. Young children often have difficulty expressing their pain. The FACES scale assesses pain in children who are verbal. Because a 4-year-old is verbal, this is an appropriate scale to use with this child

Possible HESI question: A school nurse is performing an assessment of a student who states: "I'm too tired to keep my head up in class." The student has a low-grade fever. The nurse would interpret these findings as indicating which stage of infection? A) Incubation period B) Prodromal stage C) Full stage of illness D) Convalescent period

ANS: B Feedback: During the prodromal stage, the person has vague signs and symptoms, such as fatigue and a low-grade fever.

Possible HESI question: A patient is having dyspnea. What would the nurse do first? A) Remove pillows from under the head B) Elevate the head of the bed C) Elevate the foot of the bed D) Take the blood pressure

ANS: B Feedback: Elevating the head of the bed allows the abdominal organs to descend, giving the diaphragm greater room for expansion and facilitating lung expansion.

Possible HESI question: A nurse is administering prescribed medicine to a client who experienced acute pain in the lower back after a motor vehicle accident. The client tells the nurse that compared to the previous week, his pain had reduced considerably. Which phase of pain is the client experiencing? A) transmission B) Modulation C) conduction D) perception

ANS: B Feedback: The client is in the modulation phase of pain, during which the brain interacts with the spinal nerves in a downward fashion to subsequently alter the pain experience.

Possible HESI question: The nurse instructor is teaching student nurses about the factors that may affect a patient's blood pressure. Which statements accurately describe these factors? Select all that apply. A) Blood pressure decreases with age. B) Blood pressure is usually lowest on arising in the morning. C) Women usually have lower blood pressure than men until menopause. D) Blood pressure decreases after eating food. E) Blood pressure tends to be lower in the prone or supine position. F) Increased blood pressure is more prevalent in African Americans.

ANS: B, C, E, F

Possible HESI question: A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines? A) The nurse carries the patients' soiled bed linens close to the body to prevent spreading microorganisms into the air. B) The nurse places soiled bed linens and hospital gowns on the floor when making the bed. C) The nurse moves the patient table away from the nurse's body when wiping it off after a meal. D) The nurse cleans the most soiled items in the patient's bathroom first and follows with the cleaner items.

ANS: C Feedback: According to the principles of medical asepsis, the nurse should move equipment away from the body when brushing, scrubbing, or dusting articles to prevent contaminated particles from settling on the hair, face, or uniform.

Possible HESI question: A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment? a) To collect subjective data related to the client's overall health b) To evaluate whether outcomes of treatment are met c) To determine any changes from the baseline data d) To perform a rapid assessment for prompt treatment

ANS: C Feedback: Ongoing or partial assessments help to determine any major changes from the baseline data. The nurse collects subjective data related to the client's overall health and conducts a comprehensive health assessment during the initial comprehensive assessment to determine baseline data.

Possible HESI Question: What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery? A) Assess the patient's body language. B) Observe cardiac monitor for increased heart rate. C) Ask the patient to rate the level of pain. D) Ask the patient to describe the effect of pain on the ability to cope.

ANS: C Feedback: Pain is a subjective measure. Therefore, the best way to assess a patient's pain is to ask the patient to rate the pain.

Possible HESI question: A nurse is collecting subjective data from a client as part of the assessment process. Which behavior is most appropriate for the nurse to display in this situation? a) Remaining standing during the interview b) Reading questions from the history form c) Explaining the reason for taking down notes d) Maintaining eye contact with the client at all times

ANS: C Feedback: The nurse should explain the reason for taking notes during the interview and ensure that it will remain confidential; this will help the client to provide all the required information during the interview.

Possible HESI question: A client reports throbbing pain caused by a laceration that occurred to the finger while cutting vegetables. Which terminology should the nurse use to document this pain? (Select all that apply.) A) somatic pain B) Visceral pain C) Acute pain D) Cutaneous Pain E) Chronic pain

ANS: C, D Feedback: Cutaneous pain originates at the skin level and is commonly experienced as a sensation resulting from some form of trauma. Acute pain lasts for a few seconds to less than 6 months. Therefore, the nurse documents that the client has acute, cutaneous pain.

Possible HESI Question: Which illustrates the nurse using the technique of inspection? a) The nurse detects tympany over the patient's lower abdomen. b) The nurse notes a rhythmic lub-dub over the patient's anterior thorax. c) The nurse notes increased warmth surrounding the patient's incision. d) The nurse detects a fruity odor of the patient's breath.

ANS: D Feedback: Inspection involves conscious observation of the patient's physical characteristics and behaviors and smelling for odors. The nurse uses the technique of inspection to detect a fruity odor to the patient's breath.

