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HESI Health Assessment Exam Questions and Answers (GRADED A)

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The nurse is caring for a patient with chronic lower back pain. The nurse knows that the most reliable indicator of pain in this client is: The patient is reporting "6/10" pain. The patient is r... efusing to get out of bed. The patient is refusing to eat breakfast. The patient's heart rate is 90 beats per minute. A Which of the following actions should the nurse take to ensure an accurate blood pressure (BP) reading? Ensure the width of the BP cuff is equal to 80% of the arm circumference. Ensure the client's back is supported and feet are flat on the ground. Take two BP readings 20 seconds apart. Ensure that the patient's arm is above heart level. B The patient's arm should be supported at heart level. Separate BP readings may need to be taken, but not one right after the other. The length of the BP bladder should equal 80% of the arm circumferen The nurse obtains which piece of data during the general survey? Client is alert and calm. Client's heart rate is 80 beats per minute. Client's body mass index (BMI) is 30. Client's lung sounds are "clear" to auscultation. A A man is at the clinic for a complete physical exam. He states that he is "very anxious". What steps can the nurse take to make him more comfortable? Appear confident and unhurried during the exam. Measure vital signs at the end to allow the patient sufficient time to relax. Let him leave his clothes on during the examination. Obtain another nurse to examine the patient. A A father brings his 13 month-old child in for "fever" and he reports that the child has been "pulling on his left ear". Upon entering the exam room, the child is asleep in the father's arms. The nurse should perform which assessment first? Use the otoscope to look inside the ear. Use a penlight to check the eyes and nose. Auscultate the lungs, heart, and abdomen. Assess gross motor skills using the Denver II screening tool. C An 18 year-old presents to the emergency department with "headache." Which of these assessment findings alerts the nurse to recent opioid use? Pupillary constriction Hallucinations. Fever. Tachypnea. A- constricted pupils are a sign of recent opioid use, the rest are withdrawals While collecting the pulse on a 26 year-old client, the nurse notes that the heart rate seems to speed up and then slow down in accordance with respirations. The pulse is counted at 80 beats per minute. What should the nurse do next? Obtain orthostatic vital signs. Notify the physician. Document "sinus arrhythmia." Use a doppler to confirm the finding. C An elderly client with pneumonia is being treated in the intensive care unit (ICU). He is acutely agitated, restless, and disoriented. The nurse documents his level of consciousness as: Manic. Demented. Drowsy. Delirious. D The nurse is assessing a newborn infant. How should the nurse measure the heart rate (HR)? Palpate the radial pulse for 15 seconds and multiply by four. Palpate the brachial pulse for 30 seconds and multiply by two. Auscultate the apical site for 60 seconds. Apply a pulse oximeter to obtain both the HR and SpO2. C A 28 year-old is brought to the emergency department. He is disoriented and hallucinating, and vital signs are elevated. The nurse suspects that the patient is experiencing withdrawal symptoms from which substance? Alcohol. Cocaine. Cannabis. Opiates. A- hallucinations and delirium are commonly seen w alcohol withdrawal When evaluating the temperature of older adults, the nurse should remember which aspect about an older adult's body temperature? Fever is a reliable sign of infection in older adults. The older adult's body temperature varies widely because of the thinner subcutaneous layer. There are no differences in temperature between a young and old adult. Older adults body temperature runs lower than that of an adult. D Which error may result in a falsely low blood pressure (BP) reading? The patient has a full bladder. The arm is held above the level of the heart. The cuff size is too small for the client. The BP cuff is wrapped loosely around the arm. B- at heart level During a general survey of a post-operative patient, the nurse notes that the patient's eyes are closed but they temporarily open with loud verbal stimulus and a gentle shake to the shoulder. The nurse documents his level of consciousness as: Alert. Somnolent. Stuporous. Obtunded. D A 46-year-old male presents to the Emergency Department with syncope. He says his cardiologist recently placed him on a new medication for his blood pressure (BP). What should the nurse do first? Obtain orthostatic vital signs. Educate the patient on homeopathic methods to control his BP. Administer a fluid bolus. Advise the patient to stop taking this medication. A As a mandatory reporter, the nurse notifies the authorities with which of the following? Suspicion of child or elder abuse/neglect. Proof of substance abuse in minors. Any bruising on a child or older adult. Proof of intimate partner violence. A A 50 year-old patient is in the intensive care unit (ICU) with septic shock. The nurse receives an order to notify the provider if the patient's mean arterial pressure (MAP) is <60 mmHg. What does the nurse understand to be true? A MAP >60 is needed to maintain adequate tissue perfusion. MAP can only be obtained by using a noninvasive blood pressure (NIBP) monitor. MAP is the average of the systolic and diastolic pressures. A MAP of 40-60 mmHg indicates that the stroke volume is adequate. A An adult patient presents to the E.D. with "vaginal bleeding" and dizziness. Level of consciousness is decreased. The nurse prioritizes collecting which vital signs? Respiratory rate and temperature. Body mass index (BMI). Weight and oxygen saturation. Heart rate and blood pressure. D A 40 year-old patient with hypertension (HTN) presents to the internal medicine clinic for an initial visit. When obtaining the patient's blood pressure (BP), how should the nurse proceed? Cuff should be inflated to the exact point at which the palpated pulse disappeared. Cuff should be inflated to about 200 mmHg and then slowly deflated. Cuff should be inflated about 20-30 mmHg above the palpated systolic BP. Cuff should be inflated 30 mm Hg above the patient's pulse rate. C A patient presents to the clinic with "abdominal pain." The nurse asks all of the following questions during a full pain assessment, except: "When did this pain begin?" "What does your pain feel like?" "Point to where it hurts the most." "How is your pain tolerance?" D the nurse notes a patient's peripheral pulse is weak and barely palpable, the nurse document the pulse force? 0 3+ 1+ 2+ C The nurse nurse is assessing a woman presenting with "headache" and identifies suspicious injuries upon skin examination. Which question or statement should the nurse use to further assess the situation? "I need to report this abuse to the authorities." "I can see you are a victim of domestic violence. Please tell me about this." "Why would somebody want to hurt you?" Correct! "These types of injuries can sometimes be caused by other people. Is anyone hurting you or frightening you?" D Which statement is true regarding blood pressures (BP) obtained in the thigh? Thigh pressures are obtained in all clients with a history of mastectomy. Thigh BPs should be obtained in all clients to compare to the brachial BP. Systolic blood pressures in the thigh are higher compared to the arm. Thigh BPs are obtained with the client sitting. C The nurse is examining a patient undergoing withdrawal from opiates. The temperature is 102 degrees Fahrenheit. What other vital sign change does the nurse expect to find, in relation to the fever? Low oxygen saturation. Bradypnea. Elevated heart rate. Hypotension. C An adolescent male has been brought into the emergency department after a motorized scooter accident. How should the nurse begin the mental status examination? Assess the patient's level of consciousness. Assess the patient's judgment. Assess the patient's recent memory. Determine if the patient has suicidal thoughts. A A mother brings her 6 year-old child in for "irritability." How should the nurse conduct the mental status exam? The nurse can defer the mental status exam, as irritability is normal in a 6 year-old child. The nurse should begin the exam by having the patient fill out the GAD-7 and PHQ-9. The mini-mental state exam (MMSE) should be used to obtain a baseline for cognitive ability. Appearance, behavior, cognition, and thought processes can be assessed with special consideration for developmental milestones. D The RN is gathering the vital signs of an adult athlete and finds the following: temperature-36.9° C; pulse-48 