Health Assessment- BSN 246 HESI REVIEW
Study online at https://quizlet.com/_eqwcn4
1. Which lab test would provide information about the number of megakary-
octyes in a patient w/ thrombocytopenia?
Prothrombin time (PT)
Peripheral blood smear
14C serotonin release assay
Bone Marrow examination: D.
Bone marrow examination is performed to rule out production problems such as
leukemia, aplastic anemia, and other myeloproliferative disorders as the cause of
thrombocytopenia. Therefore to confirm that the absence or decreased number of
megakaryoctyes to be the cause of thrombocytopenia, bone marrow examination
will be done. PT will be tested to assess secondary homeostasis. A peripheral
blood smear will be done to distinguish immune thrombocytopenic pupura (ITP) from
congenital disorders. 14C serotonin release assay assists with the diagnosis of ITP
2. Where are lymphocytes produced?
Spleen
Tonsils
Bone Marrow
Thymus gland: C.
Lymphocytes are produced in the bone marrow. The speel is a peripheral lymph
organ and is the primary site for filtering foreign antigens from the blood. The thymus
gland is involved in the differentiation and maturation or T lymphocytes. The tonsils
are a peripheral lymphoid organ
3. Which functional ability would the nurse anticipate for the patient who
sustained a severe spinal cord injury in the sacral and thoracolumbar regions
of the veretbral column?
Inability to urinate
ability to ambulate to the bathroom
Need to use a urinal/ bedpan to urinate
Need to call for assistance when needing to void.: A.
Together, the bladder, urethra, and pelvic floor muscles form what is called the ure-
throvesical unit. Voluntary control of this unit is defined as continenence. Stimulating
and inhibiting impulses are sent from the brain through the thoracolumbar (T11-L2)
and sacral (S2 to S4) areas of the spinal cord to control voiding. Damage in this
area will prevent voluntary control and lead to incontinence. W/o contol, the pt may
, Health Assessment- BSN 246 HESI REVIEW
Study online at https://quizlet.com/_eqwcn4
no be aware of the need to go to the bathrrom, to use a urinal/ bedpan, or to call for
assistance.
4. Which action by a nurse in a community-based clinic can help to address
potential disparities with a large Hispanic population?
providing translators and materials in the Spanish language
Ensuring that child care services are available for families during visits to the
clinic
Making sure that the values of all clinic providers align with those of the
Hispanic population
Requiring "English as a second language" classes so that the population can
become literate in the English language: A.
Providing translators and materials in the native language of the population being
served can best address potential biases and prejudices and thus increase health
care access. Ensuring that child care services are abailable may increase ease of
access to care but does not necessarily address biases and prejudices. Providers
must respect and acknowledge the beliefs and values of the population being
served, but it is not necessary that their values align. Providing "English as a second
language" classes can assist the population to acclimate and become more literate
in the English language but does not necessarily directly affect bias and prejudice.
5. The nurse provides care for a patient with a chest tube flutter valve in place
and recalls which information about the device?
it allows patient mobility
it is used to evacuate fluide from the plueral space.
It is attached to the internal end of the chest tube.
It opens when the chest pressure is less than atmospheric pressure.: A.
A fluttter falve (also called the Hemlich valve) is used to remove air from the pleural
space. It allows for patient mobility b/c the smaller drainage bag can be hidden under
the clothes while the patient ambulates. The valve evacuates air, not fluid, from the
pleural space. It is attached to the external end of the chest tube. A flutter valve
opens whenever the pressure in the chest is greater than the atmospheric pressure.
6. which is the appropriate method for a nurse to use when ascultating a
patient's abdomen?
Use the bell of the stethoscope for auscultation.
Use the diaphragm of the stethoscope for auscultation
Hold the diaphragm lightly to the skin of the abdomen
Use the inferface of the diaphragm and the bell for auscultation: B.
, Health Assessment- BSN 246 HESI REVIEW
Study online at https://quizlet.com/_eqwcn4
Auscultation of the abdomen is useful in detecting high-pitched bowel sounds. The
diaphragm of the stethoscope is sensitive in picking up high-pitched sounds of the
abdomen. The bell of the stethoscip is sensitive in detecting low-pitched sounds
like heart murmurs The interface of the bell and diaphram is less useful for clinical
assessment. B/c the bowel dounds are high-pitched, the diaphragm should be held
firmly on the skin during auscultation.
7. In the mneumonic "DELIRIUM", the M represents which cause of delirium?
Medication
Malnutrition
Memory Loss
Metabolic disorders: D.
the letter "M" represents metabolic disorders in the mnemonic of causes for delirum.
The "R" for RX represents medication. The "D" for dementia and dehydration repre-
sents memory loss. Malnurtition is not part of this mnemonic
8. What is the mneumonic "DELIRIUM"?: causes of Deliurium
D-dementia, dehydration
E-elecrtolyte imbalances, emotional stress
L-lung, liver, heart, kidney, brain
I-infection, ICU
R- Rx drugs
I- injury, immobility
U-untreated pain, unfamiliar environment
M-metabolic disorders
9. For a pateint with a head injury, for which complication r/t cerebral hemor-
rhage and edema would the nurse monitor potential development?
Anxiety
Hyperthermia
Impaired physical mobillity
Increased intracranial pressure: D.
increased intracrainal pressure can occur as a potential complication r/t cerebral
hemorrhage and edma. Anxiety can result from an abrupt change in health status,
being in a hospital environment, and having an uncertain future. Hyperthermia
can occur dut to increased metabolism, infection and hypothalamic injury. Impaired
physical mobility is r/t a decreased level of consciousness
Study online at https://quizlet.com/_eqwcn4
1. Which lab test would provide information about the number of megakary-
octyes in a patient w/ thrombocytopenia?
