HESI flashcards 246

HEALTH ASSESSMENT NAXLEX

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.

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.

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.

 Number of attempts to quit smoking.

 Packs of cigarettes smoked per day.

 Client's current age.

 Number of years the client smoked.

  Age when the client started smoking.

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.

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

  A Motor responses.

  B Eye opening.

  C Control Pane

  D Level of alertness.

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.

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.

The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which question should the nurse ask first? "Have you

 A “ever had problems with your blood sugar?"

 B “been sleeping well?

 C “ had anything to eat in the last 24 hours?

 D “been depressed lately?

The 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)?

 A Appears confused and depressed.

 B Demonstrates signs of early dementia.

 C Ambulatory and disoriented to place.

 D Wandering behavior with flat affect.

The nurse is examining the abdomen of an older male client who expresses suprapubic tenderness on palpation. The client states that it sometimes feels like there is still pressure in that area after urination. Which additional finding should the nurse expect with continued interview of the client?

 A Black tarry stools.

 B A cloudy discharge.

 C An overactive bladder

 D A weak urinary stream.

A client is seen in the emergent care clinic for right wrist pain with a pattern of ecchymosis observed on the wrist. Which motion should the nurse instruct the client to perform to assess the wrist mobility?

 A Hyperextension and palmar flexion.

 B Plantar flexion.

 C Forearm pronation.

 D Forearm supination.

While making a home visit, the spouse of an older client tells the nurse the client is becoming increasingly confused about past events and has started forgetting to all pain dictation for osteoarthritis in the knees. Which assessment should the nurse initially perform to evaluate the client's memory?

 A Ask the client to recall what was consumed for lunch and breakfast

 B Ask the spouse how often the pain medication is to be taken

 C Request for the spouse to write down the things the client forgets

 D Observe client ability to perform activities of daily living (ADLs)

An adult client presents with gnawing epigastric pain. The pain is worse when the client is hungry and abates after eating something. Which problem do these symptoms suggest?

 A Chronic pancreatitis.

 B Peptic ulcer disease (PUD).

 C Esophagitis.

 D Gastroesophageal reflux (GERD).

A client reports experiencing stomach pain and it is localized in the middle section of the abdomen below the xiphoid process. The nurse should describe the pain as occurring in which region of the abdomen?

 A Epigastric region.

 B Hypogastric region.

 C Hypochondriac region.

 D Umbilical region.

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

 A Hyperactive bowel sounds.

 B A minor variation.

 C Normal borborygmic sounds.

 D Possible renal artery stenosis.

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

 A Expected finding.

 B Cardiac atrophy.

 C Benign variation.

 D Cardiac enlargement.

During assessment of a client's abdomen, the nurse observes that the client's umbilicus is depressed and below the surface of the abdomen. What action should the nurse take in response to this observation?

 A Ask about recent abdominal trauma.

 B Palpate the area for masses.

 C Document the normal finding.

 D Observe the midline for scarring.

The nurse is assessing a client with gallstones for jaundice. Which action should the nurse perform to confirm this information?

 A Assess conjunctival sacs of lower lids for pallor.

 B Observe the client's urine for dark orange color.

 C Examine client's sclera for icterus.

 D Review recent serum bilirubin levels.

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?

 A History of a fractured patella.

 B Knee arthroplasty surgery.

 C Degenerative disease.

 D Needle aspiration of the synovial space.

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

 A Send the sample for laboratory evaluation.

 B Give the client 8 ounces (236.5 mL) of water to drink.

 C Evaluate the client for bladder distention.

 D Instruct the client to attempt to urinate again.

The nurse asks a female client about the proverb "Glass Houses," and she replies, "It will break the windows." Which conclusion should be documented about this client's response?

 A Normal mental status for age.

 B Impaired concentration.

 C Impaired memory.

 D Impaired thinking.

The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client's use of illegal drugs and alcohol?

 A Allow the client to decline answering social questions.

 B Obtain a drug urine screen to verify legitimacy of client's stated history.

 C Use the term illegal or illicit to describe street drugs.

 D Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts.

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

 A Report the client's abnormal lung sounds to the healthcare provider.

 B Continue with the remainder of the client's physical assessment.

 C Ask the client to cough and then auscultate at the site again.

 D Measure the client's oxygen saturation with a pulse oximeter.

An adult male client informs the nurse that he came to the clinic to see if, "Maybe I have lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this body-wracking dry cough that has been hanging around for the last six weeks." Which computer documentation of this client's concerns should the nurse enter?

 A An adult male presents with fears that he has "lung cancer."

 B Describes having a body-wracking dry cough" of 6 weeks duration.

 C Expresses concern of "lung cancer" symptoms for last 6 weeks.

 D Presents with a hacking non-productive cough of 6 weeks duration.

A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client's paresthesia?

 A Review the client's serum electrolytes.

 B Evaluate client's muscle strength and hand grips.

