Health Assessment HESI
The nurse uses the mini-mental state examination (MMSE) when assessing a client for admission to an assisted living facility. Which finding is the nurse assessing when requesting the client to count backward by 7s? Recall of information. Orientation to surroundings. Attention to details. Ability to follow complex commands.
Attention to details. When conducting the MMSE and having the client count backward by 7s. This evaluates their ability to do simple calculations and is specific to the client's attention to detail and staying focused and not getting distracted by external stimuli.
Which conclusion would the nurse make while caring for a hospitalized 2-yr-old child that continuously tries to climb from the crib and refuses activities that the nurse suggests?
Child is trying to assert independence Toddler exhibits typical behav for this developmental level; most toddlers will say "no" as a means of asserting their independence. Form of autonomy assertion
Which term should the nurse use to document the condition of a client who reports waking up frequently during the night to urinate? Nocturia. Polyuria. Oliguria. Dysuria.
Nocturia. Nocturia is the medical terminology used to describe when a client wakes up throughout the night more than usual to urinate. The nurse should document this condition as "nocturia" in the client's medical record.
Which area of the client's body would the nurse consider a high risk for developing pressure injury when caring for older adult with Alz dementia who consistently sleeps in semi-Fowler position in bed?
Sacrum Sacrum is center of greatest body mass; elevated torso exerts pressure toward this area. Ischial spine bears greatest pressure when in upright sitting position and greater trochanter when in side-lying position.
When preparing to assess the 4 abdominal quadrants of a client who reports stomach pain, when would the nurse assess the symptomatic quadrant? 1st 2nd 3rd last
Last Nurse systematically assesses abdomen conclusing with symptomatic area which is area with pain. Pain may be elicited in sympt area is assessed 1st, 2nd, or 3rd, causing muscles in other abdominal areas to tighten and interfere with assessment.
During a client's routine well-woman physical exam, the nurse examines the breasts. Which assessment technique should the nurse implement to evaluate for any abnormal lumps? Palpate each breast simultaneously noting any differences. Inspect the areolar area's color, shape, and the nipples for galactorrhea. Check for breast symmetry while the client's hands are above the head. With both arms at client's side, lift one arm and palpate the axilla.
With both arms at client's side, lift one arm and palpate the axilla. Lymph nodes or masses should not normally be palpated in the axilla. The best way to assess the axilla is to have the client relax her arms at her side so that the muscles are relaxed. Typically, breasts are not exactly the same size or shape, and assessing symmetry will not uncover small lumps.
A client with schizo who is receiving an antipsychotic med begins to exhibit shuffling gait and tremors. The PCP prescribes the anticholinergic med Benztropine, 2 mg daily. Which symptom should the nurse inquire about when assessing the client? constipation HTN increased salivation excessive perspiration
constipation Anticholinergic activity of each med is magnified and adverse effects such as paralytic ileus may occur. Hypotension, dryness of mouth, and decreased perspiration occurs with anticholinergics.
Which response indicated that a beta blocker prescribed for persistent ventricular tachycardia is working effectively? decreased anxiety reduced chest pain decreased heart rate increased BP
decreased heart rate Beta blockers inhibit the activity of sympathetic NS and of adrenergic hormones, decreasing heart rate, conduction velocity, and workload of heart; BB not analgesics and do not reduce chest pain. They reduce BP.
Which assessment finding indicates an improvement when the nurse is evaluating the results of treatment with erythropoietin?
decreased pallor Erythropoietin stimulates RBC production, therby decreasing pallor that accompanies anemia
By which process would total parenteral nutrition (TPN) on outpatient basis help a client with Crohn's disease prepare for surgery? decreasing fecal bulk preventing bowel infection providing stimulation of secretions maintaining negative nitrogen balance
decreasing fecal bulk By decreasing fecal bulk and bowel stim, TPN provides rest for the bowel while the client awaits surgery. TPN does not prevent bowel infection or stimulate GI secretions, but promotes positive nitrogen balance.
Which condition would a nurse monitor for in a client who is prescribed bumetanide? hypokalemia hyperchloremia hypernatremia hypoglycemia
hypokalemia Bumetanide is a loop diuretic. Diuretic therapy that affects the loop of Henle increases urinary excretion of Na, Cl, and K. As a result, clients are at risk for hypokalemia, hyponatremia, and hypochloremia.
Which clinical indicator would the nurse monitor to determine if the client's simvastatin is effective? heart rate triglycerides BP international normalized ratio (INR)
triglycerides Therapeutic effects of simvastatin include decreased levels of serum triglycerides, LDLs, and cholesterol. INR not related to simvastatin but a measure used to evaluate bld coagulation.
The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a chest measurement of 42 inches, a waist measurement of 45 inches, and a hip measurement of 50 inches. What important message should the nurse explain to the client to promote health promotion? "A waist circumference greater than 35 inches in women puts one at higher risk for type 2 diabetes and heart disease." "Your hip circumference is larger than normal and it puts you at a higher risk of hip disease." "At least your BMI is normal, so you just need to exercise." "You will need to lose weight so you are not at risk for hypertension."
"A waist circumference greater than 35 inches in women puts one at higher risk for type 2 diabetes and heart disease." A waist circumference of equal to or greater than 35 inches in women and equal to or greater than 40 inches in men increases the risk for type 2 diabetes, dyslipidemia, hypertension, and cardiovascular disease in people with a BMI between 25 and 35 (metabolic syndrome).
During a skin assessment, the nurse notes, round and discrete lesions that are dark red in color and will not blanch. The lesions range from 1 to 3 mm in size. What is the first question the nurse should ask the client? "Have you noticed any unusual bleeding?" "Have you fallen recently?" "How often do you drink alcohol?" "Have you been exposed to anyone with a rash lately?"
