Review RN HESI HEALTH ASSESSMENT

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RN HESI HEALTH ASSESSMENT

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Total Questions : 50

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Question 1:

The primary nurse asks another nurse to assist in checking a client for an apical-radial pulse deficit. One nurse counts an apical pulse of 72 beats/minute while the other nurse counts a radial pulse of 88 beats/minute. Which action should the primary nurse take?

A. Check the reading after the other nurse leaves the room. B. Document a pulse deficit of 16 beats per minute. C. Report the results of the deficit to the healthcare provider. D. Repeat the assessment to obtain another reading.

Answer and Explanation

Choice A:

Checking the reading after the other nurse leaves the room is inappropriate. This option suggests waiting until the other nurse leaves to check the reading again. However, there's no guarantee that the discrepancy will resolve itself, and waiting might delay necessary intervention if there is indeed a pulse deficit. Therefore, this option does not address the immediate need for clarification.

Choice B:

Documenting a pulse deficit of 16 beats per minute is inappropriate. While there appears to be a difference between the apical and radial pulse readings, it's important to verify the accuracy of the measurements before documenting a pulse deficit. Documenting without confirmation could lead to inaccurate information in the patient's medical record.

Choice C:

Reporting the results to the healthcare provider without confirming the accuracy of the measurements may lead to unnecessary concern or intervention. It's essential to ensure that the findings are accurate before reporting them to the healthcare provider.

Choice D:

Repeating the assessment to obtain another reading is appropriate. This option prioritizes patient safety by acknowledging the need to confirm the accuracy of the measurements. Repeating the assessment allows the nurses to ensure consistency and reliability in their findings before taking further action or reporting to the healthcare provider.

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Question 2:

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

A. White blood cell count (WBC). B. Glucose. C. Blood urea nitrogen (BUN). D. Hematocrit.

Answer and Explanation

Choice A:

White blood cell count (WBC) is inappropriate. White blood cell count is typically monitored to assess for signs of infection or inflammation. While it's important to monitor WBC count in certain situations, such as suspected infection, melena itself is not directly indicative of an increased risk of infection. Therefore, monitoring WBC count may not be the most immediate response to the finding of melena.

Choice B:

Glucose is inappropriate. Glucose monitoring is essential for patients with diabetes or those at risk of hypoglycemia or hyperglycemia. However, melena is not directly related to glucose metabolism or regulation. Therefore, monitoring glucose levels would not be the most relevant response to the finding of melena.

Choice C:

Blood urea nitrogen (BUN) is inappropriate. Blood urea nitrogen is often monitored to assess kidney function and hydration status. While severe bleeding can potentially lead to hypovolemia and prerenal azotemia (elevated BUN due to decreased renal perfusion), monitoring BUN would not be the immediate response to the finding of melena. Instead, assessing for signs of hypovolemia and monitoring other markers of blood loss, such as hematocrit, would be more appropriate.

Choice D:

Hematocrit is appropriate. Melena refers to the passage of black, tarry stools containing blood that has been digested. It indicates upper gastrointestinal bleeding, typically from the stomach or upper small intestine. Monitoring the hematocrit level is important because significant bleeding, as indicated by melena, can lead to a decrease in the hematocrit level due to the loss of red blood cells and plasma volume. Monitoring the hematocrit helps assess the severity of the bleeding and guides treatment decisions, such as the need for blood transfusions. Therefore, the nurse should monitor the hematocrit level in response to the finding of melena.

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Question 3:

When obtaining a client's health history related to smoking cigarettes, the nurse plans to determine the client's smoking pack years. Which information should the nurse obtain for this calculation? Select all that apply.

A. Number of attempts to quit smoking. B. Packs of cigarettes smoked per day. C. Client's current age. D. Number of years the client smoked. E. Age when the client started smoking.

Answer and Explanation

Choice A:

Number of attempts to quit smoking is incorrect. While the number of attempts to quit smoking may provide insight into the client's smoking cessation efforts and motivation, it is not directly relevant to calculating smoking pack years. Pack years specifically quantify the amount and duration of smoking, rather than cessation attempts.