beats per minute; respirations-12 breaths per minute; blood pressure-104/58 mm Hg. What should the nurse do next? Continue with the exam; these are normal vitals for a healthy, athletic adult. Document "bradypnea" in the client's chart. Notify the physician of the pulse and blood pressure. Recheck all vital signs to confirm the findings. A The nurse is assessing an 80 year-old client presenting for an annual check-up. As the nurse begins the mental status portion of the assessment, the nurse expects which finding? The patient will have no decrease in any of his abilities. Verbal responses may be slightly delayed. The patient may be disoriented to place. The patient may have mood swings and lapses in judgment. B The nurse is assessing an 88-year-old male patient. Which of the following assessment findings are expected in older adults? Additional fat deposits on the abdomen. Presence of lordosis and a narrow stance. Body changes including a longer trunk and shorter extremities. Increase in muscle mass from his younger years. A The nurse is conducting a mental status assessment on an adult female recovering from alcohol withdrawal. Which question by the nurse would best assess a person's judgment? "What is the similarity between a watch and a ruler?" "What are your plans once you leave the hospital?" "What brought you into the hospital 7 days ago?" "Do you ever see or hear things that aren't really there?" B A 5-year-old boy is brought to the emergency department by his mother. He points to his stomach and says, "Owie." Which pain assessment tool would be the best choice when assessing this child's pain? Wong-Baker FACES Pain Scale The nurse should use only objective data to assess for pain. Numeric rating scale Descriptor Scale A The school nurse is conducting a pain assessment on an adolescent presenting with "back pain that started last week." What should the nurse ask first? "How have you treated it?" "What were you doing when this pain started?" "Why do you think you are having this pain?" "Is it affecting your daily life?" B Which statement is true regarding head and chest circumference in infants and children? The newborn head circumference is usually about 2cm larger than the chest circumference. The nurse only needs to check a head circumference in premature infants. The head and chest circumference will even out at 3 months. Chest circumference should be greater than head circumference at birth. A A 40 year-old male with no significant past medical history presents to the clinic for his "annual check-up for work". How should the nurse conduct the mental status examination (MSE)? Defer the MSE, as the client has no concerns. Begin the MSE by assessing abstract reasoning and judgment. Start with a brief MSE by incorporating it into the interview. Integrate the Mini-Cog into the exam. C- Integrating the MSE into the health history is sufficient for most people. You will collect ample data to be able to assess mental health strengths and coping skills and to screen for any dysfunction. During new grad orientation, the nurse teaches about normal changes that can be expected in older adults. What should the nurse include in the teaching? Older adults have a slower respiratory rate. Older adults often have a wider pulse pressure. Older adults normally have joint pain. Older adults have a higher core body temperature. B A patient with a body mass index (BMI) of 24 falls under which category? Obese. Healthy weight for height. Extreme obesity. Overall rweight. B When assessing a 70-year-old patient with heart failure, the nurse notes he is consistently leaning forward with arms on the bedside table. What does the nurse understand to be true? The patient is eager and interested in participating in the exam. This position is often used when a patient is having respiratory difficulties. This is suspicious for pain; a focused abdominal exam should be prioritized. The client is in respiratory distress and should be assisted to a prone position. B The nurse is caring for an 8-year-old developmentally appropriate child who has several bruises of varying colors on the buttocks. What action should the nurse take next? Assume that the bruises were caused by spanking. Inform the child "You can tell me who did this to you and we will not allow them to see or hurt you again." Rely on the parents to provide information related to the cause of the bruising. When the child is alone, ask "How did you get these sore areas on your bottom?" D The nurse is preparing to perform brief head-to-toe assessments on assigned patients. Which technique is correct? The nurse uses the base of the fingers to assess pulsations. The nurse uses the ulnar surface of the hands to assess vibrations. The nurse uses the palmar surface of the hand to assess skin temperature. The nurse uses the dorsum of the hand to assess for crepitus. B While reviewing a patient's past medical history, the nurse notes that the patient has been diagnosed with orthostatic hypotension. What does the nurse understand to be true? Patients with documented orthostatic hypotension should be taught to get up slowly. Orthostatic hypotension is more often seen in young children. Anyone with orthostatic hypotension should have their blood pressure measured on their lower extremities. Patients with orthostatic hypotension experience a drop in heart rate of at least 20 bpm with position change. A The nurse understands which statement to be true regarding pulse pressure? Pulse pressure is an indicator of tissue perfusion. Normal pulse pressure is 10-30 mmHg. Pulse pressure is often narrower in the aging adult. Pulse pressure is reflective of stroke volume. D The nurse is assessing an elderly client presenting for an annual check-up. What question would be best for the nurse to use to assess cognitive function in this client? "Do you ever feel like people are watching you?" "What are your health goals?" "What have you eaten in the last 24 hours?" "Are you in any pain?" C A Chinese family presents to the clinic with flu-like symptoms. Upon examination of the 8 year-old child, the nurse notices linear bruising covering the chest and back . What should the nurse do first? Notify Child Protective Services. Perform a cultural assessment. Take photographs of the bruises. Document the finding as suspected abuse. B The nurse is assessing a client who recently suffered a stroke. Speech is impaired, although comprehension is intact. This finding reflects which type of aphasia? Global. Dysphonic. Wernicke's. Broca's. D During percussion of a patient's lungs, the nurse notes a clear, hollow sound. The nurse documents: Dullness. Flatness. Tympany. Resonance. D Resonance is a clear, hollow sound normally heard over adult's lungs. Dullness is a muffled thud and if heard over the lungs, it would indicate increased density associated with consolidation (pneumonia), fluid, or a mass. Tympany is a musical, drumlike sound heard over the abdomen Which of these situations could result in a falsely low blood pressure reading? Select all that apply. The cuff is loosely wrapped around the arm. The arm is held above the level of the heart. The person is sitting with his or her legs crossed.! The nurse does not inflate the cuff high enough. The blood pressure cuff is too small for the extremity. B D A patient with a history of alcoholism has been admitted to the ICU after surgery. The nurse closely monitors him for symptoms of alcohol withdrawal, including which of the following? Select all that apply. Elevated vital signs. Constricted pupils. Muscle aches. Nausea and vomiting. Headache. Auditory hallucinations. ADEF The correct method for measuring blood pressure includes deflating at what speed to identify the systolic pressure reading? 