"Have you noticed any unusual bleeding?" Petechiae are small, reddish-purple lesions that do not fade or blanch when pressure is applied and often indicate an increase in capillary fragility. Petechiae is a condition usually seen in clients with thrombocytopenia. Petechiae may indicate abnormal clotting factors. Most of the diseases that cause petechiae cause bleeding and microembolism formation.
Which response would the nurse provide to a client receiving digoxin who calls the clinic and complains of "yellow vision"?
"The medication may need to be discontinued. Come to the clinic this afternoon." Yellow vision indicates digoxin toxicity; med should be withheld until health care provider can assess client and check digoxin bld level.
The nurse is assessing a client's middle lung lobe. Which is the best location for the nurse to place a stethoscope diaphragm to hear normal lung sounds in this lobe? 4th intercostal space, right midclavicular line. 5th intercostal space, left midclavicular line. Left mid-posterior lung field. Right mid-posterior lung field.
4th intercostal space, right midclavicular line. The 4th intercostal space, the right midclavicular line is the best location for the nurse to place a stethoscope diaphragm to hear lung sounds in the client's middle lobe. The left side has only two lobes (upper and lower) and middle lobe sounds cannot normally be heard in the posterior lung fields.
Planning to provide self-care health info for several clients, which on would the nurse anticipate will be most motivated to learn?
56-yr-old client who had a heart attack last week and is requesting info about exercise
The nurse is performing a head-to-toe assessment on a client. The nurse is assessing the client's pupillary light reflex by first darkening the room and asking the person to gaze into the distance. Then, the nurse advances a light toward one eye from the client's side. What would the nurse expect to see at this time? A consensual response in the opposite eye. No change in the eye on the opposite side of the face. Dilation of the eye on the opposite side of the face. Dilation of the eye on the same side of the face.
A consensual response in the opposite eye. To test the pupillary light reflex, the nurse should darken the room and ask the client to gaze into the distance to dilate the pupils. Then the nurse should advance a bright light into one pupil and note any response. Normally there will be constriction of the same-sided pupil (a direct light reflex) and simultaneous constriction of the other pupil (a consensual light reflex). The approximate pupil size that occurs when the light is shined into the eye should be estimated in millimeters using a gauge located on the penlight or in a healthcare record. The response to light and pupil size should also be documented.
The nurse is assessing a client's range of motion as the client bends the right knee up to the chest while keeping the left leg straight, but is unable to keep the left thigh on the table. The assessment is repeated for the left knee, and the client is unable to keep the right thigh on the table. How should the nurse document this finding? Flexion contraction that indicates muscle atrophy. Limited internal rotation of the hips that suggests degeneration. A normal left and right hip flexion with expected range of motion. A flexion deformity referred to as a positive Thomas test.
A flexion deformity referred to as a positive Thomas test. Flexion flattens the lumbar spine, and the opposite thigh should remain on the table. The inability to perform the hip range of motion (ROM) as expected indicates flexion deformity referred to as a positive Thomas test.
As a part of a routine health assessment, the nurse assesses the kidneys as part of the abdominal assessment. Which assessment finding should the nurse conclude is normal when palpating the client's right kidney? A round smooth mass that slides between the fingers. The right kidney is palpated higher than the left kidney. The kidney slides forward and has movable nodules throughout. A vibration is felt slightly left of the abdominal midline.
A round smooth mass that slides between the fingers. Occasionally, when assessing the adult kidneys, the nurse may feel the lower pole of the right kidney as a round, smooth mass that slides between the fingers - or the nurse will feel nothing at all. Either condition is normal. The nurse should search for the right kidney by placing hands together in a "duck-bill" position at the client's right flank. The nurse should then press two hands together firmly and ask the client to take a deep breath. In most people, the nurse will feel no change.
Which action would the nurse take 1st for a postsurgical client who is still intubated but becoming restless, with an increased pulse rate and BP, when it has been 4 hrs since last dose of pain med?
Administer prescribed pain med B/c client is intubated, nurse cannot fully assess for pain but can seen displayed signs. Nurse would admin Rx pain med, especially is it has been several hours since last dose. No need to notify provider or perform full physical assessment. Playing soft, relaxing music, although could help relieve pain, is not best action for postsurgical client b/c its not sufficient to manage pain.
Which explanation would the nurse provide for administering prednisone to a client with an exacerbation of colitis?
Although the med decreases intestinal inflammation, it will not cure colitis Prednisone inhibits phagocytosis and suppresses other clinical phenomena of inflammation; this is a symptomatic treatment that is not curative. The med suppresses immune response and increases potential for infection Colitis is inflamm of colon
Which action will the nurse take after stopping the antibiotic infusion of a client who becomes restless and flushed, and begins to wheeze during the admin of antibiotic?
Assess the client's respiratory status Pt is experiencing allergic reaction that may progress to anaphylaxis.
A client reports a recent onset of nausea and vomiting. What subjective information is important for the nurse to ascertain? Ask how much weight the client gained on vacation. Ask whether the client has been in a foreign country recently. Observe the symmetry of the abdomen. Count the bowel sounds in each abdominal quadrant.
Ask whether the client has been in a foreign country recently. GI upset and diarrhea occur when exposed to new local pathogens in developing countries. The water supply may be contaminated.
A client is in the clinical for a yearly physical examination. Which action should the nurse take when preparing to examine the client's abdomen? Keep the room cool so the client is not perspiring. Ask the client to urinate before beginning the examination. Examine painful or tender areas first. Position the client supine with arms over the head.
Ask the client to urinate before beginning the examination. An empty bladder aids in abdominal wall relaxation. The nurse should ask the client to empty the bladder before examining the abdomen.
Which finding in a newborn whose temp over the past 4 hrs has fluctuated btwn 98 F and 97.4 F would be considered critical? RR of 60 breaths/min WBC count >15,000 mm3 Serum Ca level of 8 mg/dL Bld gluc level of 26 mg/dL
Bld gluc level of 26 mg/dL Instability of newborn's temp in indication of hypoglycemia. Gluc level below 30 mg/dL does not provide enough energy to maintain body temp at normal level. Serum Ca level of 8, RR of 60, and WBC >15,000 are all normal findings and do not affect body temp.