Choice B:

Packs of cigarettes smoked per day is correct. The number of packs of cigarettes smoked per day is a crucial factor in calculating smoking pack years. Pack years are calculated by multiplying the number of packs smoked per day by the number of years the individual has smoked. This information provides a quantitative measure of smoking exposure over time.

Choice C:

Client's current age is incorrect. While the client's current age may be relevant in assessing overall health, risks associated with smoking and in discussing smoking cessation strategies, it is not directly used in the calculation of smoking pack years. Pack years are based on the total duration of smoking and the average daily consumption of cigarettes, not the client's current age.

Choice D:

Number of years the client smoked is correct. The number of years the client has smoked is a critical piece of information for calculating smoking pack years. Pack years are calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the individual has smoked. This helps quantify the duration of smoking history.

Choice E:

Age when the client started smoking is correct. Knowing the age at which the client started smoking is essential for determining the duration of smoking history, which is a key component in calculating pack years. It helps provide a comprehensive understanding of the client's smoking habits and exposure to tobacco smoke over time.

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Question 4:

When performing a physical assessment, palpation reveals to the clinic nurse that a client has an enlarged thyroid gland. What action should the nurse take in response to this finding?

A. Request diagnostic laboratory testing for the client. B. Obtain a dietary consultation for nutrition teaching. C. Instruct the client in the need to use iodized salt. D. Schedule a follow-up appointment in one month.

Answer and Explanation

Choice A:

Requesting diagnostic laboratory testing for the client is appropriate action. Enlargement of the thyroid gland can be indicative of various thyroid disorders, including hyperthyroidism, hypothyroidism, or thyroid nodules. Diagnostic laboratory testing, such as thyroid function tests (TFTs), thyroid antibody testing, and possibly thyroid ultrasound, can help identify the underlying cause of the thyroid enlargement. These tests can include assessments of thyroid hormone levels (T3, T4, and TSH), antibodies, and imaging studies. Requesting diagnostic laboratory testing is essential to accurately diagnose the condition and guide appropriate management and treatment.

Choice B:

Obtaining a dietary consultation for nutrition teaching is inappropriate action. While nutrition can play a role in overall thyroid health, obtaining a dietary consultation for nutrition teaching is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Dietary consultation may be considered as part of comprehensive care for thyroid disorders, but it does not address the need for further evaluation and diagnosis of the thyroid enlargement.

Choice C:

Instructing the client in the need to use iodized salt is inappropriate action. While iodine deficiency can contribute to thyroid disorders, instructing the client to use iodized salt is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Using iodized salt may help prevent iodine deficiency, but it does not address the need for further evaluation and diagnosis of the thyroid enlargement.

Choice D:

Scheduling a follow-up appointment in one month is inappropriate action. While scheduling a follow-up appointment may be necessary for ongoing monitoring and management of thyroid disorders, it is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Further evaluation and diagnostic testing should be prioritized to determine the underlying cause of the thyroid enlargement and initiate appropriate treatment.

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Question 5:

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

A. Audible thud without pain. B. Rigidity and firmness. C. Rebound tenderness. D. Sharp, severe pain.

Answer and Explanation

Choice A:

Audible thud without pain is incorrect. An audible thud without pain would not be an expected response when percussing the costovertebral angle (CVA) in a client with pyelonephritis. Pyelonephritis typically presents with tenderness upon percussion of the CVA due to inflammation or infection of the kidneys. The absence of pain in this scenario would not be consistent with the expected response.

Choice B:

Rigidity and firmness are incorrect. Rigidity and firmness upon percussion of the costovertebral angle (CVA) may suggest muscle tension or guarding, rather than the tenderness typically associated with kidney inflammation or infection such as pyelonephritis. While guarding can occur in response to pain, it is not the expected response when assessing for kidney tenderness.

Choice C:

Rebound tenderness is incorrect. Rebound tenderness refers to the exacerbation of pain upon release of pressure, typically observed in conditions such as peritonitis. While rebound tenderness may be present in some abdominal conditions, it is not the expected response when percussing the costovertebral angle (CVA) to assess for kidney tenderness in pyelonephritis. In pyelonephritis, tenderness upon initial percussion is more indicative of the condition.

