fundamental Health and Physical Assessment final hesi (evolve)

A client presents with bilateral leg pain and cramping in the lower extremities. The client has a history of cardiovascular disease, diabetes, and varicose veins. To guide the assessment of the pain and cramping, the nurse should include which question when completing the initial assessment?

"Does walking for long periods of time increase your pain?"

While assessing a client who experienced an accident, the nurse found that the client is unable to move eyeballs laterally. Which nerve damage led to this condition in the client?

Abducens nerve

A client reports to the nurse sleeping until noon every day and taking frequent naps during the rest of the day. What should the nurse do initially?

Arrange a referral for a thorough medical evaluation.

The student nurse prepares a concept map while caring for a client recovering from surgery. What is the first step that the student nurse should take when preparing the concept map?

Arrange cues into clusters that form patterns.

The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration?

Change in mental status

The nurse asks the client to shrug the shoulders and to turn the head against passive resistance. Which cranial nerve is involved in this action?

Cranial nerve XI

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess?

Distended jugular veins

What is the significance of the procedure depicted in the figure?

Evaluating arterial insufficiency

"I will soak the comb used to remove lice for 15 minutes in cold water."

Kyphosis

Which statement made by the nurse indicates that the client interview is coming to a close?

"I have just one more question for you."

A registered nurse is teaching a nursing student about when a client with high blood pressure should follow up with the primary healthcare provider. Which statement made by the nursing student indicates effective learning?

"I will advise a client with a blood pressure of 130/80 mm Hg to follow up in a year."

While assessing a client's range of motion, the nurse explains adduction to the nursing student. Which statement made by the nursing student indicates effective learning?

"I will ask the client to move his or her arm towards the body."

A nurse is teaching a client about proper hair hygiene and how to protect his or her hair from lice. Which statement made by the client indicates ineffective learning?

"I will soak the comb used to remove lice for 15 minutes in cold water."

A nurse teaches a client about various measures to protect against food-borne illness. Which statement by the client indicates a need for further teaching?

"I won't eat any leftovers in my refrigerator after they've been there for 5 days."

A registered nurse is teaching a nursing student how to assess for edema. Which statement made by the student indicates the need for further education?

"If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given."

A registered nurse is teaching a nursing student about skin assessment. Which statement made by the nursing student indicates the need for further teaching?

"In the absence of sunlight, skin assessments are performed best with other sources of light instead of fluorescent light."

The registered nurse is teaching a nursing student about bulimia nervosa in adolescents. Which statement made by the nursing student indicates effective learning?

"The client experiences recurrent episodes of binge eating."

A registered nurse is supervising a student nurse while assessing a 70-year-old client who is receiving aminoglycoside therapy. Which statement about the client's condition requires correction?

"The client may have thinning of the tympanic membrane."

A client develops an allergic reaction when a student nurse is performing a physical assessment. Which statement made by the student nurse in response to this incident indicates the need for further teaching?

"The client's first exposure to latex will cause a type IV allergic reaction."

The nurse was assessing an elderly client and recorded the pulse rate as 85. After assessment the nurse determined the cardiac output as 5950. What could be the approximate stroke volume?

70 mL

A nursing student is recording the radial pulse rate in a client with dysrhythmias and documented a radial pulse of 80 beats per minute. The registered nurse reassesses the client and notices a pulse deficit of 15. What is the client's apical pulse?

95

A nurse is assessing several clients. Which client will require parenteral nutrition?

A client with severe malabsorption disorder

An older adult is found to have a thin white ring around the margin of the iris. What condition does this denote?

Arcus senilis

A client presents with a shiny appearance of abdominal skin. The skin also has a taut appearance. Which condition may the client have?

Ascites

The nurse is assessing a client who arrived at the healthcare facility for an appointment. Which action by the nurse will be beneficial during the interview?

Asking about the client's current concerns

What should the nurse assess to determine whether a 75-year-old individual is meeting the developmental tasks associated with aging?

Attainment of a sense of worth as a person

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful?

Clear breath sounds

A nurse is palpating the peripheral pulse of different clients. Which client has an unacceptable heart rate?

Client 3 (2 YEAR OLD HEART RATE 148)

A registered nurse (RN) is performing a physical assessment of four clients with various medical conditions as shown in the chart. Which client is expected to have concavely curved nails?

Client B (IRON DEFICIENCY ANEMIA)

The symptoms of four clients with different levels of impaired vision are given below:Which client is expected to be diagnosed with macular degeneration?

Client B (LOSS OF CENTRAL VISON )

While assessing the client's skin, a nurse notices a skin condition, the pathophysiology of which involves increased visibility of oxyhemoglobin caused by an increased blood flow due to capillary dilation. Which condition is associated with this client?

Erythema

The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The nurse should monitor for what complication associated with this type of surgery?

Expectoration of blood

An elderly client is admitted to the healthcare facility following a stroke. What should the nurse do when the client's relative who arrived much later asks to see the client's health record?

Explain that medical health records are confidential.

During a survey, the community nurse meets a client who has not visited a gynecologist after the birth of her second child. The client says that her mother or sister never had annual gynecologic examinations. Which factor is influencing the client's health practice?

