245 Hesi Assessments
Which statement would the nurse include in the teaching plan of a client anticipating discharge with acquired immunodeficiency syndrome (AIDS)?
"Wash used dishes in hot, soapy water."
What are the physical signs of nutrient imbalance?
-Hair is dry or brittle -Epistaxis(nose bleed) -Thyroid enlargement -Dry eyes, pale conjunctiva, -glossitis (red, sore tongue) -Dry scaly skin -Petechiae, ecchymoses -poor wound healing
What is a normal PR interval?
0.12-0.20 seconds
Beau's grooves
1-mm-wide horizontal depressions in the nail plates caused by growth arrest (involves all nails) could mean an acute or severe illness or severe malnutriton
Shat is the normal specific gravity of urine?
1.005- 1.030
Which actions would be considered in the collaborative plan of care for a client with increased lens density?
A client with cataracts has increased lens density due to drying and compression of older lens fibers. -Performing phacoemulsification, monitoring the clients blood glucose levels, assessing if the clients is on antiplatelet medication
Tinea Pedis
ALso known as athletes foot
Which is a secondary cause of adrenal insufficiency?
Adrenal insufficiency is also called Addison disease. Secondary causes of adrenal insufficiency include pituitary tumors.
What hormone influences kidney function?
Aldosterone
Tinea Cruris
Also known as jock itch
Peptic Ulcer Disease
An abrasion of the stomach or small intestine.
What are the clinical manifestations of Chronic Hepatitis?
Anemia, ascites and lower extremity edema, bleeding abnormalities, hepatic encephalopathy, Jaundice, spider angiomas
What is late clubbing?
Angle between the nail plate and the proximal nail fold exceeds 180 degreesNail base visibly edematous and spongy when palpatedEnlargement of the soft tissue of the fingertips gives a "drumstick" appearance when viewed from above could mean COPD, cystic fibrosis or a chronic heart disease
What are the clinical manifestations of Hepatitis?
Anorexia, dark urine, diarrhea or constipation, fatigue, jaundice, clay colored stools, right upper quadrant tenderness, weight loss
Which exogenous conditions are responsible for increased cortisol secretion?
Asthma, cancer chemotherapy, organ transplant
How do you calculate a person BMI?
BMI = weight (kg)/height (m2)
Which type of joint permits movement in any direction?
Ball and socket joint
peripheral cyanosis
Bluish or purplish tinge in extremities or in nose and ears
What is the cause of peritonitis?
Bowel obstruction, appendicitis
Which term refers to the Cowper gland?
Bulbourethral gland
Which sexually transmitted infection is caused by Chlamydia trachomatis?
Cervicitis
Acute pancreatitis causes
Cholelithiasis (gallstones) or alcohol
Which disorder is a primary glomerular disease?
Chronic glomerulonephritis
Plaque
Circumscribed, elevated, superficial, solid lesion. >0.5 cm in diameter ex: psoriasis
Macula
Circumscribed, flat area with a change in skin color. <0.5 cm in diameter. ex: freckles
Vesicle
Circumscribed, superficial collection of serous fluid. <0.5 cm in diameter ex: chickenpox, herpes zoster
A client arrives at a health clinic reporting a recent onset of hematuria, frequency, urgency, and pain on urination. Which diagnosis will the nurse observe in the client's medical record?
Cystitis
diabetic nephropathy
Damage to small blood vessels that supply the glomeruli of the kidney
What is hyperpigmentation?
Darking of the skin, particularly in the creases and skin folds. is found with Addisons disease
How do you find the pulse pressure?
Diastolic - Systolic
Jugular Venous Distention
Distended neck (jugular) veins with patient sitting at 30- to 45-degree angle seen in right sided heart failure
What is the cause of a UTI?
E. coli
Papule
Elevated, solid lesion. <0.5 cm in diameter. ex: wart
Pustule
Elevated, superficial lesion filled with purulent fluid Examples: acne, impetigo
When assessing a client's abdomen, the nurse palpates directly above the umbilicus. This location is known as which area?
Epigastric area
Which virus is responsible for causing infectious mononucleosis in clients?
Epstein-Barr virus
Lordosis (swayback)
Excessive curvature in the lumbar portion of the vertebral column
Which type of biopsy is required for removal of entire lesions on the skin?
Excisional biopsy
Which clinical manifestations are associated with tuberculosis?
Fatigue, nausea, low grade fever
What are the signs of heart failure?
Fatigue, orthopnea, pitting edema, dry hacking cough 4lbs weight gain
Wheal
Firm, edematous, irregularly shaped area. Diameter variable ex: insect bite
Koilonychia (spoon) nails
Flattening of the nail plate with an increased smoothness of the nail surface could mean iron deficiency
A client reports their lips feel thicker, and they have joint pain and coarse facial features. The nurse would suspect an excessive secretion of which hormone?
Growth Hormone
BMI 18-24.9?
Healthy weight
What is the Somogyi effect?
Hyperglycemia in the morning
What are the clinical manifestations for Chronic Kidney Disease?
