HESI HEALTH ASSESSMENT TEST BANK 100% CORRECT GRADED A+

The nurse is caring for a patient with chronic lower back pain. The nurse knows that the most reliable indicator of pain in this client is: The patient is reporting "6/10" pain. The patient is refusing to get out of bed. The patient is refusing to eat breakfast. The patient's heart rate is 90 beats per minute. A Which of the following actions should the nurse take to ensure an accurate blood pressure (BP) reading? Ensure the width of the BP cuff is equal to 80% of the arm circumference. Ensure the client's back is supported and feet are flat on the ground. Take two BP readings 20 seconds apart. Ensure that the patient's arm is above heart level. B The patient's arm should be supported at heart level. Separate BP readings may need to be taken, but not one right after the other. The length of the BP bladder should equal 80% of the arm circumferen The nurse obtains which piece of data during the general survey? Client is alert and calm. Client's heart rate is 80 beats per minute. Client's body mass index (BMI) is 30. Client's lung sounds are "clear" to auscultation. A A man is at the clinic for a complete physical exam. He states that he is "very anxious". What steps can the nurse take to make him more comfortable? Appear confident and unhurried during the exam. Measure vital signs at the end to allow the patient sufficient time to relax. Let him leave his clothes on during the examination. Obtain another nurse to examine the patient. A A father brings his 13 month-old child in for "fever" and he reports that the child has been "pulling on his left ear". Upon entering the exam room, the child is asleep in the father's arms. The nurse should perform which assessment first? Use the otoscope to look inside the ear. Use a penlight to check the eyes and nose. Auscultate the lungs, heart, and abdomen. Assess gross motor skills using the Denver II screening tool. C An 18 year-old presents to the emergency department with "headache." Which of these assessment findings alerts the nurse to recent opioid use? Pupillary constriction Hallucinations. Fever. Tachypnea. A- constricted pupils are a sign of recent opioid use, the rest are withdrawals While collecting the pulse on a 26 year-old client, the nurse notes that the heart rate seems to speed up and then slow down in accordance with respirations. The pulse is counted at 80 beats per minute. What should the nurse do next? Obtain orthostatic vital signs. Notify the physician. Document "sinus arrhythmia." Use a doppler to confirm the finding. C An elderly client with pneumonia is being treated in the intensive care unit (ICU). He is acutely agitated, restless, and disoriented. The nurse documents his level of consciousness as: Manic. Demented. Drowsy. Delirious. D The nurse is assessing a newborn infant. How should the nurse measure the heart rate (HR)? Palpate the radial pulse for 15 seconds and multiply by four. Palpate the brachial pulse for 30 seconds and multiply by two. Auscultate the apical site for 60 seconds. Apply a pulse oximeter to obtain both the HR and SpO2. C A 28 year-old is brought to the emergency department. He is disoriented and hallucinating, and vital signs are elevated. The nurse suspects that the patient is experiencing withdrawal