BSN 246 HESI Health Assessment V1

BSN 246 HESI Health Assessment V1 .A client comes to the clinic with a report of fever and a recent exposure to someone who was diagnosed with meningitis. Which nursing assessment should be completed during the initial examination of this client? - ANSWER-Level of consciousness. .A client has been diagnosed with bilateral lower lobe atelectasis. What percussion sound should the nurse expect to hear when percussing over the client's lower lobes? - ANSWER-Dull, thud-like. .A client has come to the clinic for a routine health assessment. What is the best assessment question for the nurse to ask a client after observing tophi on the client's ear cartilage? - ANSWER-Have you had sudden and severe pain in the toes or feet? .A client has just returned from the recovery room and asks to get out of bed to go to the bathroom. The nurse decides to obtain orthostatic vital signs first. How will the nurse position the client to begin this procedure? - ANSWER-Lying. .A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing to complete a head-to-toe assessment and will begin at the head of the client. Which technique should the nurse use to begin the assessment? - ANSWER-Inspect the hair and skin. .A client is in the clinic and is reporting lower abdominal pain and constipation. Which information is of greatest concern to the nurse when obtaining the health history from this client? - ANSWER-Family history of colon cancer on mother's side. .A client is in the clinic for a routine health examination. The nurse notices the client appears underweight. Which question is most important for the nurse to ask when completing the health history of this client? - ANSWER-Have you experienced sudden weight loss? .A client is in the clinical for a yearly physical examination. Which action should the nurse take when preparing to examine the client's abdomen? - ANSWER-Ask the client to urinate before beginning the examination. .A client is reporting chest pain. What statement made by the client, helps the nurse to understand this client has a naturalistic belief in the cause of illness? - ANSWER-"My life is really out of balance." .A client presents with a rash along the occipital area of the hairline and reports intense itching. How should the nurse begin the objective part of the examination? - ANSWER-Inspect the scalp looking for nits. .A client reports feeling increasingly fatigued for several months, and the nurse observes that the client's lips are pale. Which additional data should the nurse collect based on this presentation? - ANSWER-Use of vitamin and iron supplements. .A client reports lower abdominal pain and a feeling of pressure in the bladder. Which assessment finding indicates acute urinary retention? - ANSWER-Dull sound percussed over bladder. *Clients with acute urinary retention may present with lower abdominal pain and bladder distension. Percussion (tapping on the body wall) is performed to detect differences in pitch. A dull sound produced when percussing a distended urinary bladder is an indication of urinary retention. .A client reports pain when taking a deep breath. Which lung auscultation sound should the nurse anticipate hearing? - ANSWER-Pleural friction rub .A client states that she had a mastectomy of her left breast last year and now experiences lymphedema. What should the nurse expect to find when examining the client? - ANSWER-Swelling of the left arm and non-pitting edema. .A client with dark skin is reporting a painful and itching area on the lower left leg. What should the nurse look for when assessing this client's skin for inflammation? - ANSWER-Change in consistency. .A client with progressive hearing loss appears distressed when the registered nurse (RN) asks open-ended questions about the client's health history. Which forms of communication should the RN use? - ANSWER-Face the client so the client can see the RN's mouth. Check if the client's hearing aides are working properly. Reduce environmental noise surrounding the client. .A male executive is seen in the primary care clinic for a physical examination. While obtaining the client's health history, the nurse inquires about his drug and alcohol use. The executive denies drug use, but reports that he has "two glasses of wine" per night. Which response is best for the nurse to provide? - ANSWER-"What effect do you think your use of alcohol may have on you?" .A Muslim male client refuses to let the female registered nurse (RN) listen to his breath sounds during the examination. How should the RN respond? - ANSWER-Request a male nurse or healthcare provider to perform the exam. .A nurse is completing a nutritional assessment with a client. What is the easiest method for the nurse to use to get information about the client's nutritional intake? - ANSWER-24-hour dietary recall .A nurse is working in a healthcare facility that serves a diverse population. What action(s) by the nurse will allow the nurse to empathize with and understand this population? (Select all that apply.) - ANSWER-Be open to people who are different. Have a curiosity about people. Become culturally competent. .A postmenopausal female client is undergoing a routine physical examination. She has reported nothing out of the ordinary. When performing the examination of the genitourinary system, the nurse finds an irregularly enlarged uterus with firm, mobile, painless nodules in the uterine wall. How should the nurse explain this finding to the client? - ANSWER-You have benign fibroid tumors, a common occurrence in women your age.