Choice D:

Sharp, severe pain is correct. Sharp, severe pain upon percussing the CVA suggests tenderness, which can be indicative of kidney inflammation or infection, such as pyelonephritis. This finding would support the diagnosis and help guide further assessment and treatment.

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Question 6:

In assessing a client's level of consciousness, what should the nurse assess first?

A. Motor responses. B. Eye opening. C. Verbal response D. Level of alertness.

Answer and Explanation

Choice A:

Motor responses are important in assessing neurological function, but they are typically assessed after determining the client's overall level of consciousness and alertness. Motor responses are usually assessed when the client is unresponsive or has altered consciousness.

Choice B:

Eye opening is part of the Glasgow Coma Scale (GCS) and is an important indicator of neurological function. However, it is generally assessed after determining the client's level of alertness.

Choice C:

Verbal response is another component of the GCS, assessing how the client responds to verbal stimuli. This assessment also follows the initial determination of the client’s alertness.

Choice D:

The level of alertness is the first and most fundamental aspect to assess because it gives the nurse a baseline understanding of how aware the client is of their surroundings. This assessment sets the stage for further evaluation of motor, eye, and verbal responses. It helps determine the client's ability to interact and respond to stimuli, guiding subsequent assessments.

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Question 7:

In reading a client's record, the nurse notes that the client is experiencing tinnitus. Which assessment provides the nurse with the information needed to evaluate the effects of this condition?

A. Observe chest and upper neck for a rash. B. Perform a hearing test. C. Evaluate for a loss of peripheral vision. D. Assess deep tendon reflexes.

Answer and Explanation

Choice A:

Observing chest and upper neck for a rash is correct. This assessment is unrelated to tinnitus. Observing the chest and upper neck for a rash may be relevant in the context of other conditions, such as skin disorders or infectious diseases, but it does not provide information about the effects of tinnitus.

Choice B:

Performing a hearing test is correct. Tinnitus is the perception of noise or ringing in the ears when no external sound is present. It can affect a person's hearing and overall quality of life. Therefore, the most appropriate assessment to evaluate the effects of tinnitus is to perform a hearing test. This test can assess the client's auditory function, including their ability to hear different frequencies and intensities of sound. By conducting a hearing test, the nurse can gather objective data on the client's hearing abilities and determine the extent to which tinnitus may be impacting their hearing sensitivity and perception.

Choice C:

Evaluating for a loss of peripheral vision is incorrect. Loss of peripheral vision is not a typical effect of tinnitus. While tinnitus can affect auditory perception, it does not directly impact visual function, particularly peripheral vision. Therefore, evaluating for loss of peripheral vision is not relevant to assessing the effects of tinnitus.

Choice D:

Assessing deep tendon reflexes is incorrect. Assessing deep tendon reflexes is unrelated to evaluating the effects of tinnitus. Deep tendon reflexes are assessed to evaluate the integrity of the neurological system and are typically tested in the context of assessing motor function and nerve responses. This assessment does not provide information about the auditory effects of tinnitus.

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Question 8:

While assessing a client, the nurse notices that the client's legs are asymmetrical. Which additional physical data should the nurse collect?

A. Perform passive range of motion and compare the findings. B. Compare measured circumferences of each extremity joint. C. Instruct client to walk across room and observe the gait. D. Measure the length of each leg and document the findings.

Answer and Explanation

Choice A:

Performing passive range of motion and compare the findings is inappropriate. While assessing passive range of motion can provide information about joint mobility and flexibility, it may not directly address the asymmetry observed in the legs. Range of motion assessment is more relevant for evaluating joint function and flexibility rather than leg length asymmetry.

Choice B:

Comparing measured circumferences of each extremity joint is inappropriate. Measuring circumferences of extremity joints may help identify differences in muscle mass or swelling, but it may not directly address the asymmetrical leg length observed. Circumference measurements are more relevant for assessing muscle bulk or detecting signs of edema rather than leg length asymmetry.