6-8 mmHg/second 15-20 mmHg/second 25-30 mmHg/second 2 to 3 mmHg/second D During an eye assessment of a black patient, the nurse would consider which of these an expected finding? Yellow nodules covering the cornea. Gray-blue tint to the sclera. Asymmetry of the palpebral fissures. Pale conjunctivae. B General survey reveals pallor in a client presenting with "fatigue." What should the nurse do to further assess for signs/symptoms of an iron deficiency? Ask the client if they experience dry eyes. Observe the sclera. Examine the bones and joints. Inspect the nails. D A 62 year-old female presents to the clinic with epistaxis lasting 6 hours. What is a priority question for the nurse to ask? "Do you smoke or drink alcohol?" "What have you eaten in the last 24 hours?" "Do you take any medications?" "Have you recently been on antibiotics?" C- Epistaxis (bleeding from nose) can result from trauma, forceful blowing or picking, and anticoagulant medications. A reversal agent may be needed if it is due to medication. An adult client presents with a "sore throat" that has "gotten so much worse over the past day". Upon examination, he is febrile, neck is swollen with decreased range of motion, and he is having a difficult time swallowing. These findings are most consistent with: Acute rhinitis. Oral malignancy. Viral sinusitis. Peritonsillar abscess. D During a complete HEENT and cranial nerve examination of a 65 year-old female, the nurse notices that the tonsils are halfway to the uvula, pink, and covered with crypts. What should the nurse do next? Gently touch the oropharynx with the tongue blade to test CNs IX and X. Assess for CN XII by having the client say "ahhhhh." Refer the patient to an allergy specialist. Obtain a throat culture upon suspicion of Group A Strep infection. B The assessment findings are normal, so a throat culture and referral are not needed. CN XII is assessed by having the client stick out their tongue. An elderly client presents to the clinic complaining that her mouth and eyes have become "very dry" within the past few weeks, enough so that her taste and vision have been affected. What question or statement should the nurse use next? "This dryness is normal with age. You will adapt to these changes.' "Have you started any new medications?" "Let's refer you to an ophthalmologist to check your vision." "You aren't drinking alcohol, are you?" B During an integumentary exam, the nurse notices a lesion that is suspicious of basal cell carcinoma. What data leads the nurse to this conclusion? A raised pink, scaly patch on a sun-exposed area. A nevus with color variation and irregular borders. A non healing pearly papule with a central red ulcer. A flat brown macule on the forearm. C An adolescent presents to the emergency department after getting into a fist fight at school. He has significant swelling around his eye. What other symptom leads the nurse to suspect retinal detachment? Loss of vision in one quadrant of the eye. Bilateral loss of central vision. Clear rhinorrhea and facial pain. Photosensitivity and a nonreactive pupil. A The school nurse is preparing to assess the visual acuity of an adolescent. How should the nurse proceed? Test extraocular movements and nystagmus with the penlight. Observe the ocular fundus with the ophthalmoscope. Assess for pupillary constriction and convergence. Utilize the Snellen chart positioned 20 feet from the patient. D An adult client with liver failure has deep pitting edema all over his body. Based on this finding, the nurse documents: Anasarca. Scleroderma. Jaundice. Erythema. A An emergency department nurse is examining a client newly admitted with pneumonia. The nurse depresses the client's nail beds and notes that color return takes 4 seconds. The nurse's immediate response is to: Document "Brisk capillary refill" in the client's chart. Assess for other signs of poor perfusion. Understand this to be an expected finding in clients with pneumonia. Ask another nurse to assess the cap refill. B Which assessment finding is most consistent with psoriasis? Pink/red plaques covered with silvery scales. Unilateral vesicles on the shoulder area. Fast growing pink, scaly patches on sun-exposed areas such as the face and hands. Red nonblanching intact skin on the sacrum and heels. A The nurse is examining a Black client who presents to the E.D. with nausea and vomiting. Upon examination, the client is tachycardic and tachypneic. Oxygen saturation is 98% on room air. Which assessment finding is most concerning in this patient? Yellow nodules underneath the eyelids. Thick, dark line along the gingival margin. Slight blue tint to the lips. Fruity breath odor. D A neonatal nurse is performing morning assessments. Which finding does the nurse prioritize reporting to the physician? Appearance of a blue tint to the face during feeding in a 4-hour old infant. Yellow sclera in a 2 day-old infant. Generalized red rash in a 4 day-old infant. Small white papules on the face in a 2 week-old infant. A The nurse is performing a head-to-toe assessment on a dark-skinned client presenting with "fatigue." To best assess for pallor, the nurse should check which of these areas? Conjunctivae. Sclera. Middle ear. Hair. A-Pallor will be best seen in lesser pigmented areas such as the oral mucosa and conjunctivae, which are normally pink in color. The nurse is examining a patient presenting with "severe headache." Which assessment finding leads the nurse to suspect increased intracranial pressure? Enlarged and tender occipital lymph nodes. Red, bulging tympanic membrane. Blurred margins of the optic disc. Pupils are 4mm and reactive. C A 12 year-old child presents to the clinic complaining of "ear pain". The mother accompanies the child. The nurse utilizes which technique? While inserting the otoscope, the nurse pulls the pinna up and back. The nurse examines the middle ear with the child in the prone position. The nurse percusses the mastoid process for dullness. The nurse pulls the pinna straight down and inspects the tympanic membrane with the penlight. A During a general survey of a 20 year-old patient presenting with "ear pain", the nurse observes ptosis and drooling from the left side of the mouth. The nurse suspects dysfunction of which cranial nerve (CN)? CN II. CN IV. CN VII. CN V. C The nurse is examining a 68 year-old male with a "hearing problem." The client says it started suddenly last week, is worse in the left ear, and it sounds like everyone is mumbling and whispering but it helps when they talk louder. Based on subjective data, what should the nurse do first? Assess his mood and ask how the hearing loss is affecting his life. Assume the client is developing presbycusis and refer for audiometric testing. Perform an otoscopic examination of the external and middle ear. Suspect a sensorineural loss and assess the functions of the inner ear. C During an examination of a 70 year-old client presenting with "rash", the nurse notices small grouped vesicles along the left side of the client's chest. The client says it started earlier in the week and it is "very painful." The nurse suspects: Kaposi Sarcoma. Herpes zoster. Candidiasis. Allergic drug reaction. B The nurse is assessing an adult Black client presenting to the emergency department with gastrointestinal bleeding. Interview reveals that the patient is on blood thinners. The nurse knows to observe for petechiae in which area? Genitalia. Oral mucosa. Scalp. Middle ear. B The nurse is caring for a client with a severe deficiency of thyroid hormone. Examination reveals decreased vital signs, weakness, and nonpitting edema on the face. The nurse documents: exophthalmos. anasarca. myxedema. scleroderma. C The nurse is assessing an elderly client with presbycusis. While gathering subjective data, it would be important for the nurse to: Ask how the hearing loss is impacting his daily life. Speak very loudly and slowly so the patient can hear the questions. Check for obstruction of the auditory canal as a possible cause. Assess for otitis media as a possible cause. A The nurse observes excess body hair on the upper lip and cheeks of a client with Cushing's syndrome. The nurse documents: "Hirsutism" "Anasarca" "Alopecia" "Milia" A A client presents with an acute strep throat infection. Upon examination of the lymph nodes, the nurse expects to palpate: Enlarged and tender submandibular nodes. Hard and immobile preauricular nodes. Atrophied and firm occipital nodes. No change in the lymph nodes. A During an assessment of a 4 month-old presenting with "vomiting and diarrhea", the nurse notes that the fontanels are markedly concave. Based on this assessment finding, what should the nurse do next? Palpate for pitting edema over the wrist area. Pinch skin on the abdomen and assess for recoil. Document this expected finding. Perform an ophthalmic exam to assess for papilledema. B An elderly client with chronic obstructive pulmonary disease (COPD) and lung cancer has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding as a result of these disorders? Cherry red color to the oral mucosa. Taut skin turgor. Nail base angle >180 degrees. Scleral icterus. C Which method should the nurse use to assess for accommodation? Assess peripheral vision of the client using the confrontation test. Have the client follow an object upward, downward, obliquely, and horizontally. Touch the cornea lightly with a cotton wisp. Observe for pupil constriction and convergence with near vision. D A college student is brought to the emergency department with a "severe headache". The nurse assesses for what other sign associated with meningitis? Decreased range of motion in the neck. Loss of smell. Bulging fontanels. Hypothermia. A- the acute onset of neck stiffness and pain along with headache and fever