 C Check distal phalanges capillary refill.

 D Observe skin for erythema, edema, and warmth.

During an admission assessment, which approach should the nurse use to assess a client's speech patterns?

 A Listen while the client reads items listed on the menu.

 B Ask the client to complete a common proverb or saying.

 C Note the client's responses during the initial interview.

 D Have the client repeat a phrase containing alliteration.

In assessing an adult client, the nurse calculates the body mass index (BMI) as 14 kg/m2. Which nursing problem should be included in this client's plan of care?

Reference Range:

Underweight: BMI is less than 18.5; Normal weight: BMI is 18.5 to 24.9; Overweight: BMI is 25 to 29.9; Obese: BMI is 30 or more

 A Fluid volume excess.

 B Unbalanced nutrition, less than body needs.

 C Unbalanced nutrition, greater than body needs.

 D Fluid volume deficit.

To assess a client's pupillary reaction to accommodation, what action should the nurse take?

 A Observe pupil size when focusing on a near object and then a far object.

 B Compare the shape of each of the pupils bilaterally with normal room light.

 C Note the speed of pupil constriction when a penlight is shined into the eye.

 D Determine if dilation of the pupils occurs when the room is darkened.

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?

 A Have the client lay flat while listening to the anterior surface of the chest.

 B Use the bell of the stethoscope to listen to the lung fields over lower lobes.

 C Shave all chest hair that may distort sounds heard through the diaphragm.

 D Press the stethoscope's diaphragm firmly on the skin over each lung field.

Which is the best approach for the nurse to use when interviewing a client about alcohol and substance use?

 A Get the most difficult questions over with first.

 B Ask questions in a vague, non-specific format.

 C Share personal values to put the client at ease.

 D Begin with questions that are less sensitive in nature.

An older adult client with a history of heart failure (HF) is brought to the clinic by a family member. Which finding(s) confirm to the nurse that the client is experiencing an exacerbation of the HF? Select all that apply.

 A Jugular venous distension.

 B Peripheral edema.

 C Dyspnea.

 D Intercostal retractions.

 E Headaches.

During the admission assessment, a male client admitted with chest pain states he has no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

 A Observe for jugular vein distention while the client is flat in bed.

 B Measure the client's blood pressure when he is lying and standing.

 C Ask the client how many pillows he sleeps on at night.

 D Auscultate the client's breath sounds while he is supine.

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?

 A Coronary heart disease.

 B Iron deficiency anemia.

 C Diabetes mellitus.

 D Recent candida Infection.

While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

 A Stand directly in front of the client and ask about any hearing loss.

 B Obtain a tuning fork to complete Rinne and Weber tuning fork tests.

 C Begin to orient the client to her surroundings in the hospital room.

 D Perform a mental status exam to assess the client's thought processes.

The nurse observes that the lower legs of a client with diabetes mellitus are shiny with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?

 A Palpate the client's dorsalis pedis pulses.

 B Ask If the client often feels weak or hungry.

 C Compare the range of motion of both legs.

 D Measure the client's capillary glucose.

The nurse continues a neurologic assessment of the cranial nerve XI (Spinal accessory) for a client. Which instruction should the nurse give the client to complete this assessment?

 A Shrug shoulders against resistance.

 B Stand up slowly with eyes closed.

 C Turn head from side to side.

 D Raise both arms overhead

To assess a male client's muscle strength, the nurse first asks the client to extend his arms. Before asking the client to flex his arms, what should the nurse do?

 A Give the client an object to hold.

 B Instruct the client to close his eyes.

 C Apply resistance to the client's arms.

 D Palpate the client's muscle tone.

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?

 A Purulent secretions from eyes and nares.

 B Snoring and bilateral, pale gray nodules.

 C Intranasal edema and swelling of turbinates.

 D Eye tearing and thick yellow nasal drainage.

During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

 A Nothing by mouth.

 B Electrocardiogram.

 C Monitor urinary output.

 D Complete bed rest.

When entering a client's room, the nurse observes that the client is using pursed-lip breathing. It is most important for the nurse to monitor the client for which problem?

 A Syncope.

 B Acute pain.

 C Tetany.

 D Dyspnea.

The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

 A Cover the inflamed area and notify the healthcare provider.

 B Auscultate the lymph node for the presence of a bruit.

 C Ask the client about any localized tenderness at the site.

 D Record this normal finding in the assessment record.

An adult client exhibits an allergic reaction to an Insect bite. The nurse should observe the client's skin for which finding?

 A Excoriation.

 B Papules.

 C Wheals.

 D Fissuring.

NEW QUESTIONS 85Q

The nurse inspects the client's fingernails. Which differentiating characteristics are observed in this assessment finding?

 A Longitudinal pigmented bands and red brown linear streaks of recent onset.

 B Thinned depressed nails with lateral edges tilting up to form a concave profile and proximal subungual fungal infection.