Hypertension, Anorexia, nausea, amenorrhea, fatigue, headache, pulmonary edema, puritis, ecchymosis,
Queckenstedt sign
If there is no obstruction, pressure on the jugular vein causes increased intracranial pressure
Which type of immunoglobulin is present in tears, saliva, and breast milk?
IgA
Which infection would the nurse identify as requiring a client to be placed on droplet precautions?
Influenza
Hyperresonance
Loud, tinkling, rushes usually means intestinal obstruction
Hirsutism
Male distribution of hair in women.
Myopia
Nearsightedness
Which nursing intervention prevents footdrop in a client with osteomyelitis?
Neutral positioning of the foot with the use of a splint
BMI 30
Obesity
BMI 25-29.9?
Overweight
What hormones does the posterior pituitary gland secrete?
Oxytocin and antidiuretic hormones
What are the clinical manifestations of a peptic ulcer?
Pain occurs 1-2 hours after eating
What glands secrete hormones that regulate metabolism of carbs, proteins and fats?
Pancreas, Thyroid and Adrenal Cortex
Which term is used for the tip of a pyramid in the kidney?
Papilla
Which hormone promotes bone resorption in a client and potentially leads to decreased bone densities?
Parathyroid hormone
Which substance is released in response to low serum levels of calcium?
Parathyroid hormone
When a client injures the amphiarthrodial joint, which joint did the client injure?
Pelvic
What is moon face?
Periobital edema and facial fullness
Which hormones are most commonly produced in excess with hyperpituitarism?
Prolactin, Growth hormone
Which causative organism colonization signifies purulent exudates of greenish-blue pus with a fruity odor?
Pseudomona
What is acromegaly?
Rare condition resulting from excess secretion of growth hormone (GH).
Pivot joint
Rotation only Ex: head of radius and distal humerus
Fourth heart sound (S4)
S4 gallop, atrial gallop; very soft, low-pitched ventricular filling sound that occurs in late diastole
Which dietary selections made by the client indicate understanding of previously taught dietary principles associated with having viral hepatitis?
Salad, sliced chicken sandwich, gelatin dessert
Bounding pulse
Sharp, brisk, pounding pulse
Which physiological changes of the musculoskeletal system would the nurse associate with aging?
Slowed movement, cartilage degeneration, increased bone prominence
What is early nail clubbing?
Straightening of angle between the nail plate and the proximal nail fold to 180 degreesNail base spongy when palpated could mean hypoxia or lung cancer
What are the causes for premature atrial contractions?
Stress, tabocco, caffeine, electrolytes imbalances, home medications
Astigmatism
These uneven surfaces distort vision.
Which adverse effect can be seen in a female client with gonadotropin deficiency and who is undergoing hormone replacement therapy?
Thrombosis
Which neurological manifestation is associated with hyperthyroidism?
Tremors
heart murmur
Turbulent sounds occurring between normal heart sounds. Characterized by loudness, pitch, shape, quality, duration and timing
What are the symptoms of Hyperthyroidism?
Visual changes, exophthalmos
What are the symptoms of Cushing's syndrome?
Weight gain, truncal obesity, buffalo hump, moon face
Erythema Marginatum
a distinctive truncal rash that often accompanies acute rheumatic fever. It consists of nonpruritic, pink, erythematous macules that never occur on the face or hands.
Thready pulse
a weak, rapid pulse.
What are the classic signs of peritonitis?
abdominal rebound tenderness, diminished bowel sounds, and a rigid, boarder-like abdomen
ascites
abnormal accumulation of fluid in the abdomen
dyskinesia
abnormal voluntary movement
After measuring the clients PR interval at 0.08 seconds, how would the nurse interpret the finding?
abnormally fast conduction
anuria
absence of urine
Which complication is the nurse's main priority during the early postoperative period after a subtotal thyroidectomy?
airway obstruction
gliding joint
allows one bone to slide over another; found in wrist and ankles
Tinea Corporis
also known as ring worm
diabetes insipidus
an underproduction of ADH
pulse deficit
apical heart rate exceeding peripheral pulse rate
hematuria
blood in the urine
Central Cyanosis
bluish discoloration in central areas such as the tongue, conjunctiva, inner surface of the lips
<60 beats per min
bradycardia
What is ecchymosis?
bruising
What is exophthalmos?
bulging eyes
Growth hormone deficiency
changes tissue growth patterns, resulting in increased bone destructive activity, and reduced bone density
Cirrhosis
chronic degenerative disease of the liver
thyrotoxicosis
condition caused by excessive thyroid hormones
What are the most common presenting symptoms of pneumonia?
cough, fever, dyspnea, tachypnea, pleuritic chest pain
Dysarthria
difficulty forming words
Kyphosis (hunchback)
exaggerated thoracic curvature
The nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. Which interventions would the nurse include to decrease the risk of complications?
examine the feet daily, wear well-fitting shoes, perform regular exercise
What is hyperpituitarism?
excess production of prolactin and growth hormone
distention
excessive gas accumulation, enlarged abdomen, generalized tympany. Caused by an obstruction or paralytic ileus
Hyperkinesia
excessive movement
How is Hepatitis B transmitted?