Which respiratory condition should the nurse document after measuring a respiratory rate of 8 breaths/minute? Tachypnea. Bradypnea. Hyperventilation. Hypoventilation.
Bradypnea. Bradypnea is a regular but slow rate of breathing indicated by a respiratory rate less than 10 breaths/minute. A client with a respiratory rate of 8 breaths/minute has bradypnea. Bradypnea means abnormally slow respiration. Hypopnea refers to abnormally shallow breathing, with or without a decrease in the respiratory rate
Which mineral deficiency would a nurse suspect in a client who reports tingling in fingers and around mouth and exhibits carpopedal spasm and tremors after a surgical thyroidectomy? K Ca Mg Na
Calcium (Ca) Hypocalcemia occurs with accidental removal of parathyroid glands. Ca gluconate is administered to treat hypocalcemia.
During a health history interview, a male client reports that he smokes cigarettes and does not plan to quit. Which action is most important for the nurse to take? Document the client's statement verbatim. Calculate the client's pack year history. Express support for the client's right to choose. Ask about family history of lung cancer.
Calculate the client's pack year history Calculation of cigarette pack year history provides useful screening data regarding the client's risk for health problems, which serves as the basis for the plan of care.
When assessing levels of consciousness, which 1 of the 4 clients would the nurse identify as having the lowest neurological function? 1) Spontaneous eye movement, localizes pain for motor response, and uses inappropriate words for verbal response 2) Opens on pain for eye movement, flaccid for motor response, and uses incomprehensible sounds for verbal response 3) Spontaneous eye movement, normal flexion for motor response, and oriented for verbal response 4) Opens on sound for eye movement, abnormal flexion for motor response, and uses confused conversation for verbal response
Client 2 Glasgow Coma Scale (GCS) is used as objective measurement of consciousness on numerical scale. This scale assigns a numeric score for each area of neurological status of client. Higher score equates to higher neurological function. Client 2= score of 5, Client 1= 12, Client 3= 13, and Client 4=9
Which client is at a high risk for a rise in BP based on the given data? 1) 70 bpm w/ normal SV 2) 90 bpm w/ decreased SV 3) 40 bpm w/ increased SV 4) 100 bpm w/ normal SV
Client 3 BP rises when heart rate is decreased and the stroke volume (SV) is increased, In adults, the pulse rate should be btwn 60 and 100 bpm.
While providing care for 4 clients, the nurse assess their breathing pattern. Which client's assessment findings indicate Cheyne-Stokes respiration? 1) Regular and abnormally slow 2) Regular and abnormally rapid 3) Irregular, alternating apnea and hyperventilation 4) Abnormally shallow for 2 breaths followed by apnea
Client 3 Cheyne-Stokes respiration includes a client's breathing pattern being characterized by progressively deeper and faster breathing (hyperventilation followed by apnea). 1= bradypnea, 2= tachypnea, and 4= Biot respirations
Nurse creates plan of care for client with risk of infection. Which is the desirable expected outcome for the client?
Client will be free of signs and symptoms of infection by discharge. In client with infection, nurse's primary objective in providing care is to prevent infection or perform activities that will promote clients being free from infection by time of discharge
A client with a history of schizo, who responds poorly to meds, is now being treated for acute depression. Which info would nurse provide in light of info elicited from med list and lab results? Hemoglobin: 13.5 Hematocrit: 45% RBC: 48x10^6 Platelet: 150,000 WBC: 3500 Neutrophils: 100 Meds: clozapine, fluoxetine
Come in for weekly bld tests to monitor for med-induced agranulocytes Clozapine poses risk for development of agranulocytosis especially when paired with fluoxetine
Which statement describes a client that is in true labor?
Contractions occur every 5-10 minutes. The cervix is dilated 2 cm and 75% effaced (cervix stretches and gets thinner), and dilation has increased to 3 cm in 2 hrs.
The nurse is assessing a healthy young adult during an annual physical examination. Which assessment technique should the nurse implement when palpating the abdominal aorta? Deep palpation above and to the left of the umbilicus. Palpation of the abdomen as the client completes a deep breath. With the client standing, compress the abdomen as the nurse stands behind the client. With the palm of one hand, compress the abdomen 2 fingerbreaths below xiphoid process.
Deep palpation above and to the left of the umbilicus. Deep palpation above and to the left of the umbilicus is effective in sensing the pulsation of the aorta.
The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the nurse document that are consistent with diminished peripheral circulation? (Select all that apply.) Select all that apply Diminished hair on legs. Bruising on extremities. Skin cool to touch. Capillary refill less than 3 seconds. Darkened skin on extremities.
Diminished hair on legs. Skin cool to touch. Diminished hair on the legs and skin that is cool to touch are expectant signs of decreased arterial blood flow.
While performing a head-to-toe assessment, the nurse assesses the client's pupillary accommodation. During the second portion of the test, the nurse notes that the client's pupils constrict and there is a convergence of the axes of the eyes. What action should the nurse implement next? Document a normal finding. Request a referral to an opthamologist. Repeat the test after having the client rest for 5 minutes. Ask the client, "Have you noticed that you cannot see things close up?"
Document a normal finding. When testing for pupillary accommodation, the nurse asks the client to focus on a distant object and then shift the gaze to a penlight tip near the nose. Focusing on a distant object causes both pupils to dilate; shifting the gaze to a near object (a finger or a penlight tip), which is held about 7 to 8 cm (3 inches) from the client's nose, should result in bilateral pupillary constriction with both eyes focused on the object simultaneously.
