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Wgu rn hesi health assessment
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Showing 10 questions, Sign in for moreThe client is a 76-year-old female who arrived at the emergency department (ED) via ambulance from an assisted living facility after a fall. The client called for help using her medical alert necklace. Reports feeling dizzy and lightheaded for the past two days. The client is unable to recall the events that led up to the fall and states, "l do not know how long I was down." Past medical history includes chronic obstructive pulmonary disease (COPD), hypertension (HTN), and carotid artery stenosis. Smokes half a pack of cigarettes daily for 40 years. Attempted to quit smoking five years ago after a right carotid endarterectomy.
Vital signs on arrival
- Temperature: 98.90 F (37. 10 C) orally
- Heart rate: 101 beats/minute
- Respirations: 22 breaths/minute
- Blood pressure: 156/90 mm Hg
- Oxygen saturation: 92% on room air
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- Temperature: 98.60 F (370 C) orally
- Heart rate: 98 beats/minute
- Respirations: 22 breaths/minute
- Blood pressure: 160/92 mm Hg
- Computed tomography (CT) of the head
- Carotid duplex ultrasound
- Complete blood count (CBC), complete metabolic panel (CMP), prothrombin time/international normalized ratio (PT/INR), partial thromboplastin time (PTT), C-reactive protein (CRP), thyroid stimulating hormone (TSH), low density lipoprotein (LDL), high density lipoprotein (HDL)
- Admit to the stroke unit
- Magnetic resonance imaging (MRI) of brain
Computed tomography (CT) of brain: negative
Carotid ultrasound: left carotid 80% stenosis
Which assessment(s) should the nurse conduct? Select all that apply.
When assessing a client's range of motion, the nurse notes crepitation with movement of the left knee. Which information in the client's history is most likely related to this finding?
While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?
The nurse is assessing a client with gallstones for jaundice. Which action should the nurse perform to confirm this information?
A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?
The nurse is obtaining a health history for a client being admitted for new onset seizures. Which action should the nurse implement to accurately record the health history findings?
The nurse assesses a young adult female who was brought to the emergency department (ED) by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?
To assess for the presence of egophony, which instruction should the nurse give the client who has a lung abscess?
The client is a 46-year-old male who comes to the emergency department having difficulty breathing which has worsened over the last twenty four hours.
Assess the client's lungs decrease lung sounds in the right lower right base. The. Percussion reveals stones over the same area, using accessory muscles to breathe. Chest expansion is decreased on right side. Skin is warm to touch, but is pale in color. Client says he has had a nonproductive cough for two days.
Vital signs
- Temperature 99.00 F (37.20 C) orally
- Heart rate 86 beats/minute
- Respiratory rate 24 breaths/minute
- Blood pressure 142/86 mm Hg
- Oxygen saturation 94% on room air
Chest X-ray
Oxygen 2L/minute via nasal cannula and titrate to keep saturation above 94%
Insert peripheral IV
Begin lactated Ringers IV infusion at 125 mL/hour
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Explanation
Potential Condition: Lobar pneumonia
Actions to take:
- Auscultate the lungs for adventitious breath sounds
- Inspect the chest for lag on the affected side
Parameters to monitor
- Crackles
- Respiratory rate and pulse
Rationale:
Potential Condition: Lobar pneumonia
The client presents with worsening breathing difficulty, a mild fever, elevated respiratory rate, and borderline hypoxemia, which are indicative of pneumonia. The chest X-ray order supports the suspicion of a lung infection, such as lobar pneumonia.
Actions to Take:
Auscultate the lungs for adventitious breath sounds: Lobar pneumonia often produces abnormal lung sounds, such as crackles or bronchial breath sounds, over the affected lobe. This assessment helps confirm consolidation in the lung.
Inspect the chest for lag on the affected side: Chest lag may indicate reduced ventilation of the affected lobe, a hallmark of pneumonia.
Parameters to Monitor:
Crackles: A common finding in pneumonia, crackles result from the movement of air through fluid-filled alveoli. Monitoring for resolution or worsening crackles can assess treatment efficacy.
Respiratory rate and pulse: Both are essential indicators of respiratory and cardiovascular status. An increasing respiratory rate or tachycardia may signal worsening oxygenation or sepsis.
Rationale for Incorrect Options:
Other Conditions
Pleural effusion: While it can cause respiratory symptoms, pleural effusion typically presents with dullness to percussion and diminished breath sounds, not crackles or lobar consolidation.
Atelectasis: Usually presents with diminished or absent breath sounds and often resolves with deep breathing exercises or incentive spirometry.
Acute bronchitis: This condition is associated with a productive cough, wheezing, and diffuse lung involvement, not localized findings like in lobar pneumonia.
Other Actions:
Assess for tactile fremitus: Fremitus is reduced in pleural effusion or pneumothorax, but pneumonia typically increases fremitus over the affected lobe.
Assess for muffled heart sounds: This is associated with cardiac tamponade, not pneumonia.
Assess for prolonged expiration: This is more relevant in obstructive conditions like asthma or COPD.
Other Parameters to Monitor:
Loud bronchial breathing: Although it may occur, it is less specific and not always present in pneumonia.
Cyanosis: This would indicate advanced hypoxemia, which is not present in this client (oxygen saturation is 94% on room air).
Wheezing: More commonly associated with bronchospasm or asthma, not lobar pneumonia.
When assessing an older adult client with a history of cardiovascular disease, dyspnea, and peripheral edema, which method is best for the nurse to use to assess the client's pulse rate?
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