occurs with meningeal inflammation. A severe headache in an adult or child who has never had it before is a red flag. Head injury and cluster or migraine headaches are not associated with a fever or stiff neck. The nurse is caring for a client with an acute traumatic injury to their arm. Which assessment is the quickest and most reliable way to assess for the status of peripheral circulation? Press on the nail bed and count how long it takes for color to return. Check the angle of the fingernail base. Assess for unequal hair distribution on the forearms. Depress firmly over the wrist to check for pitting. Capillary refill is a quick and accurate assessment A The nurse is assessing the intravenous (IV) line site in a dark-skinned client. The nurse utilizes which technique to best assess for localized inflammation? Checking cap refill on the nailbeds. Assessing for increased vital signs. Utilize a Wood's lamp in a dimly lit room. Palpating the skin for temperature changes and swelling. D The nurse is examining a client with cataracts. What does the nurse expect to find during the examination? Blurred margins of the optic disk. Eye pain. Cloudy appearance to the lens. Gradual loss of peripheral vision. C A patient presents to urgent care with "excruciating" headache pain. The client reports the pain to be unilateral, occuring about twice a month, and the pain is accompanied by photophobia and nausea. These symptoms are most consistent with: Cluster headache. Sinus headache. Tension headache. Migraine headache. D- unilateral A mother brings her toddler in for a "runny nose" that "started suddenly this morning". The nurse notes a purulent, serosanguinous drainage coming from the right nare. The child's vital signs are within normal limits. What should the nurse do next? Refer to the provider for an antibiotic prescription. Inspect the right nare with the otoscope. Obtain a throat culture for possible strep infection. Tell the mother that this drainage is normal for a toddler. B-Children are prone to put an object up the nose, producing unilateral purulent drainage with a foul odor. Because some risk for aspiration exists, removal should be prompt. While examining the nares of an adult patient presenting with "cough and watery eyes" the nurse notices pale, swollen turbinates with clear nasal discharge. These findings are most consistent with which condition? Foreign object. Allergic rhinitis. Acute sinusitis. Epistaxis. B During an examination of a toddler presenting for a well check, the nurse performs an otoscopic examination to assess the tympanic membrane (TM). Which assessment finding is normal? TM is slightly retracted with a pearly gray color. TM appears amber-colored with absence of cerumen. TM appears light pink and slightly convex. TM is mobile and appears reddish-orange . A During a thyroid examination of a client presenting with "fatigue", the nurse observes no obvious enlargement. What should the nurse do next? Assume no abnormalities and document "no enlargement." Palpate the gland using a posterior approach. Auscultate the area for a bruit. Percuss the area for dullness. B A client presents to the clinic for a skin check. Which assessment finding is most suspicious for malignant melanoma? Tiny brown streaks on all of the nail beds. A 2 cm raised bright red papule on the chest. A 4 cm pink scaly patch on the forehead. An 8 mm asymmetrical nevus with purple coloration. D An elderly woman is brought to the hospital after her children found her confused and lying on the floor at home. Which examination finding is is most suggestive of dehydration in this client? Parched skin on the hands and legs. Sagging skin. Brittle, coarse hair. Dry mucous membranes. D The nurse is teaching a pregnant client about changes she may experience during her pregnancy, including: Hard and fixed cervical lymph nodes. Moderate vision loss. Inflammation of the gums. Tender, enlarged thyroid gland. C During a skin assessment, the nurse notes these lesions on a client's leg. The client says they are "itchy" and they appeared 2 days ago after a hike. What should the nurse document? picture looked like hives Papules. Urticaria. Vesicles. Macules. B An adult patient comes in with a 2-day history of nausea and vomiting. When assessing for dehydration, the most appropriate initial action by the nurse is to: Palpate the scalp for mobility. Check a urine sample. Assess for pitting edema over the tibia. Pinch skin on the forearm and assess for recoil. D A father brings his 10 month-old child to the clinic for a check-up. General survey reveals a yellow-orange tint to the child's face and hands. Sclera is white. What should the nurse do next? Reassure the father that this is an expected finding from eating too many Vitamin C-rich foods. Obtain a nutritional history. Document "acrocyanosis" in the client's chart. Notify the provider about your concern for jaundice. B The neonatal nurse notices that an infant's head looks enlarged compared to the previous shift. The nurse assesses for what other sign of hydrocephalus? Upward palpebral slant. Depressed fontanels. Downcast eyes. Lymph node enlargement. C The nurse is performing a physical examination on a child with strabismus and expects to assess: Ptosis. Asymmetrical corneal light reflex. Absence of a red reflex. Nystagmus B- Asymmetric corneal light reflex and an abnormal cover test are found with strabismus. Absence of red reflex is consistent with cataract. Poor peripheral vision describes glaucoma. Unequal palpebral fissures describes ptosis. The nurse is examining a patient with Hashimoto's disease. What sign or symptom is consistent with an underactive thyroid? Tremors. Diaphoresis. Tachycardia. Weight gain. D The nurse is examining a 92-year-old female during a check-up. The nurse concludes which findings to be normal age-associated changes? Select all that apply. Brown macules on the hands and arms. Vertical ridges on the nail beds. Tender vesicles on the left side of the face. Non blanching, red, intact skin over the coccyx bone. Bristly hairs on the chin and upper lip. Thin, loose skin with decreased turgor. 3mm pupils with a slightly sluggish pupillary light reflex. ABEFG The nurse is performing a full cranial nerve (CN) examination on an adult client. Which assessments will be performed? Select all that apply. To test CN I (olfactory nerve), the nurse looks inside the nose with the otoscope. To test CN XII (hypoglossal nerve), the nurse assesses the gag reflex. To test CN XI (spinal accessory nerve), the nurse assess neck strength. To test CN VIII (vestibulocochlear nerve), the nurse observes facial symmetry. To test CN V (trigeminal nerve), the nurse assesses jaw strength. To test CN II (optic nerve), the nurse assesses extraocular movements CE The nurse is examining a patient with Grave's disease. What findings are consistent with an overactive thyroid? Select All That Apply. Unintentional weight gain. Diaphoresis Exophthalmos. Swelling of the hands and face. Tremors. Decreased heart rate. BCE A nurse educator is leading a new graduate orientation class on pressure ulcers. Topics include pressure ulcer prevention and assessment. The nuse should include which of the following statements? Select all that apply. Common sites for pressure ulcers are the heels, sacrum, coccyx, and hips. Stage II pressure ulcers extend into the epidermis or dermis. Stage III pressure ulcers are deep, exposing muscle, bone, and tendon. Risk factors for pressure ulcers including impaired mobility, poor nutrition, and bowel and bladder incontinence. Stage I pressure ulcers appear as reddened areas that blanch with pressure. The best way to prevent pressure ulcers is to turn your immobile patients twice a day. ABD The nurse is assessing an adult male client presenting with "abdominal pain". Which finding is considered normal? Pulsatile, whooshing sounds heard during auscultation with the bell. Dark, tarry stools. Drumlike notes heard during percussion. Protuberant abdominal contour. C tympany? The nurse is caring for a client with cirrhosis. Which technique should the nurse use first to monitor for the early onset of ascites in this hospitalized client? Measure abdominal girth on a routine basis. Test for a fluid wave on the abdomen. Percuss for shifting dullness. Palpate deeply to assess for rebound tenderness A The nurse is assessing an adult client recovering from abdominal surgery. Which finding causes the nurse to suspect acute hypoxia in this client? barrel chest. clubbing of distal phalanx. sudden anxiety and restlessness. respiratory rate 20 breaths per minute. C An adult client on a ventilator becomes acutely restless and agitated. Which assessment finding alerts the nurse to a left pneumothorax? Increased tactile fremitus. Dullness