During an inspection of a client's mouth and pharynx, the nurse places a tongue blade on the back of the tongue which causes the client to gag. After removing the tongue blade, which action should the nurse take? Initiate aspiration precautions. Notify the healthcare provider. Document an intact gag reflex. Provide a warm salt water gargle.
Document an intact gag reflex. The placement of a tongue blade on the back of the tongue should stimulate a normal gag reflex, indicating that cranial nerves IX and X are intact. The nurse should document that the gag reflex is intact.
The nurse is conducting a family history as part of the assessment interview. Which action should the nurse take to ensure that sufficient information about the client's blood relatives is obtained? Document at least 3 generations of the client's family medical history if possible. Ask about any genetic conditions that may be present in the family. Instruct the client to develop a genogram to bring to the next visit. Request medical records of all the client's immediate family members.
Document at least 3 generations of the client's family medical history if possible. The family history assists the healthcare provider in determining the client's health risks. It is recommended that family medical history be traced back three generations if possible. These generations consists of the client's blood-relatives of any siblings, parents, and maternal and paternal grandparents.
The nurse is requesting the client to perform a Romberg Test to assess neurological status. During the test, the nurse notes that the client sways slightly. Which is the nurse's next action? Document the normal finding. Have the client widen the base of the feet. Ask the client to walk to the door and back. Ask the client if there is any dizziness.
Document the normal finding. To perform a Romberg Test, the client is asked to stand up with feet together and arms at the sides. Once in a stable position, the client is asked to close their eyes and hold the position for about 20 seconds. Normally a person can maintain posture and balance even with the visual orienting information blocked, although slight swaying may occur.
A client reports lower abdominal pain and a feeling of pressure in the bladder. Which assessment finding indicates acute urinary retention? Hyperactive bowel sounds. Dull sound percussed over bladder. Bruits auscultated in left lower quadrant. Tenderness with palpation of lower back.
Dull sound percussed over bladder. Clients with acute urinary retention may present with lower abdominal pain and bladder distension. Percussion (tapping on the body wall) is performed to detect differences in pitch. A dull sound produced when percussing a distended urinary bladder is an indication of urinary retention.
A client has been diagnosed with bilateral lower lobe atelectasis. Which percussion sound should the nurse expect to hear when percussing over the client's lower lobes? Dull, thud-like. Hyperresonant, booming. Tympanic, drum like. Flat, extremely dull.
Dull, thud-like. An atelectatic or consolidated lung will produce a dullness or thud-like sound when percussed during an assessment. Flatness is a soft, short tone heard when percussing over solid tissue like muscle and bone
Which term should the nurse use to document in the client's medical record for a high-pitched scratchy sound during auscultation of the heart? Murmur. Ejection click. Friction rub. Normal heart sound.
Friction rub A high-pitched, scratchy, or grating sound heard during auscultation of the heart is called a pericardial friction rub, which is associated with inflammation of the pericardium, often seen during the following week in a client after a myocardial infarction. To best hear the pericardial friction rub, the nurse should have the client sitting upright and leaning forward while the client holds their breath and the nurse listens with the diaphragm of the stethoscope at the apex and left lower sternal border.
When the defining characteristics of a client's assessment data apply to more than 1 diagnosis, which action would the nurse take? Select all that apply. Reassess the client Reject all diagnoses Gather more info Identify related factors Review all defining characteristics
Gather more info Identify related factors Review all defining characteristics Gather more info to clarify interpretations of assessment data. Related factors are conditions or etiologies that give a context for defining characteristics; these individualize a nursing diagnosis for the client. Review all characteristics to interpret data and form data clusters; validate assessment data in database and support or eliminate irrelevant ones
The nurse is completing a physical exam on an adult client. Which thyroid finding is considered normal? Gland is usually not visible on inspection. Gland is solid bilaterally. Bruits are detected bilaterally. Nodals are palpated.
Gland is usually not visible on inspection. In a normal healthy adult, thyroid glands are usually not visible on inspection.
A client has come to the clinic for a routine health assessment. What is the best assessment question for the nurse to ask a client after observing tophi on the client's ear cartilage? Have you had sudden and severe pain in the toes or feet? Do you have a family history of osteoporosis? Have you ever had pain along the side of your leg? Do you have a history of rheumatoid arthritis or bursitis?
Have you had sudden and severe pain in the toes or feet? Tophi (plural form of tophus) are deposits of uric acid crystals found in the skin, cartilage, and or on the surface of joints. Tophi are seen in the advanced stages of gout, a condition in which uric acid crystals have deposited into the joints, particularly, the toes. Gout will often present clinically as sudden and severe pain in the toes or lower extremities. The nurse should ask about a history of sudden and severe pain in the toes or lower extremities after observing tophi on the ear cartilage.
The nurse performs a physical assessment on an older female client. Which change from the prior exam may be an indication of osteoporosis? Thick and brittle fingernails. Decreased range of motion. Weight gain of 15 pounds. Height reduction of 1.5 inches.
Height reduction of 1.5 inches. Osteoporosis is a loss of bone density that causes brittle bones and an increased risk for fractures. Reduced height in older female clients with osteoporosis is generally the result of the shortening of the vertebral column due to loss of water and thinning of the intervertebral discs.
The nurse is assigned to provide care for a newly admitted client. the nurse performs a physical assessment, reviews the admission form, and examines the primary health care provider's prescriptions. Which tasks would the nurse identify as the priorities in this client's plan of care? 56 yr old man, married, catholic, history of emphysema, terminally ill w/ cancer of esophagus Soft diet, Oxy at 2L via nasal cannula, postural drainage BID, Fluticasone-Salmeterol 250/50 at 2 breaths BID Weak, anorexic, dyspneic, emaciated, apathetic
Hygiene and comfort B/c the client's condition is terminal, the nursing priority should be directed toward providing basic care and comfort. Although intake and output, diet and nutrition, and body mechanics and posture are important, provision of comfort is priority when caring for dying client.
