HESI- Quarter 1
A nurse informs a patient that her blood pressure is 128/78. The patient asks what the number 128 means. What is the nurse's appropriate response? "The 128 represents the pressure in your blood vessels when: A. "The ventricles relax and the aortic and pulmonic valves open." B. "The ventricles contract and the mitral and tricuspid valves close." C. "The ventricles contract and the mitral and tricuspid valves open." D. "The ventricles relax and the aortic and pulmonic valves close."
"The ventricles contract and the mitral and tricuspid valves close."
Mini-Mental State Examination (MMSE)
A test that is used to measure cognitive ability ( memory, reading, copying). -paper and pencil -5-10 mins
Which description of pain from the patient makes a nurse suspect the patient's pain is originating from a muscle? A. "Crampy" B. "Dull and deep" C. "Boring and intense" D. "Sharp upon movement"
A. "Crampy"
A client is reporting chest pain. What statement made by the client, helps the nurse to understand this client has a naturalistic belief in the cause of illness? A. "My life is really out of balance." B. "I knew I should have changed my diet." C. "I should have gone to church last week." D. "I forgot to take my medicines last night."
A. "My life is really out of balance."
While assessing level of consciousness, the nurse finds that a client localizes to pain, is confused during conversation, and opens the eyes to sound. How should the nurse document the Glasgow score of this client? A. 12. B. 10. C. 9. D. 7.
A. 12.
A nurse is completing a nutritional assessment with a client. What is the easiest method for the nurse to use to get information about the client's nutritional intake? A. 24-hour dietary recall B. Food diary. C. Intake and output record. D. Lab information (albumin, pre-albumin).
A. 24-hour dietary recall
The nurse is assessing a client who has a history of aortic regurgitation. Where should the nurse place the stethoscope diaphragm to listen for this condition? A. 2nd intercostal space along the right sternal border. B. 2nd intercostal space along the left sternal border. C. 3rd intercostal space on the right midclavicular line. D. 5th intercostal space on the left midclavicular line.
A. 2nd intercostal space along the right sternal border.
While assessing a man during a physical examination for work, the nurse suspects alcohol use. Which assessment tool is appropriate in this situation? A. AUDIT screening tool B. Rapid eye test C. Mental status examination D. Holmes Social Readjustment Rating Scale
A. AUDIT screening tool
During an external examination of the eyes, the nurse gently palpates the eyes while the client's eyelids are closed. The eyes are both very firm and resist movement back into the orbit. How should the nurse document this finding? A. Abnormal finding. B. Expected finding. C. Normal variation. D. Sign of aging
A. Abnormal finding.
What is the best nursing response to an older client who has not mentioned incontinence during a genitourinary assessment? A. Ask the client specifically about any leakage of urine. B. Document that the client reports having no incontinence. C. Have the client cough and then check for urine leakage. D. Determine if the client has ever had urinary tract surgery.
A. Ask the client specifically about any leakage of urine.
A patient reports having difficulty swallowing. Based on this information, how does the nurse assess the appropriate cranial nerve? A. Ask the patient to stick out the tongue and move it in all directions. B. Ask the patient to move the head to the right and left. C. Observe the symmetry of the face when the patient talks. D. Assess for taste on the anterior part of the tongue
A. Ask the patient to stick out the tongue and move it in all directions.
The nurse is preparing to assess the hearing of a client with a history of prolonged exposure to occupational noise. Which hearing test provides the most reliable assessment of hearing status? A. Audiometry. B. Whispered voice. C. Weber. D. Rinne.
A. Audiometry.
A nurse is working in a healthcare facility that serves a diverse population. What action(s) by the nurse will allow the nurse to empathize with and understand this population? (Select all that apply.) A. Be open to people who are different. B. Have a curiosity about people. C. Become culturally competent. D. Interact with each person in the same way. E. Request nurses take care of patients with the same ethnicity. F. Always request an interpreter for people from other countries.
A. Be open to people who are different. B. Have a curiosity about people. C. Become culturally competent.
A client with dark skin is reporting a painful and itching area on the lower left leg. What should the nurse look for when assessing this client's skin for inflammation? A. Change in consistency. B. Change in turgor. C. Redness. D. Pallor.