to percussion. Unequal chest expansion. Presence of bronchial breath sounds. C-Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with the presence of pneumothorax. The neonatal nurse is completing a respiratory assessment on a sleeping newborn infant. Which finding is considered a normal variation? Presence of wheezing. Diminished breath sounds. Irregular respiratory pattern with brief periods of apnea. Nasal flaring. C The nurse is examining a client with a long history emphysema. The nurse is most likely to observe which of these? Respiratory rate 10-24 breaths/minute. Narrow costal angle. High-pitched breath sounds in the lower lobes. Enlarged anteroposterior diameter. D When assessing tactile fremitus, the nurse recalls that it is normal to feel the vibrations more intensely: Over the scapular bones. Laterally, where the skin is thinner. Over the major bronchi. Over areas of atelectasis. C A 20 year-old client presents to the clinic for "flu-like symptoms." Examination reveals a congested cough, elevated vital signs (temperature, pulse, and respirations), as well as increased fremitus and crackles in the left lower lobe. The nurse suspects: Emphysema. Asthma Exacerbation. Pneumothorax. Pneumonia. D Which statement is true regarding older adults and the respiratory system? Decreased ability to cough and a los of protective airway reflexes increases the older adult's risk for postoperative pulmonary complications. Older adults have a decreased anteroposterior diameter due to curvature of the thoracic spine. The older adult takes slower, deeper breaths compared to a middle-aged adult which increased their risk for acidosis. It may be normal to hear bronchial breath sounds throughout the lungs of an older adult due to anatomical changes within the thorax. A The nurse is examining a patient with heart failure. What data leads to the nurse to suspect a pleural effusion? Drum-like notes upon percussion. Bradypnea. Positive fluid wave test. Decreased chest expansion. D-Pleural effusions often cause decreased and/or asymmetric chest expansion and shortness of breath and tachypnea. The nurse is examining an adult client presenting with "chest pain." During auscultation of the posterior thorax, the nurse notices that when the patient whispers "1-2-3" it sounds clear and distinct to the examiner. The nurse suspects which condition? Normal, healthy lungs. Consolidation of lung tissue. Constricted airways. Lung collapse. B While examining an adult patient, the nurse notes a normal abdominal aortic pulsation. What data supports this finding? Waves of peristalsis in the upper quadrants. Easily palpable pulsation between the umbilicus and suprapubic area. Pulsatile, blowing sounds heard upon auscultation with the bell. Faint pulsation visible in the epigastric area. D The nurse is examining a hospitalized client and observes respirations that are shallow and irregular, at 10 breaths per minute. What is the most likely cause of this finding? Diabetic ketoacidosis. Pneumonia. Fever. Recent administration of opioids. D A client presents to the emergency department with asthma exacerbation. What does the nurse expect to find upon examination? Wheezing and accessory muscle use. Purulent mucus production. Tracheal shift. Presence of bronchophony. A Upon examination of a patient presenting with "abdominal pain," the nurse hears high-pitched, gurgling sounds in the right lower and upper quadrants. What should the nurse do next? Relisten to those quadrants and count the sounds to determine if they are hyperactive. Auscultate the other two quadrants. Assume bowel obstruction and notify the provider. Percuss all quadrants. B The nurse is preparing to examine the lungs of an adult client. Which statement is true regarding the normal anatomy of the thorax and lungs? Both lungs have an upper, middle, and lower lobe. Lower ribs articulate with the spine at about 45 degrees. The suprasternal notch is continuous with the 2nd rib. The left lung is shorter than the right lung. B-The sternal angle (angle of Louis), not the suprasternal notch, is continuous with the 2nd rib. The right lung is shorter than the left lung because of the underlying liver. Only the right lung has a middle lobe The nurse is performing a focused respiratory assessment of a client who is in respiratory distress two days after abdominal surgery. What is mostimportant for the nurse to assess? Percussion of anterior and posterior lung fields. Assessing both anterior and posterior chest expansion. Palpation for tactile fremitus. Auscultation of bilateral breath sounds. D An adult client presents to the emergency department with "difficulty breathing." General survey reveals anxiety, accessory muscle use, and dry cough. The nurses first action would be to: Administer 2 liters oxygen via nasal cannula. Assume asthma exacerbation and prepare a nebulizer treatment. Auscultate lung fields and obtain an oxygen saturation. Assist the client to a supine position for a full respiratory exam. C An adult client is being treated for lobar pneumonia. Which collection of signs/symptoms is most likely to be found in this patient? Hyperresonance to percussion and cyanosis. A congested cough and decreased voice sounds. Wheezing upon auscultation and decreased fremitus. Tachycardia and crackles upon auscultation. D- Lobar pneumonia (consolidation of alveolar and lung tissue) will cause increased HR, RR, and fever, increased fremitus, dullness to percussion, increased voice sounds, and crackles The nurse is examining a client with severe ascites and expects to assess: Rounded contour with loose abdominal skin. Hyperactive bowel sounds. Protuberant abdominal contour with everted umbilicus. Soft abdomen with sunken umbilicus. C The nurse is preparing to perform an abdominal exam. Which method will the nurse utilize during this exam? Utilize dim lighting to assist in relaxation. Inspect, palpate, percuss, then auscultate the quadrants. Inquire about painful areas and examine those areas last. Assist the patient to a Semi-Fowler's position with their arms above their head. C The nurse is examining an adult client 1 day after hernia surgery. Which assessment finding leads the nurse to suspect atelectasis in this client? Splinting of the abdomen during coughing. Slight pallor to the conjunctivae. Hyperresonance upon percussion. Decreased breath sounds in lung bases. D- Atelectasis is collapse of alveoli. Common assessment findings include hypoxia, decreased or absent breath sounds, and there may also be dullness to percussion The nurse is caring for a patient after thoracic surgery to remove a part of the lung. The nurse documents "subcutaneous emphysema" after assessing which of these? Booming sounds upon percussion. A palpable vibration with voice sounds. An audible grating sound with breathing. A coarse, crackling sensation palpable over the skin surface. D- Crepitus that is palpable over the skin surface is consistent with subcutaneous emphysema. After auscultating a client's lungs, the nurse documents "fine crackles in lower lobes." What assessment finding led the nurse to this conclusion? Continuous, High-pitched squeaking sounds heard upon expiration. Low-pitched, bubbling sounds that diminish with coughing. High-pitched, crowing sound heard over the trachea. Discontinuous, high-pitched, popping sounds heard at the end of inspiration. D- Fine crackles are discontinuous, high-pitched, popping sounds heard upon inspiration. These are the result of fluid-filled alveoli. The nurse is preparing to auscultate the lung sounds of an adult client. It is important for the nurse to implement which of the following techniques? Auscultate lung fields on the left then move to auscultate the right lung fields. Ask the client to breathe in and out quickly through the nose. Auscultate posteriorly from the apices at C7 down to the bases at T6. Clean the diaphragm endpiece of the stethoscope and hold it firmly on the chest wall. D The nurse is examining the abdomen of a 1 day-old infant. Which of the following is not an expected finding? Marked peristalsis. Abdominal movement with breathing. Sticky, greenish-black stool. Slight bulge along the midline visible during crying. A During the examination of a client presenting with "abdominal pain", the nurse identifies a positive Blumberg sign. What should the nurse do next? Tell the patient to refrain from eating or drinking at this time and notify the provider. Suspect ascites and test for a fluid wave. Educate the patient about the importance of following a low-fat diet. Percuss for organomegaly. A A patient with a history of diabetes and recurrent urinary tract infections presents to their primary care provider with "abdominal pain." After bringing the patient to the examination room, what should