A client is receiving haloperidol for agitation, and the nurse is monitoring the client for side effects. Which response identified is unrelated to extrapyramidal tract effect? Akathisia Opisthotonos Oculogyric crisis Hypertensive crisis
Hypertensive crisis Extrapyramidal side effects: acute dystonia (opisthotonos), parkinsonism, akathisia, tardive dyskinesia
The nurse is assessing a client who reports having shoulder pain. Which sign is the best indicator of a rotator cuff tear? Inability to adduct the arm from the body. Inability to slowly lower the arm when abducted. Inability to externally rotate the arm. Inability to internally rotate the arm.
Inability to slowly lower the arm when abducted. Rotator cuff damage can be assessed with the Drop Arm test, in which the affected arm is passively abducted at 90 degrees and the client is unable to keep the arm elevated or slowly and smoothly lower the arm from this position without moving the shoulder forward to have the other muscles compensate for the torn rotator cuff muscle.
A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing to complete a head-to-toe assessment and will begin at the head of the client. Which technique should the nurse use to begin the assessment? Inspect the hair and skin. Palpate the temperature of the skin. Percuss for tenderness. Auscultate the temporal arteries.
Inspect the hair and skin. The usual order for a physical assessment is inspection, palpation, percussion, and auscultation. When beginning a physical assessment, the nurse should perform an inspection, which is a general survey of the individual as a whole and of each body system.
A client presents with a rash along the occipital area of the hairline and reports intense itching. How should the nurse begin the objective part of the examination? Inspect the scalp looking for nits. Palpate the area to determine if there are lesions. Ask the client whether the client has been in a foreign country. Take the client's temperature.
Inspect the scalp looking for nits. Pediculosis (head lice) is caused by lice that typically irritate the scalp around the occipital area and behind the ears. The scalp irritation causes intense itching in the area.
The nurse examines the skin of an older adult client. Which skin variation is considered a normal finding for a client in this age group? Dryness. Lentigines. Bruising. Tenting.
Lentigines. Lentigines or commonly referred to as liver spots are irregularly shaped dark spots on the skin caused by aging and extensive sun exposure. This skin variation is a normal finding in an older adult client.
During cardiac auscultation, the nurse hears a split in the second heart sound when listening to the second left intercostal space of a male client. To assess this sound more fully, what action should the nurse implement? Inch the stethoscope down the left side of the client's sternum. Ask the client to cough and then listen at the site again. Instruct client to hold his breath so the sound is clearer. Listen to the sound while observing the client's respirations.
Listen to the sound while observing the client's respirations. A split S2 is heard only in the pulmonic valve area (second left interspace). Listening while observing respirations allows the examiner to determine the type of S2 split that is occurring. Other actions are not useful in auscultating a split S2.
How should the nurse assess for lower extremity edema in a client who has been diagnosed with heart failure? Measure bilateral ankle circumference with a non-stretchable tape measure. Press skin over the tibia and report edema according to the grading scale. Ask if the client feels the bilateral edema has changed and to what extent. Inspect the lower extremities together to compare the amount of swelling.
Measure bilateral ankle circumference with a non-stretchable tape measure. An accurate assessment of lower extremity edema is required when a client is treated for heart failure. Measuring ankle circumference is more accurate than other objective measures that can rely on individual interpretation, such as measuring pitting edema.
Which procedure should the nurse use to assess for a pulse deficit? Compare the brachial pulse and femoral pulse. Document the observed pulse rate and quality. Obtain the systolic blood pressure and subtract the apical pulse. Measure the apical pulse and compare it to the peripheral pulse.
Measure the apical pulse and compare it to the peripheral pulse. A pulse deficit is a palpable difference between the apical pulse at the point of maximal impulse and the radial pulse palpated at the wrist. The nurse should measure the apical pulse and compare it to the peripheral pulse to assess for a pulse deficit. If the pulse number is different from the apical pulse, then the radial pulse rate should be subtracted from the apical pulse and the remaining number is the number that should be recorded for the pulse deficit.
A 26-yr-old G1 P0 client at 29 weeks' gestation has gained 8 lbs in 2 weeks; her BP has increased from 128/74 to 150/90 mmHg; and she has developed 1+ proteinuria on urine dipstick. Which condition do these signs suggest? Mild preeclampsia Severe preeclampsia Chronic HTN Gestational HTN
Mild preeclampsia Gestational hypertension is diagnosed when blood pressure readings are higher than 140/90 mm Hg in a woman who had normal blood pressure prior to 20 weeks and has no proteinuria (excess protein in the urine). Preeclampsia is diagnosed when a woman with gestational hypertension also has increased protein in her urine. Mild- BP below 160/110 w/ proteinuria but no organ dysfunction Severe- BP above 160/110 and proteinuria of 5g or more per 24-hr specimen
A client does not take their meds regularly and is depressed. Which inference can the nurse make about the client's motivational level?
Not motivated If client is not motivated, then the client may not attempt to eradicate illness and feel depressed b/c of illness. If pt intrinsically motivated, then pt shows more interest in taking meds on their own rather than b/c of pressure from other individuals. Pt is motivated extrinsically with or without self-determination when they may take med regularly when reminded to do so or when pressured by others.
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel sounds in the right upper quadrant. Which action should the nurse take next? Auscultate over the other 3 abdominal quadrants. Count the number of bowel sounds per minute. Note the character and frequency of bowel sounds. Count to determine how many bowel sounds occur in one minute.
Note the character and frequency of bowel sounds. Bowel sounds originate from the air and fluid movement through the stomach and intestines. A wide range of normal sounds can occur depending on when the last meal was ingested. The nurse should assess for hyperactive or hypoactive bowel sounds during auscultation, noting the character and frequency. It is not necessary to count the number of bowel sounds per minute and to listen to all four quadrants. It is necessary to listen for bowel sounds for a minimum of 5 minutes before declaring bowel sounds absent.