 C Transverse furrows and nail plate white spots that move forward with nail growth.

 D A nail base angle greater than 180 degrees and nail plate loosened at the distal-lateral edge, progressing proximally.

A woman comes to the clinic for her first prenatal visit. The nurse is conducting a health history and the woman begins to cry when asked about previous pregnancies. Which response is best for the nurse to provide?

 A Allow the client to compose herself then change the subject.

 B "Why don't I come back in a few minutes after you are more composed."

 C "I'm so sorry that I made you cry. I didn't mean to upset you."

 D Offer a tissue and sit quietly until the crying subsides.

The charge nurse observes a practical nurse (PN) measuring the waist circumference of a client who has expressed a concern about health problems related to obesity. Which action should the nurse implement?

 A Advise the PN that waist circumference measurements are valuable to assess fluid retention but not obesity.

 B Instruct the PN to measure the client's waist circumference every 8 hours to assess for changes.

 C Tell the PN that this assessment technique should be performed by the nurse.

 D Review the measurement obtained by the PN and compare with ideal measurements for this client.

A client has a prescription for vital sign measurement every four hours. The nurse observes that the client's blood pressure has increased from 140/60 mm Hg at noon to 180/90 mm Hg four hours later. Which action should the nurse implement?

 A Plan to measure the blood pressure in four hours as prescribed.

 B Repeat the client's blood pressure measurement in fifteen minutes.

 C Obtain an automatic blood pressure machine for hourly readings.

 D Reassess the blood pressure if the client reports other symptoms.

While-interviewing an elderly client, the nurse observes that the client's hands tremble uncontrollably while reaching for a glass of water. How should the nurse document this finding?

 A Sensory dysfunction.

 B Transient ischemic attack.

 C Muscle flaccidity.

 D Intention tremor.

A school-age child presents for a well-child visit with a hemoglobin level of 10 g/dL (100 g/L) and a body mass index of 15 kg/mm2. Which additional assessment should the nurse obtain to help identify a potential cause of these clinical manifestations?

 A Primary source of water.

 B Standard household income.

 C Family history of eating disorders.

 D Average daily intake of meals.

The nurse is assessing a darkly pigmented child for cyanosis. Which finding indicates cyanosis?

 A Blue tinge in the nail beds.

 B Ashen grey tone to lips.

 C Ashy yellow appearance of skin.

 D Reddish purple colored palms.

Which finding, obtained during a skin assessment of a student, should the school nurse report to the healthcare provider?

 A Multiple maculopapular pustules over forehead and chin on an adolescent student.

 B Red, swollen, painful nodule located on the upper back of a school aged student.

 C Small, white flecks on the hair shafts throughout scalp on a school aged child.

 D Bilateral patellar abrasions with eschar formation on a preschool aged student.

The nurse is conducting a functional assessment on an older adult client who is reporting decreased activity due to reduced energy and strength. Which action should the nurse perform during the functional assessment?

 A Question the client about the frequency of falls in recent months.

 B Request to have the client lie as still as possible for the assessment.

 C Assist the client with clarifying values about end-of-life care options.

 D Ask the client how often episodes of sundowning are experienced.

A parent brings a preschool aged client to the clinic because of having diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to the parent when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?

 A Explain to the child the reasons an examination is needed.

 B Talk to the parent and gradually focus on the child's toy.

 C Complete the assessment while allowing the child to cry.

 D Request extra staff to help with the nursing assessments.

While counting the respirations of an adult client who is bedfast, the nurse observes that the client uses the sternocleidomastoid, trapezius, and abdominal muscles during respirations. Which action should the nurse take in response to this finding?

 A Document the client's asymmetrical thoracic movement during inspiration.

 B Assist the client to a position that helps the client breathe more easily.

 C Provide the client an incentive spirometer to increase respiratory effort.

 D Encourage the client to continue to breathe deeply to expand the lungs.

The nurse plans to conduct a physical assessment of a toddler. Which protocol is best for the nurse to implement?

 A Ensure that the room is warm and undress the child completely.

 B Have the parent remove the child's outer clothing and remove the diaper or training pants when necessary.

 C Help the child take off his/her clothes, removing underwear only to conduct examination of the genitalia.

 D Prior to helping the child remove his/her clothing, use a paper doll to demonstrate removal of clothing.

Which assessment finding of an older adult client should the nurse associate with normal aging?

 A Kyphosis.

 B Barrel chest.

 C Lordosis.

 D Pectus excavatum.

 A 20-year-old nulliparous female college student sees the nurse because she has missed her last two menstrual periods. She reports she has not had sexual intercourse in one month. The nurse requests a pregnancy test, which is negative. Based on this client's history, which assessment is most important for the nurse to obtain?

 A Vaginal discharge, presence of genital warts, abdominal tenderness.

 B Urinary frequency, unsteady gait, dental enamel erosion.