A. Change in consistency.
Which of the following characteristics are true regarding changes in the respiratory system of an older adult? Select all A. Costal cartilages become calcified B. Thoracic expansion is increased C. Increase in the number of alveoli D.Increased residual volume E. Decreased vital capacity
A. Costal cartilages become calcified D.Increased residual volume E. Decreased vital capacity
A 24-year-old male patient tells the nurse he has had no energy for 2 weeks. He has no trouble falling asleep; in fact, he sleeps deeply about 12 hours every night. He states that he has gained 10 lb in the past 2 months and has no friends. The nurse associates these manifestations with which mental health disorder? A. Depression B. Schizophrenia C. Bipolar disorder D. Anxiety disorder
A. Depression
The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply.) A. Diminished hair on legs B. Bruising on extremities C. Skin cool to touch D. Capillary refill less than 3 seconds E. Darkened skin on extremities
A. Diminished hair on legs C. Skin cool to touch
A client with progressive hearing loss appears distressed when the registered nurse (RN) asks open-ended questions about the client's health history. Which forms of communication should the RN use? A. Face the client so the client can see the RN's mouth. B. Increase one's speech volume when interacting with the client. C. Repeat information to the client if misunderstood. D. Check if the client's hearing aides are working properly. E. Reduce environmental noise surrounding the client.
A. Face the client so the client can see the RN's mouth. D. Check if the client's hearing aides are working properly. E. Reduce environmental noise surrounding the client.
A nurse assesses a patient with a head injury who has slowing intellectual functioning, personality changes, and emotional lability. The nurse correlates these findings with which area of the brain? A. Frontal lobe B. Parietal lobe C. Thalamus D. Temporal lobe
A. Frontal lobe
Which condition is indicated by a fluorescent, yellow-green color when the nurse uses a Wood's lamp to examine a client's skin lesions? A. Fungal infection. B. Bacterial infection. C. Allergic reaction. D. Skin cancer.
A. Fungal infection.
Which tool should the nurse use when assessing the neurological status of a client with traumatic brain injury? A. Glasgow Coma Scale. B. Braden Scale. C. Numerical pain scale. D. Cranial nerve examination.
A. Glasgow Coma Scale.
Which statement is accurate about assessing the spleen? A. It must be enlarged at least three times normal size for it to be palpable. B. It is easily felt by reaching the left hand behind the 11th and 12th ribs. C. It is normally felt by rolling the client on the right side and palpating. D. It is a firm mass palpated slightly left of midline in the upper abdomen.
A. It must be enlarged at least three times normal size for it to be palpable.
The nurse is examining the hip joint of a client who reports hip pain. Which other assessment is most helpful in determining the cause of the client's pain? A. Knee joint evaluation. B. Cranial nerve testing. C. Postural alignment. D. Deep tendon reflexes.
A. Knee joint evaluation.
When assessing a patient's level of consciousness, what should the nurse assess first? A. Level of alertness B. Orientation to person C. Orientation to place D. Orientation to time
A. Level of alertness
A client comes to the clinic with a report of fever and a recent exposure to someone who was diagnosed with meningitis. Which nursing assessment should be completed during the initial examination of this client? A. Level of consciousness. B. Gait characteristics. C. Presence of trauma. D. Bladder control ability.
A. Level of consciousness.
Which findings does the nurse expect when assessing the mouth of a healthy adult? Select all that apply. A. Lips appear pink, smooth, moist, and symmetric B. Teeth are white, yellow, or gray, with smooth edges C. Slight roughness on the dorsum of the tongue D. Hard palate appears smooth, pale, and immovable E. Mucous membranes are dry and intact
A. Lips appear pink, smooth, moist, and symmetric B. Teeth are white, yellow, or gray, with smooth edges C. Slight roughness on the dorsum of the tongue D. Hard palate appears smooth, pale, and immovable
A client has just returned from the recovery room and asks to get out of bed to go to the bathroom. The nurse decides to obtain orthostatic vital signs first. How will the nurse position the client to begin this procedure? A. Lying. B. Sitting. C. Leaning. D. Standing.
A. Lying.
When assessing facial nerve function of a 96-year-old, the nurse asks the client to smile in an exaggerated manner. Which finding is most important for the nurse to further asses? A. Only one side of the mouth moves when smiling. B. The client's teeth have a yellowed appearance. C. The client smiles broadly but appears anxious. D. The client asks the nurse to repeat the directions.
A. Only one side of the mouth moves when smiling.
The nurse is interviewing a client who reports having a persistent, productive cough during the winter caused by bronchitis. Which additional finding should the nurse assess for bronchitis? A. Phlegm production and wheezing. B. Smoking history. C. Hemoptysis. D. Night sweats.
