HESI HEALTH ASSESSMENT TEST BANK | EXAM QUESTIONS AND ANSWERS 100% VERIFIED ()

When assessing a 68 year-old patient presenting with "left leg pain", the nurse notes that the left femoral pulse is weak. What should the nurse do next? Document the finding as normal in older adults. Auscultate the site to identify partial occlusion. Ask the client to stand and palpate again. Palpate for enlarged lymph nodes in the area. B The nurse is assessing a client with suspected peripheral arterial disease (PAD). Which assessment finding supports this hypothesis? The circumference of the left leg is 1cm larger than the right leg. The blood pressure at the ankle is significantly lower than in the arm. 3+ pedal pulses. The client has dependent edema. B An elderly patient has just been admitted to the intensive care unit (ICU) with acute decompensated heart failure. Based on this diagnosis, what does the nurse expect to assess in this client? Select All That Apply. Unilateral edema in the legs. Flat neck veins. S3 gallop. Cool, clammy skin. SpO2 96-99 on Room Air%. Bradypnea. Crackles upon auscultation of lung fields. CDFG- Manifestations of ADHF are a result of fluid volume overload and decreased cardiac output. The pt will be hypoxic and dyspneic due to pulmonary edema (crackles in lungs), and therefore the patient will be tachpyneic. blood pressure will be low and a pulse deficit will be present due to low stroke volume. The skin will be cool and clammy The nurse is examining a client with systolic dysfunction. Using the bell, the nurse hears an extra early diastolic sound at the apex of the heart. The nurse interprets this sound as: Split S1. S3 gallop. Split S2. S4 gallop. B B. Denial The spouse is exhibiting the first stage of denial (B) of Kubler-Ross's grief model by ignoring that the client's death is imminent (A, C, and D) are stages of grief that are not being displayed by the client's spouse during this observation. The registered nurse (RN) notifies the spouse of a client who was admitted to hospice with shallow respirations, of a change in the client's condition. Over the past hour, the client's respiratory pattern has changed to a Cheyne Stokes pattern. After receiving this information, the client's spouse begins vacuuming around the bed. Which stage of grief is the spouse displaying during the visit? A. Acceptance B. Denial C. Bargaining D. Depression A. Cold applications produce a topical anesthetic effect to reduce pain as well as constrict blood vessels to minimize bruising (A). Local ice over an injured area will not lower the core temperature (B). The cold pack causes vasoconstriction which reduces circulation, not (C), to traumatized tissue and limits further edema around the injury (D), but not by reabsorption of edematous fluid. The registered nurse (RN) places an ice pack on a middle school student who comes to the school clinic complaining of a sprained ankle. Which therapeutic response should the RN anticipate? A. Reduced pain and minimized bruising. B. Lowering of body core temperature. C. Increased circulation around injury. D. Reabsorption of edema at injury. A. Diminished hair on legs C. Skin cool to touch. Diminished hair on the legs (A) and skin that is cool to the touch (C) are symptoms of decreased arterial blood flow. (B, D, and E) are not indicators for impaired circulation. The registered nurse (RN) palpates a weak pedal pulse on the client'rs right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation (Select all that apply.) A. Diminished hair on legs. B. Bruising on extremities. C. Skin cool to touch. D. Capillary refill less than 3 seconds. E. Darkened skin on extremities. C. Lethargy Changes in the level of consciousness occur in the early stages of shock which decreases the perfusion to the brain which is manifested as lethargy (C). The respiratory rate increases, not (D). (A and B) are late signs of hypovolemic shock due to cardiac compensatory measures. Twenty four hours after a client returns from surgical gastric bypass, the registered nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister. Which assessment finding should the RN report as early signs of hypovolemic shock? A. Faint pedal pulses B. Decrease in blood pressure. C. Lethargy. D. Slow breathing. D. Rise slowly when getting out of bed or chair. The client's new medication is an angiotensin-converting enzyme (ACE) inhibitor, which has the side effect of orthostatic hypotension. Instructing the client to rise from a chair or bed slowly (D) is indicated to avoid dizziness and falling. (A, B, and C) are not indicated when taking an ACE inhibitor. The registered nurse (RN) is caring for a client who has taken atenolol for 2 years. The healthcare provider recently changed the medication to enalapril to manage the client's blood pressure. Which instruction should the RN provide the client regarding the new medication? A. Take the medication at bedtime. B. Report presence of increased bruising. C. Check pulse before taking medication. D. Rise slowly when getting out of bed or chair. A. Prepare the client for a chest x-ray at the bedside. A chest x-ray (A) should be performed immediately after the procedure to ensure lung expansion has been maintained after removal of the chest tube. (B) provides additional