the nurse do first? Strain the urine for debris. Perform a full pain assessment. Assess for rebound tenderness. Percuss for costovertebral tenderness. B A mother brings her 4 year-old daughter in for a "cough" that came on suddenly during the night. Which piece of data leads the nurse to suspect croup? Equal anteroposterior and transverse diameters. Temperature 99.1 degrees Fahrenheit. Audible high-pitched inspiratory crowing sound. Bronchovesicular breath sounds. C The nurse is performing a head-to-toe assessment on a pregnant female, and knows to expect which finding upon examination of the thorax and lungs? Fine crackles in the lungs. Deeper respirations. Respiratory rate 30-40 breaths/min. Wheezing with exertion. B An adult is brought to the emergency department after being found on the floor at home. The patient's respirations are fast and deep with a rate of 40 respirations per minute. What is the most likely cause of this finding? Narcotic use. Atelectasis. Inflammation of the pleura. Metabolic acidosis. D- Hyperventilation is characterized by an increase in both rate and depth, and it can be caused by extreme exertion, anxiety, or alterations that cause metabolic acidosis including salicylate OD or DKA. When performing deep palpation in the right upper quadrant of a client with abdominal pain, the nurse asks the client to take a deep breath. The patient grimaces and suddenly stops inhaling. The nurse suspects: Appendicitis Hepatomegaly. Bowel obstruction Cholecystitis D- In a person with inflammation of the gallbladder, or cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration (Murphy test) The nurse is caring for a post-operative patient who has not urinated in 6 hours. How should the nurse first assess for urinary retention? Test for shifting dullness over the abdomen. Perform a straight cath. Percuss and palpate the suprapubic area. Auscultate for rushing sounds near the groin. C A patient presents to the clinic complaining of "epigastric pain for one week". History of Present Illness reveals that the pain is "gnawing" and "worse in the middle of the night." The nurse suspects: Diverticulitis. Peptic Ulcer Disease. Appendicitis. Cholecystitis. B The nurse is examining a client with shortness of breath. What should the nurse inspect when assessing for evidence of long-standing hypoxemia? Respiratory pattern. Fingernails. Skin color. Posture. B The nurse is reassessing an adolescent client who is scheduled for an appendectomy in 4 hours. Which assessment finding alerts the nurse to immediately notify the provider? Reports of abdominal pain 4/10. Small amount of emesis containing bile. Sudden onset of abdominal rigidity. Presence of hypoactive bowel sounds. C A mother brings her 3 month-old infant to the clinic for "cold symptoms." When performing the physical assessment, the nurse notes that the child has nasal flaring and subscostal retractions. The nurse's next action should be to: Reassure the mother that these are normal symptoms of a cold. Apply a pulse oximeter and contact the provider. Conduct the rest of the head-to-toe examination. Percuss the lungs fields. B While caring for a client after hip replacement surgery, the nurse notices that a patient has had a black, tarry stool. The nurse suspects: Decreased fat absorption. Use of iron supplements. Gastrointestinal bleeding. Localized rectal bleeding. B The nurse is performing an abdominal examination on an adult client. Which finding should be reported to the provider? Vascular sounds heard with the bell. Rounded abdominal contour. Concave, midline umbilicus. High-pitched bowel sounds heard every few seconds. A During a full pain assessment, a client points to the area between the costal margins. The nurse documents this location as: Umbilical. Hepatic. Suprapubic. Epigastric. D The nurse is caring for a client admitted for heart failure exacerbation. Which assessment finding alerts the nurse to the presence of pulmonary edema? Abdominal distention. Pink, frothy sputum. Chest pain. Taut skin. B The nurse is examining a client with "flu-like symptoms." While auscultating the breath sounds, the nurse hears a low-pitched, grating sound upon inspiration and expiration. The nurse suspects: Atelectasis. Asthma exacerbation. Collapsed lung. Inflammation of the pleura. D- pleuritis Upon auscultation of the posterior thorax in a client with emphysema, the nurse hears a continuous, high-pitched, squeaking sound upon expiration at the 7th-10th intercostal spaces (ICS) bilaterally. The nurse documents: "Stridor observed." "Fine rales auscultated in 7th-10th ICS, posterior bilateral." "Wheezing noted in bilateral lower lobes." "Rhonchi in bilateral lungs." High-pitched squeaking sounds C- High-pitched squeaking sounds are consistent with air being squeezed or compressed through narrowed passageways, from acute asthma or chronic emphysema The nurse is examining an adult patient. During auscultation of the posterior thorax, the nurse notes clear, soft, low pitched breath sounds. Inspiration is louder than expiration. What is the correct interpretation of this finding? These are vesicular breath sounds, which are normal in that location. These are bronchial breath sounds, which are abnormal in that location. These are bronchovesicular breath sounds, which are normal in that location. These are diminished breath sounds, which are consistent with emphysema. A All of these statements about the sternal angle are true, except: It is the articulation of the manubrium and body of the sternum. It marks the site of tracheal bifurcation into the right and left bronchi. It is continuous with the second rib. It should be 90 degrees. D A nurse educator is teaching new graduate nurses about pneumonia, including signs/symptoms, prevention, and treatment. What should the nurse educator include in the teaching? Flu vaccination will not help to reduce one's risk of developing pneumonia Cough and chest pain are common symptoms of pneumonia. Decreased fremitus and hyperresonance upon percussion will be present. Antibiotics are used to treat all types of pneumonia. B The nurse is preparing to examine an older adult client with abdominal pain. Which statement is true? Constipation and development of hard, lumpy stools are normal and physiologic changes in the gastrointestinal system. The older adults abdomen may normally have a distended, protuberant appearance due to increased fat deposits. Because musculature is thinner in the older adult, abdominal rigidity with acute abdominal conditions is less common in aging. Absent bowel sounds are common due to decreased appetite with aging. C-Constipation, hard stools. absent bowel sounds, and abdominal distention are not normal age-associated changes. The nurse suspects intraabdominal fluid collection in a patient presenting with heart failure exacerbation. Which of these procedures are appropriate for the nurse to use when assessing for ascites? Select all that apply. Assess for rebound tenderness on the left side of the abdomen. Ask the supine client to flex the right hip against resistance. Measure abdominal girth on a daily basis. Percuss for costovertebral angle tenderness. Percuss the abdomen for shifting dullness. Test for a fluid wave across the abdomen cef Which of the following conditions may result in the nurse auscultating hypoactive bowel sounds? Select All That Apply. Gastroenteritis Peritonitis Opioid use. Post-abdominal surgery Late bowel obstruction Laxative use cdef The nurse is preparing to auscultate the lungs of an adult during an annual check-up. Which techniques are correct? Select All That Apply. Auscultating anteriorly from the subclavicular area down to the 9th rib. Auscultating while the client is sitting up on the exam table. Skipping any areas with overlying chest hair. Auscultating in a side-to-side pattern, from the apices down to the bases. Instructing the patient to take deep breaths through the mouth. Pressing the bell firmly over the thorax. bde After assessing muscle strength in an older adult client who had an ischemic stroke six months prior, the nurse documents the following findings: Left leg 2/5Right leg 5/5Left arm 2/5Right arm 5/5What does the nurse expect to find when testing his reflexes on the left side? Hyperactive reflexes Normal reflexes Lack of reflexes Diminished reflexes A hyperactive on effected side A patient has been diagnosed with venous insufficiency in the right leg. Which of these findings would the nurse most likely observe in the affected leg? Brownish discoloration. Cyanosis of the nail beds. Absent pulses. Leg pain with walking. A During an assessment of a client presenting with "fatigue", the nurse notes that the patient's apical impulse is easily palpable over the 5th and 6th intercostal spaces at the anterior axillary line. This finding most likely indicates: Cardiac atrophy. Dehydration. Ventricular dilation. A normal functioning heart. C While assessing a newborn infant, the nurse notes fanning of the toes when the nurse strokes the lateral edge and across the ball of the foot. The nurse understands this to be: A positive Babinski, which is an expected finding. A sign of central nervous system damage. A positive Moro reflex, which is normal in a newborn. A negative plantar reflex, which is an abnormal finding. A The nurse suspects arterial insufficiency in an older adult client presenting with "left leg pain." Which assessment finding best supports this hypothesis? Dorsalis pedis pulses are 2+ and popliteal pulses are 1+ bilaterally. Ankle-brachial index of 1.20. Pallor in the right leg when it is elevated off the table. 