A. Phlegm production and wheezing.
The nurse is assessing a client who has a history of mitral stenosis. How should the nurse assess this client with a stethoscope to listen for this condition? A. Place the bell on the 5th intercostal space, left midclavicular line. B. Place the bell on the 2nd intercostal space, left midclavicular line. C. Put the diaphragm on the 5th intercostal space, left sternal border. D. Put the diaphragm on the 2nd intercostal space, left sternal border.
A. Place the bell on the 5th intercostal space, left midclavicular line.
A client reports pain when taking a deep breath. Which lung auscultation sound should the nurse anticipate hearing? A. Pleural friction rub. B. Rhonchus. C. Coarse crackles. D. Wheezing.
A. Pleural friction rub.
What is the best place for the nurse to hear lower lobe lung sounds with a stethoscope? A. Posterior chest below the 3rd intercostal space. B. Posterior-axillary line at the 4th intercostal space. C. Anterior chest at the level of the 4th intercostal space. D. Anterior-axillary line at the 5th intercostal space.
A. Posterior chest below the 3rd intercostal space.
The nurse is assessing the posterior pharynx during a physical examination. Which technique should the nurse use? A. Press the tongue down one side at a time with a tongue depressor. B. Ask the client to open the mouth and say "ah." C. Listen for hoarseness after asking the client to speak. D. Palpate the neck and ask the client to swallow.
A. Press the tongue down one side at a time with a tongue depressor.
A client states that she had a mastectomy of her left breast last year and now experiences lymphedema. What should the nurse expect to find when examining the client? A. Swelling of the left arm and non-pitting edema. B. Bilateral swelling of the arms with weakened pulses. C. Complaints of pain when taking the blood pressure on the affected side. D. Metastasis of cancer due to cancer being in the lymph nodes.
A. Swelling of the left arm and non-pitting edema.
The client is experiencing severe pruritus and small papules and burrows on areas over one hand and the inner thighs. Which assessment data best explains the condition the client is experiencing? A. The client works in a daycare setting that has had a scabies outbreak. B. The client has been using a chemical stripping agent for home remodeling. C. The client has a family history of psoriasis in both parents and a sibling. D. The client routinely works with clay and paint as a hobby.
A. The client works in a daycare setting that has had a scabies outbreak.
Which is an example of data a nurse collects during a physical examination? A. The patient's lack of hair and shiny skin over both shins. B. The patient's stated concern about lack of money for prescriptions C. The patient's complaints of tingling sensations in the feet D. The patient's mother's statements that the patient is very nervous lately
A. The patient's lack of hair and shiny skin over both shins
A registered nurse (RN) is performing a mini-mental state examination (MMSE) for a client who is being admitted to an assisted living community. Which communication techniques should the RN implement to decrease anxiety in the client? (Select all that apply.) A. Use simple sentences during the examination. B. Move to another question if the client seems confused. C. Reduce environmental detractors during the examination. D. Allow family to answer for the client to decrease frustration. E. Ask questions one at a time to decrease confusion.
A. Use simple sentences during the examination. C. Reduce environmental detractors during the examination. E. Ask questions one at a time to decrease confusion.
Which question should the nurse ask in order to test a client's remote memory? A. What is your date of birth? B. Who is your current healthcare provider? C. What medications are you taking? D. How did you arrive at the hospital today?
A. What is your date of birth?
A postmenopausal female client is undergoing a routine physical examination. She has reported nothing out of the ordinary. When performing the examination of the genitourinary system, the nurse finds an irregularly enlarged uterus with firm, mobile, painless nodules in the uterine wall. How should the nurse explain this finding to the client? A. You have benign fibroid tumors, a common occurrence in women your age. B. This is a sign of uterine cancer and I will report this to the healthcare provider. C. This is a sign of endometriosis, so we will need to biopsy the lesions. D. This is a very common finding in pregnancy and it will go away..
A. You have benign fibroid tumors, a common occurrence in women your age.
A client would like to eat his dinner. The nurse would most likely assist the Pt into what position? A. high-fowlers B. supine C. prone D. Sim's
A. high-fowlers (sitting up)
The nurse is preparing to palpate the thorax and abdomen of the patient. Which of these statements describes the correct technique for this procedure? Select all that apply. A. warm hands before touching the pt B. for deep palpation of the liver, use long continuous palpation. C. start with light palpation to detect surface characteristics. D. Use the fingertips to examine skin texture and swelling. E. Identify any tender areas, palpate them last F. use the palms of the hands to assess for temp of the skin.