 C Breast tenderness, tremors, high blood pressure.

 D Body weight, hirsutism, thyroid enlargement.

A client is complaining of severe pain after being medicated one hour ago with hydrocodone with acetaminophen one tablet orally. Which intervention should the nurse implement next?

 A Tell the client the medication needs more time to work.

 B Reassess the client and the level of pain.

 C Ask the unlicensed assistive personnel (UAP) to offer a backrub to the client.

 D Encourage the client to focus on taking deep breaths.

Parents bring their 8-month-old child to the clinic because they are concerned that the child is not developing as an older sibling did. Which developmental characteristic should the nurse expect an 8-month-old to exhibit?

 A Takes a first step alone.

 B Sits alone unsupported.

 C Can feed self finger food.

 D Pulls self to sitting position.

An older adult client comes to the healthcare provider's office for a routine follow up exam for high blood pressure, osteoarthritis, constipation, and chronic sinusitis. The client recently had a cataract removed from the left eye. Which is most important for the nurse to address when obtaining this client's health history?

 A Conduct an assessment of functional capacity and environmental hazards.

 B Distinguish between symptoms caused by disease and those due to aging.

 C Obtain a medication history including prescription and non-prescription drugs.

 D Emphasize the need to place advance directives in the medical record.

Using the Ballard Gestational Age Assessment Tool, the nurse determines that a 15-minute old client has a gestational age of 42 weeks. Based on this finding, which intervention is most important for the nurse to implement?

 A Apply a pulse oximeter to the foot

 B Draw arterial blood gases.

 C Obtain a capillary blood glucose.

 D Provide blow by oxygen.

The nurse auscultates a client's breath sounds as seen in the picture. Which type of normal sounds should the nurse hear over these lung fields?

 A Crackles.

 B Vesicular.

 C Bronchial.

 D Wheezes.

The nurse is teaching an older adult client newly diagnosed with type 2 diabetes mellitus about symptoms and treatment of hypoglycemia. Which action should the nurse implement while teaching the client?

 A Stand behind the client to avoid intimidation.

 B Turn on overhead lights while giving instructions.

 C Provide handouts written at a 12th grade reading level.

 D Use background music to promote relaxation.

A client grimaces while preforming range of motion of the left knee during an annual health assessment. Which movements should the nurse utilize to assess the client's ability to normally perform range of motion on the right knee?

 A Adduction, abduction and rotation.

 B Extension, flexion, and hyperextension.

 C Internal and external rotation.

 D Pronation and supination.

During a 2-year-old well-child visit, a toddler's parent tells the nurse that this son, who is the youngest of five, rarely talks spontaneously. Which intervention should the nurse implement?

 A Suggest that the parent read aloud to the child at bedtime.

 B Discuss with the parent the need for a hearing screening.

 C Recommend that the parent enroll the child in preschool.

 D Encourage parent to tell the child to ask for what he wants.

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

 A Cries vigorously when stimulated.

 B Heart rate of 220 beats/minute.

 C A positive Babinski reflex.

 D Flexion of all four extremities.

A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?

 A Mother's use of alcohol, drugs, or cigarettes during pregnancy.

 B List of achievement timeline for developmental milestones.

 C A history of rubella, rubeola, or chicken pox.

 D Reactions to any previous hospitalizations.

In assessing an older adult client, the nurse notes that the client's right arm muscles feel soft and boggy. To gather additional data related to this finding, which assessment should the nurse complete next?

 A Determine degree of skin elasticity.

 B Measure muscle size and strength.

 C Inspect appearance of the spine.

 D Note 24-hour fluid intake and output.

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

 A Dimpled area above anus.

 B Flap of tissue at sphincter.

 C Hypotonic tone of the anal sphincter.

 D Increased pigmentation and coarse skin.

Which subjective assessment data supports the nurse's conclusion that a client is experiencing orthopnea?

 A "I cough a lot at night and it keeps me up half the night."

 B "I sleep on three pillows at night."

 C " have multiple attacks of wheezing almost daily."

 D "It doesn't take much activity before I'm out of breath."

During a routine physical examination of a client, chest palpation is determined to be normal except for a 2 inch (5.1 cm) diameter area of crepitus over the upper right anterior chest. Which interpretation is the most accurate for this finding?

 A Trapped subcutaneous air causing crepitus will be absorbed, so the finding is not significant.

 B Since this client has only a small area of crepitus, it probably is not a significant finding.

 C Crepitus is always abnormal and should be followed-up with a more detailed assessment.

 D Since a fractured rib often creates crepitus, a chest x-ray should be scheduled immediately.

An older adult client who reports pain in the arms and back is brought to the emergency department (ED) by an adult child who states the client "fell out of a chair." The nurse notes that the client has been in the ED five times in the last year for a variety of superficial injuries. Which nursing action has the highest priority?

 A Request social services to make a home visit.

