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Hesi rn health assessment
Hesi rn health assessment
Total Questions : 58
Showing 10 questions Sign up for moreThe nurse observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression. How should the nurse enter documentation of this finding in the client's electronic medical record (EMR)?
Explanation
A. Appears confused and depressed. This statement is subjective and makes an assumption about the client's emotional state without concrete evidence. It is better to document objective observations.
B. Wandering behavior with flat affect. This is the best choice because it describes specific behaviors (wandering) and observable signs (flat affect) without making assumptions about the client's mental state.
C. Ambulatory and disoriented to place. While "ambulatory" is accurate, "disoriented to place" makes an assumption about the client's mental status that may not be verified.
D. Demonstrates signs of early dementia. This choice implies a diagnosis which cannot be made based on the described observations alone. Diagnosis should be left to a healthcare provider after a thorough evaluation.
A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?
Explanation
A. Snoring and bilateral, pale gray nodules. This suggests the presence of nasal polyps, which can be associated with chronic allergic conditions but not specific to allergic rhinitis.
B. Intranasal edema and swelling of turbinates. This is the best choice as it directly describes physical signs commonly seen in allergic rhinitis, indicating inflammation and swelling due to allergen exposure.
C. Purulent secretions from eyes and nares. This suggests an infection rather than an allergic reaction. Allergic rhinitis typically causes clear, watery secretions.
D. Eye tearing and thick yellow nasal drainage. Thick yellow nasal drainage is more indicative of a bacterial infection rather than allergic rhinitis, which causes clear secretions.
The nurse should anticipate difficulty locating the point of maximal impulse (PMI) in which client? Reference Range: Body mass index [(BMI) Normal or healthy weight (18.5 kg/m2 to 24.9 kg/m2)]
Explanation
A. A 75-year-old with a pneumothorax and a chest tube.With appropriate chest tube management and resolution of the pneumothorax, the PMI may return to its normal position. While this can be a valid challenge, it is transient and less likely to make PMI consistently difficult to locate.
B. A 45-year-old long-distance runner with a body mass index (BMI) of 18 kg/m2. Despite a low BMI, there are no factors here that would inherently make locating the PMI difficult.
C. A 2-year-old who is demonstrating diaphragmatic breathing. While diaphragmatic breathing is common in young children, it does not necessarily obscure the PMI.
D. A 54-year-old who is 5 feet (152.4 cm) tall and weighs 300 pounds (136.1 kg). This client is significantly obese, which can make it difficult to palpate and locate the PMI due to the excess adipose tissue.
When evaluating a client's rectal bleeding, which findings should the nurse document?
Explanation
A. Color characteristics of each stool. This is the best choice as it provides important information about the possible source and nature of the bleeding (e.g., bright red indicates lower GI bleeding, while dark tarry stools indicate upper GI bleeding).
B. Number of blood clots expelled with each stool. While this could be relevant, it is less commonly noted and might be more subjective unless quantified consistently.
C. Unique odor noted with gastrointestinal bleeding. The odor can sometimes indicate the presence of blood, but it is not a primary characteristic to document compared to stool color and consistency.
D. Evidence of internal hemorrhoids. Internal hemorrhoids might be a source of bleeding, but this requires confirmation through a physical examination, typically by a healthcare provider.
An adult client exhibits an allergic reaction to an insect bite. The nurse should observe the client's skin for which finding?
Explanation
A. Excoriation. This indicates skin damage caused by scratching but does not specifically describe an allergic reaction.
B. Fissuring. This refers to deep cracks in the skin and is not a typical feature of an allergic reaction to an insect bite.
C. Wheals. This is the best choice as wheals are raised, red, itchy areas commonly associated with allergic reactions.
D. Papules. Papules are small, raised, solid pimples that can occur with many skin conditions, not specifically allergic reactions
While obtaining a client's health history related to smoking cigarettes, the nurse plans to determine the client's smoking pack years. What information should the nurse obtain for this calculation? Select all that apply.
Explanation
A. Number of years the client smoked. This is necessary to calculate pack years as it gives the duration of smoking.
B. Client's current age. This is not directly needed for the calculation of pack years, although it might be relevant to overall health assessment.
C. Packs of cigarettes smoked per day. This is necessary to calculate pack years as it gives the daily smoking quantity.
D. Number of attempts to quit smoking. This information is important for understanding the client's history but not needed for calculating pack years.
E. Age when the client started smoking. While this gives context, it is not needed for the calculation if the total number of years smoked is known. However, it could help calculate the number of years smoked if the current age is used and smoking start age is known.
A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?
Explanation
A. Have the client lay flat while listening to the anterior surface of the chest. This position may not allow optimal lung expansion and can cause discomfort, especially in clients with respiratory issues. It is generally better to assess lung sounds with the client in an upright position.
B. Shave all chest hair that may distort sounds heard through the diaphragm. While chest hair can sometimes interfere with sound transmission, shaving is not a practical or necessary step. Pressing the stethoscope firmly can usually mitigate this issue.
C. Use the bell of the stethoscope to listen to the lung fields over lower lobes. The bell is more sensitive to low-pitched sounds, like heart murmurs, and not ideal for lung auscultation. The diaphragm is preferred for assessing lung sounds.
D. Press the stethoscope's diaphragm firmly on the skin over each lung field. This is the best choice because the diaphragm of the stethoscope is more effective at transmitting high-frequency sounds, which are common in lung auscultation. Pressing firmly ensures better contact and clearer sounds.
While completing an admission assessment, the nurse is unable to palpate the client's left dorsalis pedis (DP) pulse. Which intervention is most important for the nurse to implement?
Explanation
A. Use a Doppler to assess an audible DP pulse. This is the most immediate and effective intervention to locate a pulse that is not palpable. A Doppler device can detect blood flow that is not perceptible by palpation.
B. Assess capillary refill distal to the DP pulse. While assessing capillary refill can provide information about peripheral circulation, it does not help locate the pulse.
C. Review client's history for vascular disease. This is important for understanding the client's overall health, but it is not an immediate intervention to locate the pulse.
D. Place a mark where DP pulse is auscultated. Marking the pulse location can be helpful once the pulse is found, but it is not an intervention to find an initially absent pulse.
While observing a client's face, which assessment finding requires immediate intervention by the nurse?
Explanation
A. Corneas are jaundiced. Jaundiced corneas indicate liver dysfunction, but it is not typically an immediate life-threatening condition.
B. Eyelids are matted and crusted. This suggests an eye infection but does not require immediate intervention unless there are signs of systemic infection or severe pain.
C. Face is flushed and diaphoretic. Flushing and sweating can indicate fever, anxiety, or other conditions, but it is not immediately life-threatening.
D. Oral mucosa is cyanotic. Cyanosis indicates hypoxia and requires immediate intervention as it suggests a lack of adequate oxygenation.
The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?
Explanation
A. Coronary heart disease. While coronary heart disease can affect overall health, it is not typically associated with changes in nail shape.
B. Recent candida infection. Candida infections can cause nail changes, but they usually result in discoloration and thickening rather than concave curves.
C. Iron deficiency anemia. This is the best choice because iron deficiency anemia is commonly associated with koilonychia (spoon-shaped nails).
D. Diabetes mellitus. Diabetes can cause various changes in skin and nails, but it is not typically associated with brittle, concave nails.
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