A. warm hands before touching the pt C. start with light palpation to detect surface characteristics. D. Use the fingertips to examine skin texture and swelling. E. Identify any tender areas, palpate them last
The nurse understands whom to be at the highest risk of suicide? A. 14 yr old overweight female who says, "I'm being bullied at school." B. 26 yr old man with anxiety and says, "I'm going to take a whole bottle of sleeping pills tomorrow." C. 45 yr old female with anorexia who reports a history of 3 suicidal attempts D. 32 yr old woman who just lost her husband and children in a whole house fire
B. 26 yr old man with anxiety and says, "I'm going to take a whole bottle of sleeping pills tomorrow." HE HAS A PLAN- highest risk!
*A patient reports smoking 1 pack of cigarettes per day for 30 years. The nurse reports this as: A. 15 pack years B. 30 pack years C. 365 pack years D. 10,950 pack years
B. 30 pack years
Which part of the body should the nurse examine when assessing for peripheral edema in a client with heart failure? A. Face. B. Ankles. C. Knees. D. Jugular veins.
B. Ankles.
The nurse is performing a thoracic assessment on a client with chronic asthma and hyperinflation of the lungs. Which finding should be expected for this client? A. Kyphosis. B. Barrel chest. C. Pectus Excavatum. D. Pectus Carinatum.
B. Barrel chest.
During the initial assessment, the nurse notes that a client has blurred vision with cloudy lenses. Which condition should the nurse document? A. Pink eye. B. Cataracts. C. Glaucoma. D. Corneal abrasion.
B. Cataracts.
Which findings can the nurse determine by palpating a client's skin? (Select all that apply.) A. Pruritus. B. Diaphoresis. C. Pallor. D. Jaundice. E. Scaling.
B. Diaphoresis. E. Scaling.
Based on the picture, what is an appropriate nursing diagnosis for this client? *crusty/cracked lips* A.Infection B. Fluid Volume Deficit C. Decreased Cardiac Output D. Acute Pain
B. Fluid Volume Deficit
A patient reports having abdominal distention. The nurse observes that the patient's sclerae are yellow. Which abnormal finding does the nurse anticipate on examination of this patient's abdomen? A. Decreased bowel sounds in all quadrants B. Glistening or taut skin of the abdomen C. Bulge in the abdomen when coughing D. Bruit around the umbilicus
B. Glistening or taut skin of the abdomen
A client is in the clinic for a routine health examination. The nurse notices the client appears underweight. Which question is most important for the nurse to ask when completing the health history of this client? A. What types of food do you like or dislike? B. Have you experienced sudden weight loss? C. Do you use dietary supplements every day? D. Can you recall the last 24 hours of food intake?
B. Have you experienced sudden weight loss?
Which information should the nurse obtain to identify the client's self-perception of health status? A. Vital signs. B. Health history. C. Informed consent. D. Genetic predisposition.
B. Health history.
The preoperative nurse is assessing a 34 year-old female student scheduled for an appendectomy. Which piece of data is most impt to collect at this time? A. obstetric history including miscarriages, abortions, and live births. B. History of complications related to anesthesia C. Immunization history including a recent flu vaccine D. Personal habits such as alcohol use and smoking.
B. History of complications related to anesthesia
A nurse is auscultating the lungs of a healthy male patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding? A. Make sure the bell of the stethoscope is used, rather than the diaphragm. B. Hold the stethoscope firmly to prevent movement when placed over chest hair. C. Ask the patient not to talk while the nurse is listening to the lungs. D. Change the patient's position to ensure accurate sounds.
B. Hold the stethoscope firmly to prevent movement when placed over chest hair.
When inspecting a patient's posterior wall of the pharynx and tonsils, a nurse documents which finding as abnormal? A. Both tonsils have a smooth surface. B. Left and right tonsils meet at the midline. C. Left and right tonsils extend beyond the posterior pillars. D. Both tonsils have a glistening appearance.
B. Left and right tonsils meet at the midline.
Which action should the registered nurse (RN) implement to complete an assessment for a client while using an interpreter? A. Ask closed-ended questions with the assistance of the interpreter. B. Maintain eye contact with the client while listening to the translation. C. Instruct interpreter to answer questions from interpreter's point of view. D. Protect the client's privacy by asking a limited number of questions.
B. Maintain eye contact with the client while listening to the translation.
The nurse performs a series of cranial nerve tests on a client with a head injury. Which test should the nurse use to assess damage to the first cranial nerve? A. Ask the client to count down from 100 by 7s for as long as possible. B. Occlude one nostril and have the client identify various odors. C. Have the client follow the tip of a moving penlight with the eyes. D. Tell the client to walk heel to toe in a straight line for nine steps.