 B Interview the client privately without the adult child present.

 C Complete a neurological and musculoskeletal assessment.

 D Ask the client if an assisted living facility is an option for safety concerns.

The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?

 A Offer the child bubbles before the stethoscope is placed.

 B Allow the child to use a stethoscope on a stuffed animal.

 C Place a toy in the child's hands while listening to the breath sounds.

 D Have the child blow a cotton ball and have the parent catch it.

During a routine health screening of an adult client, the nurse notes several changes that have occurred over the past year. Which change indicates the need for a bone density screening?

 A Diminished appetite.

 B Lower body mass index (BMI).

 C Decreased height.

 D 15-pound weight loss.

In assessing a primigravida woman at 15 weeks gestation by dates, the nurse palpates the fundus at the umbilicus. Based on this assessment finding, it is most important for the nurse to obtain information about the occurrence of which condition?

 A Urinary frequency.

 B Lightening.

 C Fetal movement.

 D Braxton-Hicks contraction

The nurse completes percussion of the abdomen on an adult client. Which finding is considered normal?

 A Absolute dullness.

 B Absent sounds.

 C Pain.

 D Musical and drum like.

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

 A Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly.

 B Looking at the client from the side, observe the size and shape of the chest wall.

 C Place the palm of the hand on the chest wall to feel vibrations while the client speaks.

 D Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation.

A client who is 32 weeks gestation arrives at the clinic reporting nausea and vomiting for the past 24 hours. The nurse reviews the record and observes there has been a rapid weight gain over six weeks. Which action should the nurse implement next?

 A Inspect for pedal edema.

 B Obtain a blood pressure.

 C Listen to fetal heart rate.

 D Ask for a 24-hour diet recall.

The nurse is admitting an older adult client with possible malnutrition. Which parameters are most indicative of the client's nutritional status?

 A Triceps skin fold and mid-arm circumference.

 B Twenty-four-hour food recall, preferences, and allergies.

 C Weight loss history and body surface area (BSA)

 D Body mass index (BMI) and serum albumin level.

The nurse completes palpation of the thoracic region on an adolescent client. Which finding is considered normal for this adolescent client?

 A Bulges.

 B Nontender.

 C Tenderness.

 D Thrill.

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

 A Takes an oral anticoagulant.

 B Works in a day care center.

 C Adheres to a gluten free diet.

 D Recently had dental surgery.

While assessing the skin on an older adult client, the nurse notices hyperpigmented freckles on the client's hands and arms. Which additional nursing assessments are indicated?

 A Assess subconjunctival color for pallor

 B Review serum creatinine results.

 C No additional assessment needed.

 D Obtain every 2-hour blood pressure readings.

The nurse is assessing a client who is having pain of the right upper abdominal area. To assess the quality of the client's abdominal pain, which approach should the nurse use?

 A Ask the client to describe the pain.

 B Observe body language and movement.

 C Identify effective pain relief measures.

 D Provide a numeric pain scale.

An older client presents to the emergency department 3 days after a minor motor vehicle collision (MVC) with an airbag deployment. The client reports a new onset of confusion and nausea. Which assessment warrants immediate intervention by the nurse?Reference Range: Glucose [Reference Range: 0 to 50 years: less than 140 mg/dL or less than 7.8 mmol/L)

 A Description of head pain.

 B Concentrated urine output.

 C Bruising on both arms.

 D Blood glucose is 160 mg/dL (8.88 mmol/L).

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 Obtain a dietary consultation for nutrition teaching.

 B Instruct the client in the need to use iodized salt.

 C Request diagnostic laboratory testing for the client.

 D Schedule a follow-up appointment in one month.

Gestational Ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting the ultrasound is to obtain which information?

 A Fetal growth and gestational age.

 B Lecithin-sphingomyelin ratio.

 C Chromosomal abnormalities.

 D Sex and size of the infant.

The nurse prepares to begin a systematic assessment of a client's heart sounds. Upon positioning the stethoscope as seen in the picture, which should the nurse do first?

 A Listen for abnormal sounds.

 B Identify S1 and S2 heart sounds.

 C Move the stethoscope to the apical site.

 D Change to the bell of the stethoscope.

When-obtaining an adolescent's health history, which intervention is most important of the nurse to implement?

 A Assess for the use of illicit drugs.

 B Obtain a smoking history first.

 C Evaluate vital signs and laboratory findings.

 D Ask the parents to leave the room.

Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?

 A Inspection.

 B Auscultation.

 C Palpation.

 D Percussion.

During the admission assessment of an older adult female, the nurse notes the presence of kyphosis. The client tells the nurse that she has a history of osteoporosis. To obtain additional information related to this finding, the nurse should question the client about what additional information in her history?

 A Decreased height.

 B Loss of appetite.

 C Weight gain.

 D Painful swallowing.