Which action will the nurse take in a client hospitalized for uncontrolled HTN and chest pain on daily diuretic for 2 days whose K level this morning is 2.7?
Notify health care provider that K level is below normal. Health care provider should be notified immediately b/c client's K is below normal. Normal K level range is 3.5-5. Clients on diuretic therapy require close monitoring of their electrolytes b/c some can cause hypokalemia, whereas others spare K, which can cause hyperkalemia. Retesting serum K level is unnecessary and will delay treatment required by client.
During the interview portion of the health assessment, a nurse notes the person's posture, physical appearance, and ability to converse. How should the nurse document these findings? Objective. Subjective. Expected. Reportable.
Objective. Although the purpose of the interview is not to collect objective data, there are some things the nurse observes at this time: the person's posture, physical appearance, ability to carry on a conversation, and overall demeanor.
Which technique should the nurse use to assess a client for scoliosis? Watch gait while the client ambulates down the hallway. Observe spine while the client is erect and bent forward. Palpate neck while the client rotates head from side to side. Assess for presence of pain when the client twists the torso.
Observe spine while the client is erect and bent forward. Scoliosis is a lateral curvature of the spine seen upon inspection of the spine while the client stands erect and then bends forward.
The nurse observes peristaltic movement in the left lower quadrant of a client's abdomen. Which further assessment of the area should the nurse perform? Observe the direction of movement. Auscultate the area of movement. Lightly palpate the area of movement. Percuss the area of movement.
Observe the direction of movement Increased peristaltic movements are occasionally seen in very thin clients and may indicate the presence of intestinal obstruction. In addition to noting the quadrant of origin, the nurse should also note the direction of the peristaltic flow and report these findings to the healthcare provider.
How will the nurse eval the effectiveness of training after teaching a family member how to admin SC enoxaparin sodium? Return demonstration on manikin Verbalization of side effects of med Observing fam member admin enox sodium to client Correctly verbalizing all necessary steps in enox admin
Observing fam member admin enox sodium to client The best way to eval effectiveness of teaching is to observe fam member admining med to client. The fam member may be able to verbalize or admin on a manikin but fear puncturing the skin with the needle or fear hurting the fam member.
After completing the initial general assessment, the nurse is now completing a focused abdominal assessment of a client who was admitted for abdominal pain. Which assessment is most important for the nurse to implement? Inspect for abdominal distension then percuss for tympany. Palpate the abdomen after auscultating for bowel sounds. Measure the client's oxygen saturation. Ask if pain medication was taken.
Palpate the abdomen after auscultating for bowel sounds. During a focused assessment of the abdomen, the nurse should palpate for abdominal tension and tenderness after auscultating for bowel sounds, which can be altered by palpation and percussion. The abdominal assessment should progress in the sequence of inspection, auscultation, palpation, and then percussion.
Following abdominal auscultation of a client who is admitted for signs of splenomegaly, which additional assessment should the nurse use to verify splenomegaly? Rebound tenderness. Percussion. Deep palpation. Inspection.
Percussion. When splenomegaly is suspected, percussion of the spleen produces a dull sound and is a safe method of verifying enlargement. A normal-sized spleen is positioned above the percussion point even when it descends during inspiration, and the percussion tone is tympanic on both expiration and inspiration.
The nurse uses a tongue depressor to assess a client's mouth. Which structure should the nurse be able to visualize? Esophagus. Pharynx. Trachea. Maxillary sinus.
Pharynx. Depressing the tongue when examining the mouth allows the nurse to visualize the pharynx, tonsils, and adenoids.
Which technique should the nurse implement when performing a Weber test? Tap the patellar tendon using a reflex hammer. Shine the light of an ophthalmoscope into the pupil. Visualize the tympanic membrane using an otoscope. Place a vibrating tuning fork midline on top of the head.
Place a vibrating tuning fork midline on top of the head. The Weber test is used to evaluate hearing by bone conduction through the skull, which should sound equally loud in both ears. The tuning fork should be struck and then placed on the midline of the head. If the client describes hearing that sounds louder in one ear than the other, it may indicate unequal hearing loss, and further assessment is needed.
The nurse is testing the client's shoulders for range of motion. What should the nurse document to record normal internal rotation? Ability to lift both arms over the head and swing each arm across the front of the body. Range of 90 degrees when the hands are placed at the small of the back. A 90 degree range with both hands behind the head with elbows out. Rolling of shoulders in a circular motion clockwise and counter clockwise.
Range of 90 degrees when the hands are placed at the small of the back. To document normal internal rotation of the shoulders, the client should be able to demonstrate a range of 90 degrees when the hands are placed at the small of the back.
An older client pushes the nurse's hand away when palpation is initiated during physical assessment. Which additional objective sign aids the nurse in assessing for abdominal tenderness? Takes deep breaths when palpation is performed. Rebound tenderness. Closes eyes during palpation of the abdomen. Smiles when asked if pain is illicited with palpation.
Rebound tenderness. An objective sign that can aid in determining abdominal tenderness is the assessment of rebound tenderness when the person reports abdominal pain or when you elicit tenderness during palpation.
A Muslim male client refuses to let the female nurse listen to his breath sounds during the examination. How should the nurse respond? Explain how the nursing skill will be performed before proceeding. Examine client with an additional healthcare provider for support. Request a male nurse or healthcare provider to perform the exam. Avoid any skills that involve touching the client during the exam.
Request a male nurse or healthcare provider to perform the exam. Modesty is an important value in the Muslim community, and Muslims are reluctant to expose any part of their body to healthcare members. Muslim clients are accustomed to examination by "same-sex" healthcare providers.
A client with COPD has a bld pH of 7.25 and a partial pressure of carbon dioxide (PCO2) of 60mmHg. Which complication would the nurse suspect the client is experiencing? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory acidosis PCO2 levels are a parameter for resp function. Expected PCO2 is 40 mmHg. Normal bld pH is 7.35-7.45.