data after removal of the CT. (C) may assist the client to breathe easily, but the priority after chest tube removal is to ensure that the procedure was successful. The entire system, including the chest tube is discarded and not taken apart (D). The registered nurse (RN) is assisting the healthcare provider (HCP) with the removal of a chest tube. Which intervention has the highest priority and should be anticipated by the RN after removal of the chest tube? A. Prepare the client for chest x-ray at the bedside. B. Review arterial blood gases after removal. C. Elevate the head of the bed to 45 degrees. D. Assist with disassembling the drainage system. D. A fracture that bends or splinters part of the bone. An incomplete fracture (D) occurs through part of the thickness of bone. A linear (A) and a spiral fracture (B) describe the direction of the fracture line. An open fracture (C) is a compound fracture that breaks through the skin. A male client is admitted after falling from his bed. The healthcare provider (HCP) tells the family that he has an incomplete fracture of the humerus. The family asks the nurse what this means. Which type of fracture should the RN explain from these findings? A. Straight fracture line that is also a simple, closed fracture. B. Nondisplaced fracture line that wraps around the bone. C. A complete fracture that also punctures the skin. D. A fracture that bends or splinters part of the bone. A. Hematemesis B. Gastric pain on an empty stomach D. Intolerance of spicy foods (A, B and D) correct. Manifestations of PUD include hematemesis (A), gastric pain (B), and spicy food intolerance. (C) is consistent with cholecystitis (D). (E) is not consistent with PUD. The registered nurse (RN) is caring for a client with peptic ulcer disease (PUD). What assessment should the RN identify that is consistent with PUD? (Select all that apply) A. Hematemesis B. Gastric pain on an empty stomach C. Colic-like pain with fatty food ingestion D. Intolerance of spicy foods E. Diarrhea and stearrhea D. A client who has chronic constipation (D) often strains to pass constipated stool which increases intestinal pressure that weakens the intestinal walls and causes out-pouching sacs, called diverticula which commonly occur in the signmoid. Regular use of laxatives (A) can result in the bowel's dependency on the laxative to stimulate intestinal motility, but constipation due to lack of fiver in diet, not (C), is a predisposing factor for formation of diverticula. Growths that protrude into the colon lumen are polyps (B), which are often pre-cancerous lesions. A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statement by the client conveys the client's understanding of the etiology of diverticula? A. Over use of laxatives for bowel regularity result in loss of peristaltic tone. B. Inflammation of the colon mucosa that cause growths that protrude into the lumen. C. Diverticulosis is the result of high fiber diet and sedentary life style. D. Chronic constipation causes weakening of colon wall which result in outpouching sacs. C. In some Asian cultures, it is not appropriate to look a person of authority in the eyes, so the client is being respectful bu looking down while speaking with the nurse (C). (A, B, and D) does not reflect behaviors common to Asian culture. The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response? A. The client cannot understand the nurse. B. The client is uncomfortable with the nurse. C. The client is treating the nurse with respect. D. The client is purposefully disrespecting the nurse. A. A decrease in urine output is a sign of dehydration. When the urine output returns to a normal range, 40 ml/hour (A), the client's kidneys are perfusing adequately and indicates the client's status is stabilizing. A blood pressure of 76/42 (B) and tented skin (D) are consistent with dehydration and possible hypovolemia, however the client's urine output is improving. Specific gravity of 1.001 is indicative of the kidney's ability to concentrate urine adequately. The registered nurse (RN) is caring for a client who developed oliguria and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the RN that the client is stabilizing? A. Urine output of 40 ml/hour B. Apical pulse 100 and blood pressure 76/42. C. Urine specific gravity of 1.001. D. Tented skin on the dorsal surface of the hands. B Orthostatic hypotension (B) can be a sign of fluid volume deficit in an older adult client who has experienced severe diarrhea. (A and C) are signs of excess fluid volume. Cheyne Stocks respirations (D) is an abnormal breathing pattern often seen in a client who is near death. An older client is admitted to the hospital with severe diarrhea. The registered nurse (RN) is completing an assessment and notes the client has dry mucous membranes and poor skin turgor. Which assessment data should the RN gather to determine if the client has fluid volume deficit? A Combination therapy is necessary to decrease the development of resistant strains of TB (A) and ensure treatment effectiveness. (B, C, and D) are not the rationales for multiple drug protocol for TB. The registered nurse (RN) is caring for a client with tuberculosis (TB) who is taking a combination drug regimen. The client complains about