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While assisting a client to ambulate who has left hemiplegia due to a stroke, the nurse notices that the client is having difficulty walking in a straight line. Based on this assessment finding, it is most important to include which intervention in this client's plan of care?

 A Teach the client to rotate the meal plate to visualize all the food on the plate.

 B Instruct the client to lift the left extremities with the right hand when transferring.

 C Implement precautions when the client is judging distances during transfers.

 D Encourage the client to touch, wash, look at, and dress the affected side first.

The nurse hears crackles when auscultating a client's lung sounds. Which is an accurate description of the sound of crackles?

 A A bubbling sound heard during inspiration and expiration in the central airways.

 B A crowing noise heard during inspiration over the trachea.

 C Popping, nonmusical sounds heard in the lung bases, usually during inspiration.

 D Superficial squeaking or grating sounds heard during inspiration and expiration.

Which method is best for the nurse to use in determining early development of ascites?

 A Inspection of the abdomen for enlargement,

 B Palpation of an abdominal fluid wave.

 C Bimanual palpation for liver enlargement.

 D Successive measurements of abdominal girth.

In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

 A Determine the client's most recent hemoglobin level.

 B Document the presence of nailbed clubbing.

 C Administer a PRN prescription for oxygen.

 D Consult with a podiatrist to trim the client's toenails.

While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

 A Deep, continuous pain in the calf muscles.

 B Painful symptoms alleviated by warmth.

 C Cool, pale skin below the knees.

 D Decreased pain when legs are elevated.

 A client reports episodes of syncope. Which assessment finding should the nurse anticipate?

 A Decreased BP during orthostatic blood pressure measurement.

 B Grade 3 systolic murmur auscultated at the pulmonic site.

 C 3+ carotid pulse volume bilaterally.

 D Positive jugular vein distention (JVD) bilaterally.

Six days following a minor vehicle crash, an older client returns to the emergency department to have stitches removed. While the nurse is removing the stitches, the client reports feeling bloated and not having a bowel movement since the accident. Which intervention should the nurse implement first?

 A Increase fiber in diet and add daily prune juice.

 B Perform a digital examination for fecal impaction.

 C Assess type and frequency of physical activities.

 D Check bowel sounds and abdominal tenderness.

In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. Which should the nurse do next?

 A Observe for eye opening to a painful stimulus.

 B Ask the client to open his eyes.

 C Notify the healthcare provider.

 D Check the pupillary response to light.

The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

 A Demonstrates startle reflex.

 B Has doubled birth weight.

 C Turns head to locate sound.

 D Plays "peek a boo."

While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

 A The gallbladder is normal.

 B Deeper palpation technique is needed.

 C The client is too obese.

 D Palpating in the wrong abdominal quadrant.

To compare arterial circulation in a client's lower extremities, which assessment should the nurse complete?

 A Compress the tissue around the ankles.

 B Observe plantar flexion and dorsiflexion.

 C Palpate the volume of the pedal pulses.

 D Stroke the soles and note toe movement.

An older Native-American client with hypertension presents to an outpatient clinic for follow-up evaluation after initiation of treatment with oral antihypertensive medications. Report of which client behavior requires additional assessment by the nurse?

 A Eats less salt-cured meats.

 B Participates in healing rituals.

 C Uses herbal remedies.

 D Meditates in sweat lodges

When assessing a client's skin, which finding should the nurse report to the healthcare provider?

 A Multiple yellow lesions with a grainy surface.

 B Large, flat, dark red irregular area on the neck.

 C Bluish discoloration of the nail beds.

 D Multiple silver striae on the abdomen

During an admission assessment, the nurse observes the presence of kyphosis on an older adult female client with a history of osteoporosis. Which action should the nurse take in response to this finding?

 A Notify the healthcare provider.

 B Observe muscle fasciculations.

 C Document the assessment finding.

 D Palpate the area for an effusion.

During a health assessment, the client reports being treated for osteoarthritis. The nurse examines the client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record?

 A Distal interphalangeal joint nodules that deviate.

 B Proximal intertarsal joint swelling of big toe.

 C Frozen, non-movable phalangeal joints.

 D Non-painful enlarged interphalangeal joints.

An older adult client who has been talking to the client's deceased mother is referred to the psychiatric clinic for an evaluation. Which assessment should the nurse complete first?

 A Assess daily alcohol intake.

 B Identify signs of depression.

 C Determine cognitive status.

 D Review risk factors for abuse.

*****

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.

History and Physical Nurses' Notes

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

History and Physical Nurses' Notes

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.

Nurse analyzes the findings.

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

 Reach under a gown to listen and take care that no clothing rubs on the stethoscope

 Ensure the room is as quiet as possible

 Keep the examination room warm, and warm the stethoscope

 Document the roaring and crackles

  Wet the chest hair before auscultating

The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which question should the nurse ask first? "Have you

  A “ever had problems with your blood sugar?"

  B “been sleeping well?