B. Occlude one nostril and have the client identify various odors.
A patient tells the nurse, "I've been having gnawing pain in my upper belly for several weeks that is worse on an empty stomach." The nurse suspects: A. Gastroesophageal reflux disease B. Peptic ulcer disease C. Appendicitis D. Cholecystitis
B. Peptic ulcer disease
What is the most important nursing action to reduce transmission of microorganisms during a physical assessment? A. Clean the bell and diaphragm of the stethoscope between patients. B. Perform hand hygiene. C. Wear gloves when anticipating exposure to body fluids. D. Wear eye protection when anticipating spatter of body fluids.
B. Perform hand hygiene.
The nurse enters an examination room to conduct a routine health assessment on an adolescent female client, who is accompanied by her mother. Which action by the nurse is likely to facilitate accurate responses to personal and social history questions? A. Include the mother in the interviewing process. B. Request that the mother leave the exam room. C. Allow the client to broach discussion of any sensitive topics. D. Use highly structured and directed questions to explore sensitive topics.
B. Request that the mother leave the exam room.
The client reports to the nurse a recent exposure to the mumps. Which assessment finding suggests the client has contracted the mumps? A. Enlargement centered along the anterior lower neck region. B. Swelling anterior to the ear lobe on one side of the face. C. Generalized rounded shape of the face. D. Paralysis on one side of the face.
B. Swelling anterior to the ear lobe on one side of the face.
The nurse is assessing a client who has experienced a sudden onset of hearing loss in the right ear. Which finding should alert the nurse to a potentially serious medical condition that requires further evaluation? A. The client works in a busy office setting. B. There is no sign of associated infection. C. The client has no prior history of hearing loss. D. The hearing loss involves high frequencies.
B. There is no sign of associated infection
A 45 year old American Indian female was recently placed on a new blood pressure medication. At a follow up visit, the nurse notes that her BP has not decreased. It would be most important for the nurse to assess for which of the following? A. use of sweat lodges B. Use of herbal supplements C. Meditation practices D. 24- hour diet recall
B. Use of herbal supplements
As a patient is walking down the hall, the nurse notices the patient's staggering, unsteady gait and suspects a cerebellar problem. What findings does the nurse anticipate on the neurologic examination? A. When the patient stands with feet together, eyes open and then closed, an upright posture is maintained. B. When the patient touches the end of each finger to the thumb of the same hand, a tremor is observed in the fingers. C. When the patient is giving a history to the nurse, a tremor is noticed as the patient's hands rest in the lap. D. When lying supine, the patient is able to move the heel of one foot down the shin of the other leg.
B. When the patient touches the end of each finger to the thumb of the same hand, a tremor is observed in the fingers.
A nurse assessing a patient with liver disease expects to find which manifestation during the examination? A. Yellowish color in the axilla and groin B. Yellow pigmentation in the sclera C. Very pale skin on the palms D. Ashen-gray color in the oral mucous membranes
B. Yellow pigmentation in the sclera
While assessing a clients LOC, the nurse notes that the client opens his eyes when the nurse calls his name in a normal voice but then quickly falls asleep. The nurse documents this as: A. alert B. lethargic C. obtunded D. Semi-comatose
B. lethargic
In a client undergoing withdrawl from opiates, the nurse expects which assessment findings? Select all that apply: A. bradycardia B. n/v C. muscle pain D. fever E. dry skin F. pupillary constriction G. anxiety *think worse flu of your life*
B. n/v C. muscle pain D. fever G. anxiety
A patient asks, "Why is touching my toes necessary? This is a sports physical examination, not exercise class." What is the most appropriate response by the nurse? A. "This is the best way to check for symmetry of your arms." B. "I am looking at the stretch of your hamstrings." C. "This allows me to see how straight your spinal column is." D. "I am assessing the rotation of your spine."
C. "This allows me to see how straight your spinal column is."
A male executive is seen in the primary care clinic for a physical examination. While obtaining the client's health history, the nurse inquires about his drug and alcohol use. The executive denies drug use, but reports that he has "two glasses of wine" per night. Which response is best for the nurse to provide? A. "You alcohol intake should be reduced by 8 ounces daily." B. "Does your use of alcohol concern any of your family members?" C. "What effect do you think your use of alcohol may have on you?" D. "The amount of alcohol you are drinking concerns me."