taking "so many pills." What information should the RN provide to the client about the prescribed treatment? A. The development of resistant strains of TB are decreased with a combination of drugs. B. Compliance to the medication regimen is challenging but should be maintained. C. Side effects are minimized with the use of a single medication but is less effective. D. The treatment time is decreased from 6 months to 3 months with this standard regimen. A The two hour postprandial level should be less than 140 mg/dl for a young adult client (B). (A, C and D) are elevated and not normal at 2 hours after ingesting the glucose solution. The registered nurse (RN) is caring for a young adult who is having an oral glucose tolerance test (OGTT). which laboratory result should the RN assess as a normal value for the two hour postprandial result? A. 140 mg/dl B. 160 mg/dl C. 180 mg/dl D. 200 mg/dl C Vital signs should be checked every 10 to 20 minutes (C) to assess for bleeding after biopsy of the liver, which is highly vascular. The client should be positioned on the right side, not the left (A), with a pillow or sandbag under the costal margin and supporting the biopsy site. Voiding immediately after the procedure (B) is not the highest priority intervention after a liver biopsy. The client should be maintained on bedrest (D) for several hours to decrease the risk of bleeding from the biopsy site. After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned the care of the client. Which nursing intervention is most important for the RN to implement? A. Position the client on the left side with pillow placed under the costal margin. B. Assist the client with voiding immediately after the procedure. C. Evaluate teh vital signs q10 to 20 minutes for every 2 hours after the procedure. D. Ambulate client 3 times in first hour with pillow held at abdomen. B Closed angle glaucoma C Chronic hypertension (B and C) are correct. OTC decongestants can increase intraocular pressure and should be avoided in clients with closed angle glaucoma (B). Decongestants can increase the heart rate and blood pressure which impact the client's management of chronic hypertension (C). Although the healthcare provider should be informed of all medications taken, (A, D, and E) are not directly affected by a decongestant. While reviewing the client's electronic medical record (EMR), the registered nurse (RN) assesses a client who is at risk for possible interaction with an over- thecounter (OTC) decongestant. Which client health history should the RN report to the healthcare provider concerning the OTC medication? (Select all that apply) A. Type I diabetes mellitus (DM) B. Closed angle glaucoma C. Chronic hypertension D. Rheumatoid arthritis E. Crohn's disease B RLQ rebound abdominal tenderness (B) may be related to acute appendicitis and should be reported to the healthcare provider. (A, C and D) are expected findings associated with gastroenteritis that are not urgent findings or life threatening. The registered nurse (RN) is evaluating a client who presents with symptoms of gastroenteritis. Which assessment finding should the RN report to the healthcare provider? A. Dry mucous membranes and lips. B. Rebound abdominal tenderness over right lower quadrant. C. Dizziness when client ambulates from a sitting position. D. Poor skin turgor over client's risk. A. All alcohol (A) and any foods that contain tyramine should be avoided while taking an MAO inhibitor, which interact to cause a hypertensive crisis. (B and C) should be discussed, but are not as important as (A). Although assessing blood pressure and pulse may be indicated, it is not necessary prior to taking each dose (D). The registered nurse (RN) reviews the new prescription, phelezine, a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is most important for the RN to assess? A. Consumption of any alcohol or tyramine-rich foods. B. Complaints of nausea or vomiting. C. Therapeutic serum drug levels. D. Blood pressure and pulse prior to taking each dose. B When completing an assessment, the RN should maintain eye cotnact with the client (B) to gather additional information from the client's nonverbal cues. (A, C, and D) do not use both verbal and nonverbal communication techniques to gather data during an assessment. Which actions should the registered nurse (RN) implement to complete an assessment for a client using an interpreter? A. Ask close-ended questions with assistance of the interpreter. B. Maintain eye contact with the client while listening to the translation. C. Instruct interpreter to answer questions from the interpreter's point of view. D. Protect the client's privacy by asking a limited number of questions. A A chronic seasonal cough related to bronchitis is likely accompanied with phlegm production and wheezing (A). Although smoking can contribute to chronic cough, the typical seasonal cough is an inflammatory reaction to seasonal changes (B). Hemoptysis (C) or a "new" cough or changes in a persistent chronic cough is likely related to lung cancer (C). Night sweats (D) is a trend in fever that is often seen with tuberculosis. The registered nurse (RN) is interviewing a female client who states she has a persistent cough during the winter caused by bronchitis. Which