  C “ had anything to eat in the last 24 hours?

  D “been depressed lately?

The 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)?

  A Appears confused and depressed.

  B Demonstrates signs of early dementia.

  C Ambulatory and disoriented to place.

  D Wandering behavior with flat affect.

The nurse is examining the abdomen of an older male client who expresses suprapubic tenderness on palpation. The client states that it sometimes feels like there is still pressure in that area after urination. Which additional finding should the nurse expect with continued interview of the client?

  A Black tarry stools.

  B A cloudy discharge.

  C An overactive bladder

  D A weak urinary stream.

A client is seen in the emergent care clinic for right wrist pain with a pattern of ecchymosis observed on the wrist. Which motion should the nurse instruct the client to perform to assess the wrist mobility?

  A Hyperextension and palmar flexion.

  B Plantar flexion.

  C Forearm pronation.

  D Forearm supination.

While making a home visit, the spouse of an older client tells the nurse the client is becoming increasingly confused about past events and has started forgetting to all pain dictation for osteoarthritis in the knees. Which assessment should the nurse initially perform to evaluate the client's memory?

  A Ask the client to recall what was consumed for lunch and breakfast

  B Ask the spouse how often the pain medication is to be taken

  C Request for the spouse to write down the things the client forgets

  D Observe client ability to perform activities of daily living (ADLs)

A client reports experiencing stomach pain and it is localized in the middle section of the abdomen below the xiphoid process. The nurse should describe the pain as occurring in which region of the abdomen?

  A Epigastric region.

  B Hypogastric region.

  C Hypochondriac region.

  D Umbilical region.

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

  A Hyperactive bowel sounds.

  B A minor variation.

  C Normal borborygmic sounds.

  D Possible renal artery stenosis.

During assessment of a client's abdomen, the nurse observes that the client's umbilicus is depressed and below the surface of the abdomen. What action should the nurse take in response to this observation?

  A Ask about recent abdominal trauma.

  B Palpate the area for masses.

  C Document the normal finding.

  D Observe the midline for scarring.

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?

  A History of a fractured patella.

  B Knee arthroplasty surgery.

  C Degenerative disease.

  D Needle aspiration of the synovial space.

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

  A Send the sample for laboratory evaluation.

  B Give the client 8 ounces (236.5 mL) of water to drink.

  C Evaluate the client for bladder distention.

  D Instruct the client to attempt to urinate again.

When performing a neurologic assessment on an alert client, the nurse observes that the client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?

  A Pupils equal, round, reacts to light, and accommodation (PERLA).

  B Glasgow Coma Scale (GCS) of 15.

  C Pupils equal, round, reacts to light (PERRL).

  D Neurological status intact.

An older male client reports to the nurse that his feet are cold. Before covering the client's feet, which assessment(s) should the nurse complete? Select all that apply.

 Test feet for a positive Babinski reflex.

 Observe color of the feet and toes.

 Measure skin elasticity around the ankles.

 Assess volume of the pedal pulses.

  Palpate dorsal surface of feet for warmth.

The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client's use of illegal drugs and alcohol?

  A Allow the client to decline answering social questions.

  B Obtain a drug urine screen to verify legitimacy of client's stated history.

  C Use the term illegal or illicit to describe street drugs.

  D Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts.

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

  A Report the client's abnormal lung sounds to the healthcare provider.

  B Continue with the remainder of the client's physical assessment.

  C Ask the client to cough and then auscultate at the site again.

  D Measure the client's oxygen saturation with a pulse oximeter.

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?

  A Coronary heart disease.

  B Iron deficiency anemia.

  C Diabetes mellitus.

  D Recent candida Infection.

The nurse continues a neurologic assessment of the cranial nerve XI (Spinal accessory) for a client. Which instruction should the nurse give the client to complete this assessment?

  A Shrug shoulders against resistance.

  B Stand up slowly with eyes closed.

  C Turn head from side to side.

  D Raise both arms overhead

To assess a male client's muscle strength, the nurse first asks the client to extend his arms. Before asking the client to flex his arms, what should the nurse do? IDK ITS C OR D

  A Give the client an object to hold.

  B Instruct the client to close his eyes.

  C Apply resistance to the client's arms.

  D Palpate the client's muscle tone.

Patient DataThe client presents to the clinic with concerns regarding the multiple raised areas noted after a camping trip over the weekend.

Red, irregularly shaped, raised areas varying in size are noted over bilateral forearms and axillary regions. The client is rubbing the areas and Informs they itch a lot.

Vital signs Temperature 98.6° F (37° C) orally

Heart rate 88 beats/minute

Respiratory rate 22 breaths/minute

Blood pressure 128/72 mm Hg

During the assessment, the nurse notes that the areas are filled with a fluid-like substance.

Which of the following primary skin lesions contain fluid? Select all that apply.