C. "What effect do you think your use of alcohol may have on you?"
When auscultating the heart of a patient with pericarditis, the nurse expects to hear which sound? A. A systolic murmur B. An S3 heart sound C. A friction rub D. An S4 heart sound
C. A friction rub
The nurse is obtaining a complete health history on a 24-yr old female. What should the nurse do to make the client feel more comfortable during the exam? A. Keep 1 foot of space between nurse and client to provide a feeling of intimacy. B. Ask the client to change into a gown for the interview C. Ask staff to monitor call lights during interview. D. Use leading questions to assist the client in answering questions related to personal habits.
C. Ask staff to monitor call lights during interview.
A patient complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what of the following findings will suggest that the cause of this patient's dyspnea is due to heart disease rather than respiratory disease? A. Increased anteroposterior diameter B. Clubbing of the fingers C. Bilateral peripheral edema D. Increased tactile fremitus
C. Bilateral peripheral edema
A nurse is assessing a patient's peripheral circulation. Which finding indicates venous insufficiency of this patient's legs? A. Paresthesias and weak, thin peripheral pulses B. Leg pain that is worsened by walking C. Edema that is worse at the end of the day D. Leg pain that decreases when the legs are lowered
C. Edema that is worse at the end of the day
A client is in the clinic and is reporting lower abdominal pain and constipation. Which information is of greatest concern to the nurse when obtaining the health history from this client? A. Administration of rubeola vaccine at age 7. B. Removal of gallbladder 5 years ago. C. Family history of colon cancer on mother's side. D. Family history of hypertension on father's side.
C. Family history of colon cancer on mother's side.
While palpating a client's breasts, the nurse detects a nontender, solitary, round lobular mass that is solid and firm and slides easily through the breast tissue . The findings of this breast exam are consistent with which condition? A. Mastitis. B. Paget disease. C. Fibroadenoma. D. Plugged mammary duct.
C. Fibroadenoma.
The nurse is prepared to complete a respiratory exam. First step should be: A. palpate the thorax for crepitus or pain B. Auscultate all lung fields C. Inspect the thorax for shape, symmetry, lesions D. Percuss to identify areas of consolidation
C. Inspect the thorax for shape, symmetry, lesions
Which nurse is performing the technique of light palpation appropriately? A. Nurse A applies the bimanual technique to determine size and location of the patient's heart. B. Nurse B uses the fingertips to feel for temperature differences on the patient's legs. C. Nurse C places the ulnar surface of the hands on the patient's thorax to detect vibrations. D. Nurse D depresses the patient's abdomen approximately 4 cm to assess pulsations.
C. Nurse C places the ulnar surface of the hands on the patient's thorax to detect vibrations.
A 65 yr old hispanic male client is being discharged post- cholecystectomy. While the nurse is attempting to provide discharge instructions, the nurse notes that the pt seems to be having difficulty understanding and is speaking in broken english. The wife frequently interrupts you and him to assist with interpretation. What is the nurses next best action? A. Provide the family with written instructions B. Ask the wife to leave the room C. Obtain a medically trained interpreter D. Assign a new caregiver to the pt.
C. Obtain a medically trained interpreter
*A client with a history of HIV comes to the outpatient clinic complaining of cough and chest pain with breathing. The nurse should first: A. Inspect for chest expansion and accessory muscle use. B. Retrieve a sputum sample to evaluate for hemoptysis C. Obtain data relating to a History of Present Illness D. Check CD4 count
C. Obtain data relating to a History of Present Illness
The nurse is completing a physical assessment of a client who fell from a tree. The client's abdomen is soft with hyperactive bowel sounds in all four quadrants. Which assessment technique should the nurse implement when evaluating the client's spleen? A. Elevate head of bed 30 degrees to percuss the spleen. B. Palpate the splenic borders before percussing. C. Percuss the splenic area as the client takes a deep breath. D. Place client in a Trendelen burg position to isolate the spleen.
C. Percuss the splenic area as the client takes a deep breath.
A 64-yr old woman presents the clinic. Her husband reports that she fell last week and seems to be having memory problems. The nurse should: A. assure the pt and husband these are normal findings associated with aging B. Perform a brief mental status exam by incorporating into the interview. C. Perform a full mental status exam D. Refer the pt for neurological testing
C. Perform a full mental status exam
Leading questions may initiate untrue or inaccurate responses because such questions: A. Encourage short or vague answers B. Require an educational level the patient may not possess C. Prompt the patient to try to give a particular answer D. Confuse the patient
C. Prompt the patient to try to give a particular answer
The nurse just administered 2mg of morphine to a post-op pt complaining of pain level 7/10. what would be the next appropriate action? A. ask cna to check on the pt B. identify expected outcomes (goals) for the patient C. Reassess the pt's pain level in 15-30 mins. D. Identify the reason for the pt's pain
C. Reassess the pt's pain level in 15-30 mins.
The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response? A. The client cannot understand the nurse. B. The client is uncomfortable with the nurse. C. The client is treating the nurse with respect. D. The client is purposefully disrespecting the nurse.