additional finding should the RN assess for bronchitis? A. Phlegm production and wheezing. B. Smoking history C. Hemoptysis D. Night sweats A, B, C, E (A, B, C, and E) are correct. To ensure compliance, language (A), education (B), lifestyle (C), and financial resources (E) should be considered when preparing the client's discharge instructions about continued treatment of TB. (D) does not directly impact compliance with long term treatment of TB. The registered nurse (RN) is teaching a client who is being discharged after treatment of tuberculosis (TB). Which cultural issues should the RN assess when preparing the client for discharge? (Select all that apply.) a. native language b. education level c. type of lifestyle d. previous medical history e. financial resources A Checking the pH of the aspirate (A) is the best method to validate that the NGT is not displaced and should reveal an acidic pH of 1.5 to 3.5 due to presence of gastric acid. (B, C and D) are not reliable methods to ensure NGT placement in the stomach. The registered nurse (RN) is caring for a client with a newly placed nasogastric tube (NGT). Once the placement of the NG tube is verified by xray, which technique should the RN use as a reliable method to ensure the NGT is not displaced? a. check the pH of aspirated stomach contents obtained from the NGT b. auscultate over the epigastrium while injecting air into the NGT c. disconnect and place the end of NGT in water to see if bubbles appear d. listen for hyperactive bowel sounds in all four quadrants in the abdomen A, C, E (A, C, and E) are correct, and these interventions aid the client in maneuvering through the stages of grieving and establishing a foundation to continue life. Assisting the client in finding the support group and sharing stories of other clients can be miscontrued as a violation of HIPPA rights of other clients (B). Each client deals with grief differently, so offering a time line for grieving (D) is not an expected outcome for this client and offers false reassurance. A client is admitted for dehydration, weight loss, and a flat affect. After reviewing the client's history, the registered nurse (RN) discovers that the client's spouse died 2 weeks ago. Which nursing interventions should the RN implement to help the client begin the process of dealing with loss? a. Establish trust by creating a safe atmosphere for sharing. b. Share personal stories about how other clients dealt with grief. c. Help the client identify ways to adapt lifestyle to accommodate loss. d. Assure the client that their grief will last a short period of time. e. Explore ways to assist the client to make new emotional investments. D A characteristic finding of DI is excretion of large quantities of urine (5 to 20L/day), and most clients compensate for fluid loss by drinking large amounts of water (polydipsia) (D). (A) is indicative of an infection, not DI. (B) can be characteristic of hypovolemia, but not an initial finding of DI. Muscle rigidity (C) can be a serious manifestation of a closed head injury that requires immediate action, but is not related to DI. The registered nurse (RN) is caring for a client who has a closed head injury from a motor vehicle collision. Which finding should the RN assess the client for the risk of diabetes insipidus (DI)? a. high fever b. low blood pressure c. muscle rigidity d. polydipsi a D Pursed lip breathing helps eliminate CO2 (D) by increasing positive pressure within the alveoli which makes it easier to expel air from lungs. (A, B and C) do not explain the reason for using pursed lip breathing. The registered nurse (RN) is teaching a client who is newly diagnosed with emphysema to perform pursed lip breathing. What is the primary reason for teaching the client this method of breathing? a. Decreases respiratory rate b. Increases O2 saturation throughout the body c. Conserves energy while ambulating d. Promotes CO2 elimination D The RN should ask the client if he has a history of ulcerative colitis (D), which is characterized by these presenting symptoms. Irritable bowel (A) often includes irregular bowel movements with constipation. Diverticulitis (B) is related to constipation, bowel irregularity and cramping. Crohn's disease (C) can cause constipation or diarrhea, abscess formation, and abdominal cramping, but tenesmus is rare. The registered nurse (RN) is assessing a male client who arrives at the clinic with severe abdominal cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose stools with rectal bleeding. Which condition should the RN ask the client about his medical history? a. Irritable bowel syndrome b. diverticulitis c. Crohn's disease d. ulcerative colitis C, D (C and D) are correct. Beta 2 receptor agonist agents provide immediate return of airflow and resolve wheezing (C) and improve oxygenation (D). (A and B) are side effects. (E) is not an expected response. The registered nurse (RN) is making early morning rounds on a group of clients when a client begins exhibiting symptoms of an acute asthma attack. The RN administers a PRN prescription for a Beta 2 receptor agonist agent. Which client response should the RN expect? a. tachycardia b. increased blood pressure c. rapid resolution of wheezing d. improved pulse oximetry values