expose to blood or blood products, sexual contact, perinatal transmission
How is Hepatitis C transmitted?
exposure to blood or blood products, high risk sexual contact, perinatal contact
Glasgow Coma Scale
eyes, verbal, motor Max- 15 pts, below 8= coma
Hyperopia
farsightedness
How is Hepatitis A transmitted?
fecal-oral route
cheilosis
fissuring and cracking of the lips at the angles of the mouth
Hinge joint
flexion and extension (elbow and knee)
What is GERD?
gastroesophageal reflux disease. damage caused by reflux of the stomach acid into the lower esophagus
sensorineural hearing loss
hearing loss caused by damage to the cochlea's receptor cells or to the auditory nerves; also called nerve deafness
pyrosis
heartburn
Graves disease
hyperthyroidism with toxic goiter
Central Nervous System (CNS)
includes the brain and spinal cord
Which information would the nurse consider when planning care for a group of clients with myasthenia gravis, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS)?
increased risk for respiratory complications
cheilitis
inflammation of the lip
peritonitis
inflammation of the peritoneum (membrane lining the abdominal cavity and surrounding the organs within it)
Motor dysfunction
is characterized as alterations of motor tone, movement and complex motor performance
Wernicke's area
is located in the temporal lobe and is responsible for the processing of words into through and understanding
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
is the over production of ADH
Emmetropia
is the perfect refraction of the eye in which light rays from a distant source are focused into a sharp image on the retina
What is the purpose of pursed lip breathing?
is to prolong exhalation and thereby prevent bronchiolar collapse and air trapping.
ataxia
lack of muscle coordination
Where is the stomach located?
left upper quadrant, or epigastric area
Broca speech center
located in the frontal lobe and is responsible for the formation of words into speech
Romburg test
loss of balance when eyes are closed
aphasia, dysphasia
loss of or impaired language faculty
Borborygmi
loud, gurgling bowel sounds. means hyperactive bowel
Olguria
low urine output
What does cortisol do?
maintains the blood glucose concentration by stimulating the liver for gluconeogenesis
A client has bright-red erythematosus macules and papules on the skin. The nurse would expect to teach the client about which condition?
medication eruption
What is tetany?
muscle spasms primarily of the hands and face due to low PTH
A diagnosis of myasthenia gravis is suspected for a client who sees the primary health care provider because of fatigue, double vision, and muscle weakness. Which information would the nurse expect the client to report in the health history?
muscle weakness improving after a period of rest
venous ulcers
necrotic crater-like lesion found on the leg
Diabetic Neuropathy
nerve damage that occurs because of the metabolic derangements associated with diabetes mellitus
Clubbing of the fingernails
obliterations of normal angle between base of nail and skin could mean endocarditis, prolonged 02 deficiency
Odynophagia
painful swallowing
dysuria
painful urination
Atrial Ulcers
pale ischemic base, well defined edges usually found on the toes or heels
Thrill
palpable vibration on the chest wall accompanying severe heart murmur
paraplegia
paralysis from the waist down
opthalmoplegia
paralysis of the eye
What is depigmentation?
patchy, areas of light skin
When obtaining a health history from a client recently diagnosed with type 1 diabetes, the nurse expects the client to report which clinical manifestation?
polyuria
What is myxedema?
puffiness, periorbital edema, masklike affect
What does calcitonin do?
reduced serum calcium levels
What does parathyroid hormone do?
regulates blood and calcium levels
contracture
resistance of movement of muscle or joint as a result of fibrosis or soft tissues
What are the symptoms of peritonitis?
rigid, boarderlike abdomen, abdominal pain
pericardial friction rub
scraping or grating noise heard on auscultation of the heart; suggestive of pericarditis
macula densa
sense changes in the volume and blood pressure
Splinter hemmorrhages
small red to black streaks under the fingernails
Third heart sound (s3)
soft, low-pitched ventricular filling sound that occurs in early diastole (S3 gallop) and may be an early sign of heart failure
ankylosis
stiffness and fixation of a joint seen in rheumatoid arthritis
What is striae?
stretch marks
What are the clinical manifestations of pyelonephritis?
sudden onset of chills, fever, vomiting, malaise, flank pain and costovertebral tenderness. Sysuriai, urinary urgency and frequency
> 100 beats per min
tachycardia
Where is the S1 heart sound best heard?
the apex of the heart
WHere is the S2 heart sound best heard?
the base
What is heart failure?
the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients
peripheral nervous system
the sensory and motor neurons that connect the central nervous system to the rest of the body.
Leukoplakia
thickened, white, leathery-appearing spots on the mouth
What do parafollicular cells produce?
thyrocalcitonin hormone
Atrial bruit
turbulent flow sould in peripheral artery can be caused by Afib/ atrial flutter
Saddle joint
type of joint found at the base of each thumb; allows grasping and rotation
hematemesis
vomiting blood
What is peristalsis?
wave-like muscle contractions
condyloid joint
wrist