Choice C:

Instructing client to walk across the room and observe the gait is inappropriate. Observing the client's gait can provide valuable information about their walking pattern and any abnormalities in movement. While an abnormal gait may be associated with leg length asymmetry, directly measuring leg length would provide more precise data for evaluation.

Choice D:

Measuring the length of each leg and document the findings is appropriate. Measuring the length of each leg can help identify any significant differences in leg length, which could be contributing to the asymmetry observed. Leg length discrepancy can result from various musculoskeletal conditions such as scoliosis, hip dysplasia, or unequal growth rates. Documenting the findings allows for accurate tracking of changes over time and provides important information for healthcare providers to determine appropriate interventions, such as orthotic devices or physical therapy.

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Question 9:

The nurse examines a client's right great toe. The joint is red, edematous, and very painful with limited range of motion. The client's serum uric acid levels are elevated. Which action should the nurse tell the client to make?

A. Splint the affected joint. B. Encourage fluid intake. C. Increase Intake of red meat. D. Measure urine output.

Answer and Explanation

Choice A:

Splint the affected joint is inappropriate action. While splinting may help stabilize the joint and reduce movement, it may not directly address the underlying cause of the symptoms, which is9levated uric acid levels leading to gout. Additionally, splinting may further restrict range of motion and exacerbate discomfort.

Choice B:

Encouraging fluid intake is appropriate action. Encouraging fluid intake, particularly water, is beneficial for individuals experiencing a gout flare-up. Adequate hydration helps to dilute uric acid in the bloodstream and promote its excretion through urine, which can help alleviate symptoms and prevent further flare-ups. Therefore, option B is the most appropriate action for the nurse to advise the client in this situation.

Choice C:

Increasing intake of red meat is inappropriate action. Red meat is high in purines, which can contribute to elevated uric acid levels and increase the risk of gout flare-ups. Therefore, increasing intake of red meat would not be advisable for someone experiencing gout symptoms. In fact, dietary modifications often involve reducing intake of purine-rich foods like red meat to help manage gout.

Choice D:

Measuring urine output is inappropriate action. While monitoring urine output is important for overall hydration status, it may not be the most immediate or relevant action in this situation. The priority in managing a gout flare-up is to address the underlying cause by promoting uric acid excretion through adequate hydration, rather than solely focusing on measuring urine output.

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Question 10:

Hearing "roaring" sounds when auscultating as well as crackles. Client has a hairy chest. Exam is taking place behind a privacy screen there are no individual rooms with doors.

The client is a 35-year-old male with no history of any medical conditions is in the clinic for an annual physical.

Exhibits

Nurse analyzes the findings.

What can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.

A. Reach under a gown to listen and take care that no clothing rubs on the stethoscope B. Ensure the room is as quiet as possible C. Keep the examination room warm, and warm the stethoscope D. Document the roaring and crackles E. Wet the chest hair before auscultating

Answer and Explanation

Choice A:

This option can help minimize clothing-related artifacts that may interfere with auscultation. Ensuring that the stethoscope is in direct contact with the skin allows for better transmission of sounds

Choice B:

Ensuring the room is as quiet as possible is appropriate. Background noise can interfere with the clarity of auscultatory sounds. Ensuring a quiet environment helps reduce external interference and improves the nurse's ability to accurately hear and interpret the sounds.

Choice C:

Keeping the examination room warm, and warm the stethoscope is appropriate. Cold temperatures can cause vasoconstriction and muscle tension, leading to increased tension in the skin and subcutaneous tissues, which may affect the quality of auscultatory sounds. Keeping the examination room warm and warming the stethoscope helps minimize this effect, ensuring clearer auscultation.

Choice D:

Document the roaring and crackles is inappropriate. Documenting auscultatory findings such as roaring and crackles is important for clinical assessment and documentation but does not mitigate artifacts during auscultation. It is crucial to focus on optimizing the auscultation environment and technique to ensure accurate interpretation of sounds.

Choice E:

Wetting the chest hair before auscultating is appropriate. Chest hair can create friction and produce artifacts during auscultation, particularly when using a stethoscope. Wetting the chest hair helps reduce friction and minimize artifacts, allowing for clearer auscultatory sounds.

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RN HESI HEALTH ASSESSMENT

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