 Macule

 Papule

 Wheal

 Vesicle

  Nodule

  Pustule

Patient Data

History and Physical Nurses' Notes

The client is a 58-year-old male with history of hypertension, respiratory infections, and long term smoking.

Assessment is completed. The nurse notes that the nail angle is 180 degrees when viewed from the side and is spongy when palpated.

The nurse reviews client data.

Select the 3 possible conditions that could have the symptom of clubbed nails for this client.

 Pneumonia

 Flu

 Chronic obstructive pulmonary disease (COPD)

 Lung cancer

  Chronic bronchitis

Hesi RN Health Assessment ( 52 Questions)

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An adult client presents with gnawing epigastric pain. The pain is worse when the client is hungry and abates after eating something. Which problem do these symptoms suggest?

 A Esophagitis.

 B Peptic ulcer disease (PUD).

 C Gastroesophageal reflux (GERD).

 D Chronic pancreatitis.

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?

 A Use a doppler ultrasonic stethoscope.

 B Notify the healthcare provider.

 C Apply warm blankets to both feet.

 D Palpate pulse points with legs dependent.

When evaluating a client's rectal bleeding, which findings should the nurse document?

 A Number of blood clots expelled with each stool.

 B Evidence of internal hemorrhoids.

 C Unique odor noted with gastrointestinal bleeding.

 D Color characteristics of each stool.

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 Encourage fluid intake.

 B Measure urine output.

 C Splint the affected joint.

 D Increase intake of red meat.

The nurse completes palpation of the thoracic region on an adult client. Which finding is considered normal for this client?

 A Tenderness.

 B Crepitus.

 C Thrill.

 D Non-tender.

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

 A Give the client 8 ounces (236.5 mL) of water to drink.

 B Evaluate the client for bladder distention.

 C Instruct the client to attempt to urinate again.

 D Send the sample for laboratory evaluation.

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

 A Dimpled area above anus.

 B Flap of tissue at sphincter.

 C Increased pigmentation and coarse skin.

 D Hypotonic tone of the anal sphincter.

To assess a client's pupillary reaction to accommodation, which action should the nurse take?

 A Compare the shape of each of the pupils bilaterally with normal room light.

 B Determine if dilation of the pupils occurs when the room is darkened.

 C Note the speed of pupil constriction when a penlight is shined into the eye.

 D Observe pupil size when focusing on a near object and then a far object.

The nurse is calculating the one-minute Apgar score for a newborn infant and determines that the heart rate is 150 beats/minute, a vigorous cry is present, muscle tone is good with total flexion, quick reflex irritability noted, and skin color is dusky and cyanotic.

Which Apgar score should the nurse assign to this infant? 9

The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

 A Auscultate the lymph node for the presence of a bruit.

 B Ask the client about any localized tenderness at the site.

 C Cover the inflamed area and notify the healthcare provider.

 D Record this normal finding in the assessment record.

The school nurse is interviewing an adolescent who wants to go home from school because of "back pain." Which question should the nurse ask first?

 A "What were you doing when you first noticed the problem?"

 B "Have you taken any medications to relieve the pain?"

 C "Do you remember ever having this type of pain in the past?"

 D "Does changing your position make the pain worse?

While the nurse is obtaining a health history, the client reports experiencing shortness of breath at times. The nurse determines that the client's respirations are regular and deep and respiratory rate is 14 breaths/minute. Which is the best nursing action?

 A Explain to the client the possible causes of dyspnea or "shortness of breath."

 B Ask the client to describe the episodes of dyspnea in more detail.

 C Document "dyspnea on exertion" in the client's medical record.

 D Ask the client to perform light exercise and observe the respiratory effort.

While the nurse is taking a health history, the client announces, "I don't have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide?

 A "I am sorry you feel that way. Perhaps you'd like to return when you have more time."

 B "You sound angry. Would you like to tell me about it?"

 C Ignore the angry outburst and continue with the history questions.

 D Move closer and place a hand on the client's shoulder to demonstrate concern.

A clinic nurse is assessing infants and toddlers for fine and gross motor development. Which child should the nurse refer to a healthcare provider for further evaluation?

 A 3-year-old preferring to walk on the tip toes.

 B 1.5-year-old attempting to scribble on paper.

 C 5-month-old with use of whole hand grasp.

 D 3.5-month-old with diminished Moro reflex.

On the first postpartum day, the nurse examines the breasts of a new mother. Which condition is the nurse most likely to find?

 A Firm, larger, and very tender to touch.

 B Soft, with no change from before delivery.

 C Filling and secreting colostrum.

 D Slightly firm with immediate let-down response.

A nurse is interacting with a client who is a victim of intimate partner violence (IPV). The client reports feeling unable to leave the relationship because of the children. The nurse responds by saying, "I know this must be very difficult for you." Which type of therapeutic communication is the nurse providing?

 A Open-ended question.

 B Clarification.

 C Empathizing.

 D Paraphrasing.