The nurse is conducting an interview with a client who speaks limited English. Which action should the nurse implement? Seek the assistance of a healthcare team member who speaks the client's preferred language. Continue with the client's assessment interview using simple English words. Have the client reschedule for a time when a family member can be there to interpret. Ask the client to call a friend who speaks English and is able to interpret.
Seek the assistance of a healthcare team member who speaks the client's preferred language. A healthcare team member who speaks the client's preferred language or a medical interpreter must be provided whenever English is not the preferred language of the client.
Which action is next when a nurse determines that an adolescent with newly diagnosed type 1 diabetes has sufficient knowledge of the disorder? setting goals with client developing rapport with client teaching client how to give insulin injections instructing client how to monitor bld gluc
Setting goals with client Negotiation of goals is essential to successful learning; mutual goal-setting provides focus for learning. Rapport should be developed before teaching the adolescent about diabetes was started.
The nurse explains to the parents of a 6-yr-old with pinworm infestation how pinworms are transmitted. Which statement indicated that the teaching has been understood?
She needs to wash her hands before eating anything Pinworm infestation is transferred by way or oral-anal route and effective hand washing is best way to prevent transmission; not transmitted by coughing
While conducting an interview to obtain a health history, the nurse notices that the client pauses frequently and looks at the nurse expectantly. Which response is best for the nurse to provide? Reassure the client that there are no wrong answers. Tell the client to return later for another interview. Continue to ask questions until the client responds. Sit quietly to allow the client to respond comfortably
Sit quietly to allow the client to respond comfortably. A silent attentiveness or intelligent repose communicates that the nurse has time and is willing to listen to the client's responses.
Which clinical finding in a newly postpartum client requires immediate investigation? Inflamed episiotomy Slow trickle of bld from vagina Estimated bld loss of 1/2 L during vaginal birth Boggy fundus that becomes firm after prolonged massage
Slow trickle of bld from vagina vag bleeding may be an early sign of hemorrhage; hypovolemic shock can develop. An inflamed episiotomy is an expected finding (surgical cut made at the opening of the vagina during childbirth, to aid a difficult delivery and prevent rupture of tissues); ice packs help resolve inflamm. Expected bld loss for vag birth is 300-500mL. A fundus that has been overstretched or is multiparous may require prolonged massage until it becomes firm.
When assessing a client with dyspnea, the nurse hears an audible inspiratory crowing sound. Which lung sound should the nurse document? Stridor. Crackles. Wheezing. Pleural rub.
Stridor. Stridor is an audible monophonic inspiratory crowing sound. Stridor in a client with dyspnea indicates airway obstruction.
An emaciated older adult with dementia develops a large pressure ulcer after refusing to change position for extended periods of time. The family blames the nurses and threatens to sue. What is considered when determining the source of blame for the pressure ulcer?
The client should have been turned regularly. Pts should change position q2h to prevent pressure ulcers. The nurse should not deviate from this standard of practice b/c of cognitively impaired client's refusal to move. The nurse was negligent for not changing client's position. Although pressure injuries may occur, nursing care must include preventive measures. If the client refuses to change position for extended periods, the nurse would consult the agency policy or management for a strategy to handle this situation. For example, a formal shared decision-making (SDM) protocol can be instituted upon admission or as soon as refusal has started to involve the client, the family, and the health care staff with a collaborative agreement on how to resolve the problem.
Which info about the teenager's developmental stage would be considered before starting a counseling program for 15-yr-old with type 1 diabetes who has a history of noncompliance with therapy regimen?
The struggle for identity is typical Striving to attain identity and independence are tasks of adolescent, and rebellion against established norms may be exhibited. Denial may be present but is not developmentally related to adolescence.
Which conclusion would the nurse make when observing a group of toddlers sitting at a table coloring but not talking or sharing their crayons?
This is a typical expression of toddlers' social development. As part of socialization process, toddlers enjoy playing beside other children (parallel play) but are not developmentally ready for interactive (cooperative) play, which begins in preschool years
When teaching a client how to perform a monthly breast self-assessment, the nurse should tell the client that it is most important to assess which part of the breast more closely for changes? Upper outer quadrant. Lower inner quadrant. Upper inner quadrant. Lower outer quadrant.
Upper outer quadrant. Although the client should be instructed to perform a thorough breast self-assessment every month to check for tissue changes, evidence has shown that the upper outer quadrant is the site of most breast tumors.
The nurse is assessing for the presence of a hernia. Which action should the nurse ask the client to perform while lying supine? Bring the knees toward the chest. Place the chin onto the chest. Roll from one side to the other. Use abdominal muscles to sit up.
Use abdominal muscles to sit up. Engaging the abdominal muscles can reveal a protruding hernia. When assessing for the presence of a hernia, the nurse should ask the client to use the abdominal muscles to sit up without hand support.
The nurse performs the Weber and Rinne tests to assess which cranial nerve? VIII. VI. I. V.
VIII. The Weber and Rinne tuning fork tests are used to evaluate for hearing loss. These tests are performed to assess cranial nerve VIII, also known the acoustic or vestibulocochlear nerve.
An older client has just returned to the room following a surgical procedure. Which pain scale should the nurse use when assessing the client's pain level? Verbal descriptor scale. Wong-Baker scale. Numeric rating scale. Faces pain scale-revised.
Verbal descriptor scale. The descriptor scale uses words rather than numbers or pictures to describe pain. This method of reporting pain is less confusing and less abstract for older adults. The choices provided for rating the intensity of pain include the following: no pain, mild pain, moderate pain, and severe pain.
Which action would the nurse expect in the plan of care of a client scheduled for an adrenalectomy? provide low-protein diet admin parenteral corticosteroids collect preoperative 24-hr urine specimen withhold all meds 48 hrs before surgery
administer parenteral corticosteroids Steroid therapy is usually given IM or IV preoperatively and continued intraoperatively to prepare for acute adrenal insufficiency that follows surgery. The diet must supply ample protein and K+.