Family practices

A client who has been admitted to the hospital with chest pain complains of shortness of breath, weakness, and vomiting. The nurse suspects cardiac arrest. Which site is the most appropriate place to check the client's pulse rate?

Femoral

Which Korotkoff sound represents systolic blood pressure in children?

First

A client complains of difficulty breathing. The nurse auscultates wheezing in the anterior bilateral upper lobes. What could be the possible reason for this sound?

High velocity airflow through an obstructed airway

A client has a history of a persistent cough, hemoptysis, unexplained weight loss, fatigue, night sweats, and fever. Which risk should be assessed?

Human immunodeficiency virus (HIV) infection

The nurse is performing an assessment of the client's reproductive system. Which finding of the past medical history indicates the client is at risk of cervical cancer?

Human papilloma virus infection

After an eye assessment, the nurse finds that both of the client's eyes are not focusing on an object simultaneously and appear crossed. What could be the cause for this condition?

Impairment of the extraocular muscles

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)?

Inactivity

The nurse recognizes that a common conflict experienced by older adults is the conflict between what?

Independence and dependence

A nurse is discussing weight loss with an obese individual with Ménière disease. Which suggestion by the nurse is most important?

Keep a diary of all foods eaten each day.

A pregnant woman in her second trimester arrived at the hospital for a general health checkup. The physician recommended a pelvic examination to the client. Which position is most suitable for assessing the client in this condition?

Lithotomy position

The nurse is caring for an African American client with renal failure. The client states that the illness is a punishment for sins. Which cultural health belief does the client communicate?

Magicoreligious belief

The nurse is caring for a client with a family history of diabetes mellitus. The client has been following a diet regimen recommended by the dietician and walking for 45 minutes daily for the past eight months. How should the nurse document the client's stage based on the transtheoretical model of health behavior change?

Maintenance

While assessing a client, a nurse finds adventitious breath sounds. Upon further evaluation, the nurse finds loud, low-pitched, rumbling coarse sounds during inspiration. This sound can be clearly heard while the client is coughing. What could be the reason behind these sounds?

Muscular spasms in the larger airways

A registered nurse (RN) is instructed to assess the body temperature of a neonate. Which site for placing the thermometer is contraindicated in these clients?

Oral cavity

An older client with shortness of breath is admitted to the hospital. The medical history reveals hypertension in the last year and a diagnosis of pneumonia three days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention?

Oxygen Saturation: 89%

The nurse discovers several palpable elevated masses on a client's arms. Which term most accurately describes the assessment findings?

Papules

The nurse has just arrived to begin a shift in a healthcare facility nursing unit. Two new clients have been recently admitted to the unit. What should the nurse do first to collect the initial information about the assigned clients?

Participate in shift report.

The nurse suspects that an intraoperative client has a distended bladder. Which method is correct to assess for this condition?

Percuss and palpate in the hypogastric region.

A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client?

Pulmonary edema

When assessing a client, the nurse auscultates a murmur at the second left intercostal space (ICS) along the sternal border. This reflects sound from which valve?

Pulmonic

While caring for a postoperative client, the nurse observed a pulse deficit during physical assessment. Which pulses are used to assess the pulse deficit?

Radial and apical pulse

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes?

Respiratory and urinary

A client is admitted to the hospital with severe diarrhea, abdominal cramps, and vomiting after eating. These symptoms have lasted 5 days. Upon further assessment, the primary healthcare provider finds that the symptoms occurred after the client ate eggs, salad dressings, and sandwich fillings. Which food borne disease would be suspected in this client

Salmonellosis

A client suspected to have a prostate disorder is encouraged to have a rectal examination. What position of the client will facilitate a rectal examination by the registered nurse (RN)?

Sims position

While performing a physical assessment in a client, the registered nurse (RN) notices reddish linear streaks in the nail bed. Which systemic condition can the registered nurse (RN) suspect in the client based on these assessment findings?

Subacute bacterial endocarditis

Which nursing intervention is employed to encourage the client to fully reveal the nature of their health problem?

The nurse leans forward attentively during the discussion.

A client who does not understand English requires an interpreter. Which nursing student action may exacerbate health disparities?

The student talks only to the interpreter about the client.

A nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator?

Tissue turgor

During an assessment, the client complains of tenderness when the nurse palpates the calf muscle. What would be the nurse's next assessment?

To evaluate for swelling, warmth and muscle firmness

While assessing a client, the nurse finds inflammation of the skin at the bases of the client's nails. What might be the reason behind this condition?

Trauma

While assessing a client who sustained a road traffic accident, a nurse notices that the client is unable to clench his teeth. Which cranial nerve might have been affected?

Trigeminal nerve

The nurse is overseeing a nursing student who is conducting an assessment of a client who does not speak English. No interpreter is available. Which action requires further teaching?

Using medical terminology

The nurse is caring for a client whose forehead feels warm to the touch. The nurse uses a thermometer and obtains the client's temperature. What is the nurse doing?

Validation

A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining that it causes gas and bloating. Which food should the nurse suggest that is rich in calcium and digested easily by clients who do not tolerate milk?

Yogurt