Prothrombin time (PT)
Peripheral blood smear
14C serotonin release assay
Bone Marrow examination: D.
Bone marrow examination is performed to rule out production problems such as
leukemia, aplastic anemia, and other myeloproliferative disorders as the cause of
thrombocytopenia. Therefore to confirm that the absence or decreased number of
megakaryoctyes to be the cause of thrombocytopenia, bone marrow examination
will be done. PT will be tested to assess secondary homeostasis. A peripheral
blood smear will be done to distinguish immune thrombocytopenic pupura (ITP) from
congenital disorders. 14C serotonin release assay assists with the diagnosis of ITP
2. Where are lymphocytes produced?
Spleen
Tonsils
Bone Marrow
Thymus gland: C.
Lymphocytes are produced in the bone marrow. The speel is a peripheral lymph
organ and is the primary site for filtering foreign antigens from the blood. The thymus
gland is involved in the differentiation and maturation or T lymphocytes. The tonsils
are a peripheral lymphoid organ
3. Which functional ability would the nurse anticipate for the patient who
sustained a severe spinal cord injury in the sacral and thoracolumbar regions
of the veretbral column?
Inability to urinate
ability to ambulate to the bathroom
Need to use a urinal/ bedpan to urinate
Need to call for assistance when needing to void.: A.
Together, the bladder, urethra, and pelvic floor muscles form what is called the ure-
throvesical unit. Voluntary control of this unit is defined as continenence. Stimulating
and inhibiting impulses are sent from the brain through the thoracolumbar (T11-L2)
and sacral (S2 to S4) areas of the spinal cord to control voiding. Damage in this
area will prevent voluntary control and lead to incontinence. W/o contol, the pt may
, Health Assessment- BSN 246 HESI REVIEW
Study online at https://quizlet.com/_eqwcn4
no be aware of the need to go to the bathrrom, to use a urinal/ bedpan, or to call for
assistance.
4. Which action by a nurse in a community-based clinic can help to address
potential disparities with a large Hispanic population?
providing translators and materials in the Spanish language
Ensuring that child care services are available for families during visits to the
clinic
Making sure that the values of all clinic providers align with those of the
Hispanic population
Requiring "English as a second language" classes so that the population can
become literate in the English language: A.
Providing translators and materials in the native language of the population being
served can best address potential biases and prejudices and thus increase health
care access. Ensuring that child care services are abailable may increase ease of
access to care but does not necessarily address biases and prejudices. Providers
must respect and acknowledge the beliefs and values of the population being
served, but it is not necessary that their values align. Providing "English as a second
language" classes can assist the population to acclimate and become more literate
in the English language but does not necessarily directly affect bias and prejudice.
5. The nurse provides care for a patient with a chest tube flutter valve in place
and recalls which information about the device?
it allows patient mobility
it is used to evacuate fluide from the plueral space.
It is attached to the internal end of the chest tube.
It opens when the chest pressure is less than atmospheric pressure.: A.
A fluttter falve (also called the Hemlich valve) is used to remove air from the pleural
space. It allows for patient mobility b/c the smaller drainage bag can be hidden under
the clothes while the patient ambulates. The valve evacuates air, not fluid, from the
pleural space. It is attached to the external end of the chest tube. A flutter valve
opens whenever the pressure in the chest is greater than the atmospheric pressure.
6. which is the appropriate method for a nurse to use when ascultating a
patient's abdomen?
Use the bell of the stethoscope for auscultation.
Use the diaphragm of the stethoscope for auscultation
Hold the diaphragm lightly to the skin of the abdomen
Use the inferface of the diaphragm and the bell for auscultation: B.
, Health Assessment- BSN 246 HESI REVIEW
Study online at https://quizlet.com/_eqwcn4
Auscultation of the abdomen is useful in detecting high-pitched bowel sounds. The
diaphragm of the stethoscope is sensitive in picking up high-pitched sounds of the
abdomen. The bell of the stethoscip is sensitive in detecting low-pitched sounds
like heart murmurs The interface of the bell and diaphram is less useful for clinical
assessment. B/c the bowel dounds are high-pitched, the diaphragm should be held
firmly on the skin during auscultation.
7. In the mneumonic "DELIRIUM", the M represents which cause of delirium?
Medication
Malnutrition
Memory Loss
Metabolic disorders: D.
the letter "M" represents metabolic disorders in the mnemonic of causes for delirum.
The "R" for RX represents medication. The "D" for dementia and dehydration repre-
sents memory loss. Malnurtition is not part of this mnemonic
8. What is the mneumonic "DELIRIUM"?: causes of Deliurium
D-dementia, dehydration
E-elecrtolyte imbalances, emotional stress
L-lung, liver, heart, kidney, brain
I-infection, ICU
R- Rx drugs
I- injury, immobility
U-untreated pain, unfamiliar environment
M-metabolic disorders
9. For a pateint with a head injury, for which complication r/t cerebral hemor-
rhage and edema would the nurse monitor potential development?
Anxiety
Hyperthermia
Impaired physical mobillity
Increased intracranial pressure: D.
increased intracrainal pressure can occur as a potential complication r/t cerebral
hemorrhage and edma. Anxiety can result from an abrupt change in health status,
being in a hospital environment, and having an uncertain future. Hyperthermia
can occur dut to increased metabolism, infection and hypothalamic injury. Impaired
physical mobility is r/t a decreased level of consciousness