Possible HESI question: Prioritization: Place the following descriptions of the phases of Korotkoff sounds in order from Phase I to Phase V. A) Characterized by muffled or swishing sounds that may temporarily disappear; also known as the auscultatory gap B) Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery C) The last sound heard before a period of continuous silence, known as the second diastolic pressure D) Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; known as the systolic pressure E) Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; considered to be the first diastolic pressure

ANS: D, A, B, E, C

Possible HESI Question: The nurse is caring for a client who has active tuberculosis (TB) and is in Airborne Precautions. The primary care provider orders a computed tomography (CT) examination of the chest. Which of the following actions by the nurse is appropriate?

ANS: Place a surgical mask on the client and transport to the CT department at the specified time.

korotkoff sounds phase 4

Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; in adults, the onset of this phase is considered to be the first diastolic pressure

korotkoff sounds phase 3

Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery

korotkoff sounds phase 2

Characterized by muffled or swishing sounds; these sounds may temporarily disappear, especially in hypertensive people; the disappearance of the sound during the latter part of phase I and during phase II is called the auscultatory gap

objective Data

Done by observation - Assessment (inspection, palpation, percussion, auscultation) - Body functions - Appearance - Behavior - Measurements (numbers) - Results of testing

Focused/problem-oriented Assessment

Focuses on a specific problem

disease

Many acute and chronic health conditions affect a patient's pulse rate. Some diseases, such as chronic obstructive pulmonary disease and pneumonia, impair oxygenation and alter the pulse rate.

Afebrile

Normal body temperature (without fever)

Emergency Assessment

Rapid- performed in life-threatening situations Example: Cardiac arrest

evaporation

The conversion of a liquid to a vapor

radiation

The diffusion or dissemination of heat by electromagnetic waves

convection

The dissemination of heat by motion between areas of unequal density

korotkoff sounds phase 5

The last sound heard before a period of continuous silence; the pressure at which the last sound is heard is the second diastolic pressure

hypertension

above normal bp

Full stage of illness

The presence of specific signs and symptoms indicates the full stage of illness.

Physical Activity

The pulse rate increases with exercise. However, well-conditioned athletes may have a significantly decreased pulse rate. This is due to greater efficiency and strength of the heart muscle from regular cardiovascular exercise.

conduction

The transfer of heat to another object during direct contact

medications

There are many medications that can cause alterations in pulse rate. Some medications increase a patient's pulse rate and others decrease a patient's pulse rate.

Transduction

Transduction of pain begins when a mechanical, thermal, or chemical stimulus results in tissue injury or damage stimulating the nociceptors, which are the primary afferent nerves for receiving painful stimuli.

Contact Precautions

Use these for patients who are infected or colonized by a multidrug-resistant organism (MDRO).

Airborne precautions

Use these for patients who have infections that spread through the air such as tuberculosis, varicella (chicken pox), rubeola (measles), and possibly SARS (severe acute respiratory syndrome).

Droplet precautions

Use these for patients with an infection that is spread by large-particle droplets such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children.

pain threshold

amount of stimulation required before a person experiences the sensation of pain

perception of pain

awareness of the characteristics of pain

hypotension

below normal bp

FLACC pain scale

can be used for children 0-5 years of age who cannot self-report pain F- face L- legs A- activity C- cry C- consolability

neuropathic pain

causes an abnormal processing of pain messages and results from past damage to peripheral or central nerves due to sustained neurochemical levels

Transmission

conduction along pathways (A-delta and C-delta fibers)

Febrile (pyrexia)

elevation above the upper limit of normal body temperature.

neuromodulators

endogenous opioid compounds, meaning they are naturally present, morphine-like chemical regulators in the spinal cord and brain.

Chronic Pain

episode of pain that lasts for 6 months or longer; may be intermittent or continuous

Korotkoff Sounds Phase 1

first appearance of faint but clear tapping sounds that gradually increase in intensity; the first tapping sound is the systolic pressure

modulation

inhibition or modification of pain

incubation period

interval between the pathogen's invasion of the body and the appearance of symptoms of infection. During this stage, the organisms are growing and multiplying.

dysrhythmia

irregular pattern of heartbeats

Dyspnea

labored or difficulty breathing

diastolic pressure

lowest pressure present on the arterial walls.

normal respirations in newborn

newborn: 30-55 bpm

Eupnea

normal respirations

Acute pain

pain that lasts from seconds to less than 6 months. usually associated with recent injury

possible HESI question: During a physical examination of a client, the nurse assesses the size of the liver. Which of the following techniques should the nurse use for this assessment?

palpation

endorphins

powerful pain-blocking chemicals that have prolonged analgesic effects and produce euphoria.

Medical Asepsis

practices designed to reduce the number and transfer of pathogens; synonym for clean technique

surgical Asepsis

practices that render and keep objects and areas free from microorganisms; synonym for sterile technique

Transmission-based precautions (tier 2)

precautions used in addition to standard precautions for patients in hospitals with suspected infection with pathogens that can be transmitted by airborne, droplet, or contact routes.

Convalescent period

recovery period from the infection. The signs and symptoms disappear, and the person returns to a healthy state.