C. The client is treating the nurse with respect.
The nurse is assessing a client for a hip flexion contracture. Which finding indicates a negative Thomas test when the client's right knee is brought toward the chest? A. The left leg internally rotates. B. The left leg rises off of the table. C. The left leg remains on the table. D. The left leg externally rotates
C. The left leg remains on the table.
A nurse is using the finger pads to palpate a patient's dorsalis pedis pulses and is unable to feel any pulses. Which action is appropriate for the nurse to perform next? A. Document that the dorsalis pedis pulses are not palpable. B. Have the patient stand and try again to palpate the pulses. C. Use a Doppler to detect the presence of the pulses. D. Palpate the dorsalis pedis pulses using the ulnar surface of the hand.
C. Use a Doppler to detect the presence of the pulses.
The nurse is assessing a client with liver disease who is jaundice and exhibits scleral edema. During the health assessment, the nurse should implement which technique to determine evidence of hepatomegaly? A. Tap the liver's boundaries lightly with a percussion hammer to produce a sound. B. Push gently using fingers of both hands to determine the boundaries of the liver. C. Use a bouncing motion to tap the middle finger placed within boundaries of the liver. D. Cup hands and clap with alternating contact with the skin over regions of the liver.
C. Use a bouncing motion to tap the middle finger placed within boundaries of the liver.
A client reports feeling increasingly fatigued for several months, and the nurse observes that the client's lips are pale. Which additional data should the nurse collect based on this presentation? A. Current alcohol and tobacco use. B. A 24-hour dietary recall. C. Use of vitamin and iron supplements. D. Daily pattern of oral hygiene practices.
C. Use of vitamin and iron supplements.
A 45-year-old woman tells the nurse she is distressed by the presence of dark, coarse hair on her face that has recently developed. What is the nurse's most appropriate response to this patient? A. "This is simple vellus hair and it will decrease in amount over time." B. "Some women in your cultural group normally have dark hair on their faces." C. "This is unusual; female hair distribution should be limited to arms, legs, and pubis." D. "Coarse dark hair could result from hormonal changes such as from menopause."
D. "Coarse dark hair could result from hormonal changes such as from menopause."
The nurse is assessing a pt who admits to being physically abused by her spouse. The pt says, "I wish I could have agreed with my husband, because then I wouldn't have been hit." Which is the nurses best response? A. "changing your reaction to your spouse will likely change his actions against you" B. "try not to blame yourself. You will know better next time." C. "Your husband has to want to change his life. Lets focus on you for now." D. "It is not your fault that your husband lost control. Changing your actions will not prevent him from abusing you again."
D. "It is not your fault that your husband lost control. Changing your actions will not prevent him from abusing you again." *reassure the pt, its not their fault*
While performing a mental status exam (MSE), the nurse asks a client to remember three unrelated words and repeat them later. The client was able to repeat the words as directed. Which computer documentation is accurate? A. "Exhibits an above average intelligence." B. "Reflects no apparent lapses in concentration." C. "Demonstrates appropriate judgment in everyday scenario." D. "Short-term memory is intact."
D. "Short-term memory is intact."
When performing range of motion exercises on the joints of an older adult client, the nurse notes that joint range is greater with passive ranging than with active ranging. A goniometer indicates that this difference is as much as 15% in some joints. How should this finding be documented? A. Normal. B. Expected in older adults. C. Minor deviation. D. Abnormal.
D. Abnormal.
A patient comes to the emergency department and tells the triage nurse that he is "having a heart attack." What is the nurse's top priority at this time? A. Determine the patient's personal data and insurance coverage. B. Ask the patient to take a seat in the waiting room until his name is called. C. Request that a nurse collect data for a comprehensive history. D. Ask a nurse to start a focused assessment of this patient now.
