226 HESI PREP

excessive outward curvature of the spine

kyphosis

three areas of assessment for GCS

motor response to verbal commands, eye opening in response to speech, and verbal response to speech

fourth korotkoff sound

muffled and low diastolic pressure in a toddler

which statement indicated that the interview is coming to an end

"I have just one more questions for you" this lets the client know that after one more question, the interview will be over

which statement made by the nurse indicated the need for futhur teaching when assessing clients with dark skin

"I will use a fluorescent light source to asses skin color" the nurse should use a natural light to assess skin color. fluorescent light would cast a blue color on the skin

which assessment finding in a client who had a history of chicken pox and arrived at the hospital complaining of itching and deep pain on the skin helps confirm the diagnosis

multiple lesions in a segmental distribution on the skin (herpes zoster)

when performing a focused respiratory assessment, which action is done FIRST

observe for signs of resp distress

which nursing actions is important for establishing good communication with the client who has impaired hearing

obtain the client's attention before speaking

which korotkoff sound represents the diastolic blood pressure

5th

when is VS delegation appropriate

only if the patient is nonurgent, such as an ankle sprain. possible pneumonia, substernal chest pain, and unstable VS since admission are emergent cases that cannot be delegated

cataract

opactiy (cloudy) of lens

nursing process

Assessment (collect sub and obj data) Diagnosis Planning (includes priorities, goals, and expected outcomes) Implementation (care is delivered) Evaluation (re asses)

instruction for a testicular self exam

a firm, smooth, egg shaped organ can be palpated each testicle is examined individually after relaxing the scrotal skin the thumb and fingers of both hands can be used to apply firm and gentle pressure a raised swelling that can be palpated on the superior aspect of the testicle is the epidydmis

which finding would be expected with varicose veins

ankle edema (pallor, yellowed toenails, and diminished pedal pulses occur with arterial insufficiency)

which glasgow coma scale indicated a coma

anything below a 8

artieral vs venous insufficiency

arterial: pale when elevated and dusky red when lowered, cool to touch, absent pulses, shin skin, decreased hair growth, thick nails venous: normal color ext, normal temp, normal pulse, marked edema, brown pigmentation on ankles

a client with a suspected kidney disorder reports flank pain; which nursing interventions would be performed during assessment

ask the client to sit up and place one fat flat on the costovertebral angle (CVA) while the other makes a fist. deliver a firm hand thump over the CVA

if a client has a weak right radial pulse, which additional actions would be taken

assess all peripheral pulses, comparing both radial pulses, ask a second nurse to check, assess for edema or other issue that may restrict blood flow, observe for pallor/skin temp differences distal to weak pulse

collecting data about a client's physical, psychological, and social culture which step of nursing process

assessment

if the nurse hears the first sound at 128 mmHg, then no sound is heard until 110 mmHg, and then sounds are heard again and disappear at 72 mmHg how would you document

auscultatory gap (absence of korotkoff sounds between the first and second sounds and can be as large as 40mmHg)

which aspect would the nurse use to determine whether intracrnaial pressure is rising around the medulla

breathing and HR the medulla is concerned with vital function like breathing and heart rate

third korotkoff sound

intense tapping

clinical manifestation of a cluster headache

ipsilateral tearing of the eye (tearing on the same side as the headache) vertigo, neck rigidity, phonophobia is migraine

psoriasis

chronic skin condition producing sharply demarcated silvery scaling plaques on reddish skin

symptoms of severe, sharp, stabbing headache and intense pain in and around the eye that lasts for up to an hour with similar episodes for the last 10 weeks

cluster headache rhinorrhea (runny nose), lacrimation (tearing), pupillary constriction (myosis), ptosis

strabismus

congenital condition in which both eyes do not focus on an object simultaneously, leaving a crossed eye appearance. this condition is caused by impaired extra ocular muscles.

which assessment finding would the nurse use to test a clients trigeminal nerve function

corneal sensation

which clinical manifestation would be expected in a patient with pulmonary edema

crackles, coughing, orthopnea, (yellow sputum wound indicate an infection)

when auscultating lungs sounds and assessing RR, which is the nurse doing

data collection

which adverse hemodynamic effects occurs with tachycardia

decreased ventricular filling time, low cardiac output, weaker pulses

which complication would be seen in parkinson disease and myasthenia gravis

difficulty swallowing

which teaching will be done with a client with peripheral artery disease.

do not cross legs or wear compression stocking bc it will decrease blood flow. Inspect your feet daily to detect injury or breakdown.

which assessment finding is expected in a client who has myringotomy

drainage into the external auditory canal

pulsus paradoxus

drop in blood pressure >10 mmHg with inspiration common in pericardial effusion

medium pitched, "thud-like" sounds head with lung consolidation (pneumonia)

dullness

extrinic factors responsible for falls in older adults

environmental hazards, inappropriate footwear, and improper use of assistive devices (impaired vision and cognitive impairment = intrinsic factor)

identifying the success in meeting desired outcomes which step of nursing process

evaluation

high pitched, short duration sounds heard over a pleural effusion

flatness

pes planus

flatness of the sole and arch of the foot

when the client is an active participant in care and therapies which step of nursing process

implementation

if a client has chills and a fever, what rectal temp wold you anticipate

in older adults the temp range is 36.6 -37.5 Celsius rectally. A rectal temp of 38.5 would indicate a fever

myringotomy

incision into the tympanic membrane to relieve pressure and prevents spontaneous rupture of the eardrum by allowing fluid to escape from the middle ear into the external auditory canal

nursing process, such as developing an individualized care plan which step of nursing process

planning

for a client with varicose veins, which teaching would you use with knee length elastic support stockings

put the stockings one before getting out of bed

low pitched hollow sound normally heard over the air filled lungs during percussion

resonance

for a patient with psoriasis, which parameters would the nurse monitor

serum uric acid (arthritis), serum triglyceride and serum cholesterol (cardio)

cluster headaches

sharp, stabbing pain each episode may last from a few minutes to 3 hours constriction of the pupil, swelling of the eyes, and facial flushing occur remission after a few weeks or months

which action made by the nurse may exacerbate health disparities in someone using an interpreter

speaking to the interpreter instead of the client

which signs would the nurse expect to see in a client with cystocele and rectocele

stress incontinence and low abdominal pressure

first korotkoff sound

systolic pressure

for a patient with peripheral arterial disease, what action would the nurse take if leg cramps are experiences while walking

the client should walk until pain is felt, then stop and rest until the pain resolves

which questions would a nurse ask when obtaining health history

the health history includes: food habits, lifestyle patterns (alcohol, tobacco), allergies and reations when you ask about personal losses, you are evaluating stress-related problems. when you ask about family illness, you are collecting family history

a patient is unable to clench teeth. which cranial nerve might have been affected

trigeminal nerve

torticollis

twisting of new in an unusual position to one side

high pitched and musical; might be heard over a pneumothroax

tympanic sounds

circumscribed elevations of the skin filled with serous fluid, measuring about 0.5 x 0.5 cm

vesicles which can lead to herpes simplex infection and chicken pox

chalk white patches on the skin

vitiligo

which activities may cause chest pain in a patient with stable angina

walk outside on a cold day, sex, smoking ciggs, use of oral decongestant