3+ pitting edema in the right leg. C-S/S of PAD include elevational pallor, delayed venous filling >15 sec While performing a head-to-toe assessment on a hospitalized client, the nurse notes the capillary refill time on the fingers is 4 seconds. What should the nurse do next? Consider this a normal capillary refill time that requires no further assessment. Assess for additional signs of poor perfusion. Use the profile sign to detect early clubbing. Suspect that the patient has a deep vein thrombosis. B In the assessment of a 7 month-old, the mother reports that in the last week he has been sleeping all of the time, and is extremely fussy when he is awake. Which assessment finding alerts the nurse to potential neurological damage? Presence of the Moro reflex. Babinski sign. Absence of the palmar grasp. Absence of the rooting reflex. A During a health assessment, the client reports being treated for osteoarthritis. Which finding alerts the nurse to the presence of Bouchard's nodes? Proximal interphalangeal joint nodules. Proximal intertarsal joint swelling of big toe. Frozen, non-movable phalangeal joints. Nontender enlargement of the distal interphalangeal joints. A While performing a head-to-toe assessment on a client with diabetes, the nurse is unable to palpate the client's pedal pulses. What should the nurse do next? Palpate pulse points with legs dependent. Use a doppler to check blood flow. Notify the healthcare provider. Apply a heating pad to both feet to stimulate blood flow. B The nurse is testing the deep tendon reflexes (DTRs) of an adult client who is in the clinic for an annual physical examination. When striking the achilles tendon, the nurse is unable to elicit a reflex. The nurse's next response should be to: Ask the patient to lock their fingers and pull. Refer the patient to a specialist for further testing. Document these reflexes as 0 on a scale of 0 to 4+. A Which collection of signs/symptoms is most consistent with acute coronary syndrome (ACS)? Radiating chest discomfort that fully subsides with rest. Epigastric pain exacerbated by food. Heavy, aching chest pain with dizziness and pallor. Palpitations and sharp chest pain with deep breaths. C-unstable agina The nurse is assessing a newborn baby that was born breech. What should the nurse do to assess for congenital hip dysplasia? With knees flexed, adduct and abduct the legs and assess for clicking or pain. Assess for weakness with the stepping reflex. Assess leg strength bilaterally against resistance. Elicit the tonic neck reflex and assess for asymmetry A A young adult presents to the clinic complaining of "dizziness." The client describes it as "the room is spinning." Based on the subjective data, what does the nurse expect to assess during the neurological examination? Abnormal word recall test. Absence of a pain sensation. Hemiparesis. Positive Romberg test. D The nurse is completing a neurological examination on an elderly client. Which finding is expected? Smaller pupils with absent light reflex. Hyperactive deep tendon reflexes. Asymmetric tracking of the eyes. Slower, more deliberate gait, with a wider stance. D A post-mastectomy patients presents to the clinic complaining that her right arm is "aching and stiff." The nurse suspects lymphedema with which assessment finding? Tricolor change in response to cold temperatures. Hard, lumpy swelling of the right arm. Severe pitting edema in both upper extremities. Atrophy and pallor of the right arm. B During an examination of an adult with rheumatoid arthritis, the nurse hears a whooshing sound with the stethoscope's bell over the left carotid artery. What does the nurse understand to be true? Auscultation of the carotids should reveal complete and total silence. This client may be at an increased risk of ischemic stroke. This is an expected finding in older adults. Carotid pressure should be estimated next in the examination. B The nurse is performing a neurological assessment on a 7 year-old. What would the nurse include in the cranial nerve portion of the examination? "I'm going to use my finger to tap on your arm." "Close your eyes and tell me if I am tapping your arm or leg." "I'm going to make some silly faces and I want you to copy me." "Hop up and down on one foot." C When assessing cerebellar function on an adult client, the nurse should ask the client to: "Stare straight ahead while I shine this penlight in your eye'." "Resist my attempt to move your left arm." "Close your eyes and tell me what number I draw on your hand." "Alternate touching your nose and my finger." D During the monofilament test on an adult client presenting with "foot pain", the patient is able to feel 4 out of 10 tested points. Given this information, what would the nurse suspect? Peripheral neuropathy. Cerebellar dysfunction. Expected finding for age. Frontal lobe lesion. A An older adult client with diabetes states that he recently began to have pain in his left calf when going for his evening walk. This pain is relieved by resting in a chair for a few minutes. The nurse interprets that this patient is most likely experiencing: Claudication caused by blockage of an artery supplying the left calf. Musculoskeletal symptoms related to age and decreased activity tolerance. Neuropathy related to his diabetes. Ischemia related to a venous obstruction. A An adult client is recovering from a myocardial infarction and complaining of "sharp chest pain." Upon examination, the nurse hears a high-pitched, scratchy sound during S1 and S2 at the apex. The nurse suspects: Ventricular atrophy resulting from muscle damage. Increased cardiac output. Systolic and diastolic regurgitation. Inflammation of the pericardial membranes. D During a neurological assessment of a client who has had a stroke, the nurse simultaneously places two pin points on the client's skin. The patient is able to feel only one point at 16mm on the right index finger and 85mm on the upper arms. The nurse understands this to be: A normal response in the middle-aged adult. An abnormal response as a result of a sensory cortex lesion. Suspicious of a cerebellar lesion; the RN should assess their gait. Consistent with occitibal lobe damage. B The nurse is examining an adolescent client. Using the diaphragm, the nurse hears an intermittent extra early diastolic sound at the second interspace, left sternal border. The nurse knows this is a: Split S2. Tricuspid murmur. Carotid bruit. Physiologic S3. A The nurse is examining a school-aged child. Using the bell of the stethoscope, the nurse hears a midsystolic, soft, blowing, whooshing sound at the left middle sternal border. The nurse understand this to be mostconsistent with a: S3 gallop. Systolic murmur S4 gallop. Diastolic murmur B-Systolic murmurs occur with between S1 and S2. The nurse is performing a complete examination on an older adult client. Which of the following is a normal age-associated change? Pain with hip adduction and abduction. Decline in blood pressure due to decreased cardiac output. Resting heart rate decreases over time. Stiffening of arterial walls resulting in a wider pulse pressure. D A patient with peripheral arterial disease and associated paresthesia is most likely to report which of the following during the health history: "Wearing my compression socks at work helps a lot." "It feels much better when I walk or elevate my legs." "I often have a pins and needles feeling in my foot." "My legs are so swollen and heavy at the end of the day." C During assessment with the Glasgow Coma Scale, the nurse depresses the client's sternum and notices extension of the upper extremities and plantar flexion of the feet. The nurse documents this finding as: Withdraws from painful stimulus. Motor response 3/5. Decerebrate posturing. Decorticate posturing. C The home health nurse is performing a cardiovascular assessment. While auscultating the apical pulse and palpating the radial pulse at the same time, the nurse records