D. Ask a nurse to start a focused assessment of this patient now.
During a symptom analysis, a patient describes his productive cough and states his sputum is thick and yellow. Based on these data, the nurse suspects which factor as the cause of these symptoms? A. Virus B. Allergy C. Fungus D. Bacteria
D. Bacteria
A nurse is completing a symptom analysis with a patient complaining of chest pain. When asked what makes the chest pain worse, the patient reports that coughing and sneezing increase the chest pain. Based on these data, what does the nurse suspect as the cause of this patient's chest pain? A. Stable angina B. Esophageal reflux disease C. Mitral valve prolapse D. Costochondritis
D. Costochondritis
While taking a history, a nurse learns that this patient experiences shortness of breath (dyspnea). If the cause of the dyspnea is a cardiovascular problem, the nurse expects which abnormal finding on examination? A. Flat jugular neck veins B. Red, shiny skin on the legs C. Absent peripheral pulses D. Edema of the feet and ankles
D. Edema of the feet and ankles
The nursing process offers a framework to identify needs, create a plan of care, and determine the effectiveness of interventions. Which of the following stages of the nursing process involves the assessment of which interventions were successful and which ones were not? A. Assessment B. Diagnosis C. Planning D. Evaluation
D. Evaluation
The nurse is performing a routine physical examination on an adult client. When gathering a health history, which question is included in the CAGE questionnaire? A. When did you have your last alcoholic drink? B. How does alcohol usually affect you? C. What is your favorite alcoholic drink? D. Have you ever felt guilty about your drinking?
D. Have you ever felt guilty about your drinking?
What sound does a nurse expect to hear when using the bell of the stethoscope over the epigastric area of the abdomen of a healthy patient? A. bowel sounds B. Venous hum C. Soft, low-pitched murmur D. No sounds
D. No sounds
During the history, a 65-year-old male patient reports smoking two packs of cigarettes a day for more than 40 years. With this knowledge, what should the nurse look for during the examination of this patient's mouth? A. Cracks and erythema in the corners of the mouth B. Slightly rough papillae on the dorsal surface of the tongue C. Smooth or beefy, red-colored, edematous tongue D. Painless, non-healing mouth ulcers
D. Painless, non-healing mouth ulcers
The nurse is assessing a patient's abdomen and suspects ascites. Which technique is used to confirm the presence of abdominal ascites? A. Auscultation of fluid movement within the abdominal cavity B. Palpation of rebound tenderness C. Palpation of pitting edema of the abdomen D. Percussion of dullness over dependent areas of the abdomen
D. Percussion of dullness over dependent areas of the abdomen
When performing a skin assessment of an adult patient, the nurse expects what finding? A. Reddened area does not blanch when gentle pressure is applied B. Indentation of the finger remains in the skin after palpation C. Flaking or scaling of the skin D. Return of skin to its original position when pinched up slightly
D. Return of skin to its original position when pinched up slightly
An adult client is in the clinic for a regular physical examination. The nurse is assessing the client's hydration status by pinching then releasing the client's skin. Which finding is indicative of good hydration status? A. The skin remains tented. B. The skin appears blanched and returns to pink. C. The skin slowly falls back into place. D. The skin immediately returns to normal position.
D. The skin immediately returns to normal position.
A patient has been complaining of abdominal cramping and gas; the nurse notes that his abdomen is slightly distended. Which sound does the nurse expect to hear during percussion of this patient's abdomen? A. Flatness B. Dullness C. Resonance D. Tympany
D. Tympany
While assessing for substance abuse, the nurse: A. refers to drugs using their "street" names so the client understands B. only assess for substance abuse in at-risk clients C. educated the client about the benefits of marijuana D. ask about each drug, one at a time.
D. ask about each drug, one at a time.
CAGE
LIFETIME ABUSE! C- Cut down A- annoyed G- guilty E- eye opener
Mini cog
OLDER ADULTS reliable and quick *3 item recall and clock drawing*
History of Present Illness (HPI)
OPQRSTU O- onset P- provoking Q-quality R- radiating S- Severity T- time/treatment U- understanding
SMAST-G
alcohol test in elderly who report social or regular drinking
The nurse is obtaining the heart rate of a patient with heart failure and peripheral arterial disease. Where should the nurse obtain a heart rate?
apical
Denver II screening test
detect developmental delays in CHILDREN!
AUDIT
detects both less severe alcohol problems, alcohol abuse and dependence disorders.
Montreal Cognitive Assessment (MoCA)
examines more cognitive domains than MMSE. -Free test -10 mins
TWEAK
found in women, majority during PREGNANCY! T- tolerance W-worry E- eye opener A- amnesia K- kut down
AUDIT-C
test for heavy drinking