Which clinical finding leads the nurse to conclude that an IV had infiltrated rather than caused inflammation? pain coolness localized swelling cessation in flow of solution
coolness When IV infiltrates (IV fluid enters SC tissue around venipuncture), the IV solution entering interstitial space is at room temp, whereas body temp approximately 98.6; therefore client's skin will feel cool to touch at IV infiltration site. Pain, cessation inflow of solution, and increase in interstitial fluids, associated with both inflam and infiltration.
Which action by the nurse would be therapeutic after obtaining the consent of an adolescent girl who is concerned about her body image after amputation of a leg for bone cancer?
encouraging her peers to visit Peer acceptance is crucial during this period; friends must have opportunity to accept client with 1 leg. Concealment does not help adolescent or others accept the loss. Isolating will increase feelings of alienation and being different. Adolescent needs to relate to and be accepted by peers and family.
Which assessment after admin of diltiazem to client with supraventricular tachycardia (SVT) and a heart rate of 170 bpm indicates that the med was effective? increased urine output BP of 90/60 heart rate of 98 bpm no longer complaining of heart palpations
heart rate of 98 bpm Diltiazem hydrochloride's purpose is to slow down the heart rate. SVT has a heart rate of 150-250 bpm. Increased urine output may occur over period of time b/c of increased ventricular filling time but would not occur until after heart rate had stabilized. Hypotension is a side effect of diltiazem, not a desired effect. Heart palpations are experienced by some with various dysrhythmias. A decreased sensation of heart palps is a + finding but not present in all clients.
A client, transferred to the post-anesthesia care unit after a transurethral resection of the prostate (TURP), has an IV line and a urinary retention catheter. During the immediate postoperative period, for which potentially critical complication would the nurse monitor? sepsis phlebitis hemorrhage leakage around the urinary catheter
hemorrhage After transurethral surgery, hemorrhage is common b/c of venous oozing and bleeding from many small arteries in the area. Hemorrhage is more important than phlebitis.
Which complication will a nurse monitor for before replacement steroid therapy is regulated fully in a client who has had an adrenalectomy? hypotension hypokalemia hypernatremia hyperglycemia
hypotension B/c of instability of vascular system and circulating adrenal hormones, hypotension frequently occurs until the hormonal level is controlled by replacement therapy. K+ excretion is a response to excessive adrenal hormones. After adrenalectomy, adrenal hormones are decreased until replacement therapy is regulated. Na retention is a sign of hyperadrenalism; doesn't occur after the adrenals are removed. Hyperglycemia is a sign of excessive adrenal hormones; after adrenalectomy, adrenal hormones are not secreted.
A breast-feeding mother experiences redness and pain in left breast, a temp of 100.8 F, chills, and malaise. Which condition would the nurse suspect? mastitis engorgement blocked milk duct inadequate milk production
mastitis B/c of presence of generalized symptoms, the nurse would suspect mastitis. Engorgement would involve both breasts, not one. Blocked milk duct is usually marked by swelling and pain in 1 area of breast but does not have systemic symptoms.
Which is suspected when a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity followed by fundal tenderness and a small amount of dark-red bleeding? true labor placenta previa partial abruptio placentae abdominal muscular injury
partial abruptio placentae Manifestations of sudden sharp localized pain and small amounts of dark-red bleeding caused by some degree of placental separation. True labor begins with regular contractions. There is no pain with placenta previa, just presence of bright-red bleeding
Nurse is caring for a child who has an external fixation device on the leg. Which the nurse's priority goal when providing pin care? easing pain minimizing scarring preventing infection avoiding skin breakdown
preventing infection Pin sites provide direct avenue for organisms into the bone. Pin site care is priority over easing pain. Skin has tendency to grow around pin rather than break down as long as infection is prevented
Immediately following rupture of membranes, the fetal hear rate monitor shows variable decelerations of more than 90 secs followed by bradycardia. Which condition does the nurse suspect? fetal acidosis prolapsed cord head compression uteroplacental insufficiency
prolapsed cord Variable pattern of bradycardia is omnious sign indicative of prolapsed cord/ cord compression which can result in fetal hypoxia. Fetal acidosis, not fetal heart rate changes, occur with uteroplacental insufficiency. Early decelerations are associated with head compression and are benign. Late decelerations and tachycardia, not variable decelerations followed by bradycardia, are associated with uteroplacental insuff.
Which relationship reflects the relationship of naloxone to morphine sulfate? aspirin to warfarin amoxicillin to infection enoxaparin to dalteparin protamine sulfate to heparin
protamine sulfate to heparin Protamine sulfate is the antidote for heparin overdose while naloxone reverses effects of opioids. Aspirin and warfarin are both anticoagulants. Enox and daltaparin are both low-molecular-weight heparins.
Which inference would the nurse draw when crackles are heard while auscultating lungs of a client admitted with severe preeclampsia?
pulmonary edema may have developed As vasospasms worsen, capillary endothelial damage results in capillary leakage into the alveoli. Crackles are not an indication of an impending seizure; signs of impending seizure include hyperreflexia, developing or worsening clonus, severe headache, visual disturbances, and epigastric pain. Impaired diaphragmatic function is a discomfort associated with pregnancy that may result in shortness of breath or dyspnea, not crackles
What mechanism of action would the nurse identify for levodopa therapy prescribed to a client diagnosed with Parkinson disease?
restores dopamine levels in brain Levodopa= precursor of dopamine, catecholamine neurotrans. It increases dopamine levels in brain that are depleted in Parkinson disease. Anticholinergic meds: block acetylcholine effects
Zolpidem is used for
sleep It's a sedative-hypnotic that produces CNS depression in limbic, thalamic, and hypothalamic areas of brain