the apical pulse as 60 bpm and the radial pulse as 68 bpm. What should the nurse do next? Use a doppler device to confirm flow at the apical site. Recheck the pulse rates at the apical and radial sites. Document the pulse deficit as 8 bpm. Document the pulse deficit as -8 bpm. B- It is not possible for the apical to be slower than the radial pulse. The nurse should recheck. During a routine head-to-toe examination of an adult, the nurse is unable to palpate the ulnar pulses. Cap refill is 2 seconds. What should the nurse do next? Refer the individual for further evaluation. Continue with the examination. Obtain a doppler to confirm ulnar flow. Perform a modified allen test to check patency. B The nurse is gathering a health history. Which of the following is a risk factor for peripheral vascular disease? Consumption of 1 alcoholic drink per day. Occupation requires a lot of walking. High level of high-density lipoprotein (HDL) cholesterol. Body mass index of 36 kg/m2 D During the health history of an older adult client, the client's significant other states "he is always confused and never listens to me!" During the neurological examination, the nurse should: Assess his mental status and ability to follow directions before testing cerebellar function and sensation. Proceed with the complete neurological exam, knowing that mental status does not affect his ability to participate. Defer the exam due to his altered level of consciousness. Limit him to a brief screening exam due to the patient's altered mental status. A The nurse is examining an adult client presenting with "headache". Which assessment finding indicates limited cervical spine range of motion (ROM)? Left lateral bending 45 degrees. Right rotation 75 degrees. Forward flexion 20 degrees. Extension 60 degrees. C Which of the following is an expected musculoskeletal change during the last trimester of pregnancy? Decreasing estrogen causes the ligaments in the body to shorten which cause joint pain and inflammation. Relaxation of the pelvic muscles may cause a kyphotic stance. The lower back curves inward, which puts strain on the low back muscles. Excess fluid puts pressure on the upper extremity nerves which may cause ascending weakness. C While assessing a 3 month-old infant, the nurse offers his finger to the baby's palm and the baby tightly grasps. What does the nurse know about this response? Persistence of this Moro reflex can indicate neurological damage. This is consistent with occipital lobe damage. This response is expected at this age. This reflex should have disappeared shortly after birth. C The nurse is performing a functional assessment on an elderly male with limited range of motion (ROM) in the knee. Which assessment finding is consistent with this data? Quadriceps strength is 4/5 bilaterally. The patient has a deliberate gait with a wider stance. Absence of bulge sign. Client displays a limping gait. D The nurse suspects a patient has different true leg lengths. To confirm this suspicion, what should the nurse do next? Measure each leg from the anterior iliac spine to the medial malleolus. Perform the Bulge or Ballottement tests. Ask the patient to walk across the room. Measure bilaterally from the umbilicus to the medial malleolus. A bilateral edema in the legs. Based on these findings, what should the nurse do next? Assume chronic venous insufficiency and notify the provider. Observe the neck veins for distention. Suspect coronary artery disease as the cause for these symptoms. Obtain ankle-brachial index (ABI) bilaterally. B A pregnant female in her third trimester is in the clinic for "leg pain and swelling." How should the nurse assess for deep vein thrombophlebitis (DVT)? Observe for atrophy of the lower leg muscles. Assess for elevational pallor bilaterally. Assess for increased pain with dorsiflexion of the foot. Check ankle-brachial index (ABI) on the affected leg. C The nurse is preparing to assess a client with chronic venous insufficiency. Upon examination of the affected leg, the nurse should expect which findings? Select all that apply. Coldness to palpation. Ankle-brachial index less than 0.90 Edema. Absent pedal pulses. Irregularly shaped, weeping ulcer. "Aching" leg pain is relieved with elevation. CEF Which of the following signs is most likely to be seen with severe peripheral arterial disease? Dependent rubor. Multiple varicose veins. 4+ pitting edema. Ankle-brachial index of 0.98. A-Dependent rubor is consistent with severe PAD. Chronic hypoxia produces loss of vasomotor tone and pooling of blood in the veins. During an examination of an adult male presenting with "lower back pain", how should the nurse assess for herniated intervertebral disc? Observe for an outward curvature of the thoracic spine. Ask the patient to flex the left and right hip against resistance. Assess for hyperreflexia in the upper extermities. Assess for pain while the nurse raises each leg off the table. D- Lateral tilting and sciatic pain with passive straight leg raising (Lasegue test) are findings that occur with a herniated nucleus pulposus. The nurse is performing a neurological recheck on an adult client who sustained a head injury. Which of the following signs/symptoms alerts the nurse to increasing intracranial pressure? Select all that apply. Glasgow Coma Scale score of "0". Nonreactive pupil. Intact plantar reflex. Systolic hypertension. Stereognosis. Drowsiness. BDF To assess for rotator cuff injury, what should the nurse do? Check for a positive bulge sign. Evaluate muscle tone bilaterally. Assess arm span with a tape measure. Assess the patient's ability to abduct the arm. D The nurse auscultates a loud murmur just after S2 over the pulmonic valve area. A slight thrill is palpated over the area. The nurse documents: Grade 6/6 systolic murmur present at left midclavicular line. Grade 5/6 systolic murmur present at left upper sternal border. Grade 4/6 diastolic murmur present at 2nd left intercostal space. Grade 5/6 diastolic murmur present at 4th left intercostal space. C What should the nurse include in the examination of a newborn infant born 2 hours earlier? Auscultate for soft, systolic murmurs, which strongly suggest cardiac pathology. Assess for overall cyanosis, which may signal congenital heart disease. Obtain the heart rate, which should fall within 80-160 beats per minute. Obtain the apical heart rate at the 6th intercostal space left sternal border. B- Overall cyanosis, not acryocyanosis, signals congenital heart disease. During the health history interview, an adult client with hyperlipidemia reveals that he sometimes feels "pressure" in his chest during strenuous activity, but it subsides after resting for about 5-10 minutes. The nurse suspects: Normal age-related chest pain. Peripheral arterial disease. Coronary artery disease. Transient ischemic attack. C When assessing a 68 year-old patient presenting with "left leg pain", the nurse notes that the left femoral pulse is weak. What should the nurse do next? Document the finding as normal in older adults. Auscultate the site to identify partial occlusion. Ask the client to stand and palpate again. Palpate for enlarged lymph nodes in the area. B The nurse is assessing a client with suspected peripheral arterial disease (PAD). Which assessment finding supports this hypothesis? The circumference of the left leg is 1cm larger than the right leg. The blood pressure at the ankle is significantly lower than in the arm. 3+ pedal pulses. The client has dependent edema. B An elderly patient has just been admitted to the intensive care unit (ICU) with acute decompensated heart failure. Based on this diagnosis, what does the nurse expect to assess in this client? Select All That Apply. Unilateral edema in the legs. Flat neck veins. S3 gallop. Cool, clammy skin. SpO2 96-99 on Room Air%. Bradypnea. Crackles upon auscultation of lung fields. CDFG- Manifestations of ADHF are a result of fluid volume overload and decreased cardiac output. The pt will be hypoxic and dyspneic due to pulmonary edema (crackles in lungs), and therefore the patient will be tachpyneic. blood pressure will be low and a pulse deficit will be present due to low stroke volume. The skin will be cool and clammy The nurse is examining a client with systolic dysfunction. Using the bell, the nurse hears an extra early diastolic sound at the apex of the heart. The nurse interprets this sound as: Split S1. S3 gallop. Split S2. S4 gallop. B [Show More]

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HESI OB/MATERNITY V 2 1. The nurse is caring for a client who had an emergency cesarean section, with her husband in attendance the day before. The baby’s Apgar was 9/9. The woman and her partner ha...

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