Fundamentals of Nursing Health and Physical Assessment HESI Quiz

Fundamentals of Nursing Health and Physical Assessment HESI Quiz The nurse recognizes that which is the mental process most sensitive to deterioration with aging? 1 Judgment 2 Intelligence 3 Creative thinking Correct 4 Short-term memory During the aging process there is a progressive atrophy of the convolutions of the brain with a decrease in its blood supply, which may produce a tendency to become forgetful, a reduction in short-term memory, and susceptibility to personality changes. There should be little or no change in judgment. There is little or no intellectual deterioration; intelligence scores show no decline. Creativity is not affected by aging; many people remain creative until very late in life. The nurse is assessing a client after surgery. Which assessment finding does the nurse obtain from the primary source? 1 X-ray reports Correct 2 Severity of pain 3 Results of blood work 4 Family caregiver interview The primary source of information during an assessment is the client. The nurse gathers information about the client’s pain from the primary source, the client. Medical records such as x-ray reports and results of blood work are secondary sources of information. The client’s family caregiver is a secondary source of information. When should the nurse consider family members as the primary source of information? Select all that apply. 1 The client is an elderly adult. Correct 2 The client is an infant or child. Correct 3 The client is brought in as an emergency. Correct 4 The client is critically ill and disoriented. 5 The client visits the outpatient department. The nurse interviews the parents who care for the infant or child. Thus, the parents become the primary source of information. A client who is brought to the emergency department may not be in a position to explain the circumstances that led to the visit. In this case, the family or significant others who accompany the client become the primary source of information. The family becomes the primary source of information when the client is critically ill, disoriented, and unable to answer questions. Generally, the client is the primary source of information. The elderly adult who is conscious, alert, and able to answer the Fundamentals of Nursing Health and Physical Assessment HESI Quiz nurse’s questions is the primary source of information. The client who visits the outpatient department is capable of providing accurate answers to the nurse’s questions. This client is the primary source of information during assessment. What is the correct order of steps of the nursing diagnostic process? Correct 1. Assess the client’s health status. Incorrect 2. Interpret the meaning of the data. Incorrect 3. Cluster data. Incorrect 4. Look for defining characteristics. Incorrect 5. Identify the client’s needs. Incorrect 6. Formulate nursing diagnoses. Incorrect 7. Validate the data with other sources. The diagnostic reasoning process involves the use of assessment data for the client. The assessment data is obtained from the client, family, and health care resources. The nurse validates and ensures the data is accurate and uses critical thinking to interpret and analyze the data before it is classified and organized into data clusters. This organization helps the nurse identify the client’s health needs. The nurse then formulates the nursing diagnoses using standard formal nursing diagnostic statements. The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data? 1 The client weighs 151 lbs (68.5 Kg). Correct 2 The client’s pain is 7 on a scale of 1 to 10. 3 The client’s fasting blood sugar is 95 mg/dL. 4 The client’s blood pressure is 140/90 mm/Hg. Subjective data is information conveyed to the nurse by the client, such as the client’s feelings, perceptions, and self-reporting of symptoms. The client rates pain as a 7 on a scale of 1 to 10, therefore it is subjective data. Objective data are observations or measurements of a client’s health status. The client’s weight is measured on a weighing scale; therefore, it is objective data. A laboratory result such as fasting blood sugar and blood pressure are measurable quantities. A client with a recent history of head trauma is at risk for orthostatic hypotension. Which assessment findings observed by the nurse would relate to this diagnosis? Select all that apply. Correct 1 Fainting Fundamentals of Nursing Health and Physical Assessment HESI Quiz 2 Headache Correct 3 Weakness Correct 4 Lightheadedness 5 Shortness of breath Head trauma may cause blood loss and clients with recent blood loss are at risk for orthostatic hypotension. Symptoms of hypotension include fainting, lightheadedness, and weakness. Headaches and shortness of breath are symptoms of hypertension.