BSN 246 HESI Health Assessment Exam V2 Exam: 100 Verified Questions & Answers: Latest Updated

In observing a client's face, which assessment finding requires the most immediate intervention by the nurse? (Ans- Oral mucosa is cyanotic. While obtaining a health history, a male client tells the nurse that he sometimes experiences shortness of breath. The nurse determines that the client's respirators are regular and deep, and his respiratory rate is 14 breaths/minutes. What is the best nursing action? (Ans- Ask the client to describe the episodes of dyspnea in more detail. When assessing a male client's respiratory status, which technique should the nurse use to assess his anterior- posterior (AP) chest diameter? (Ans- Observation. Which assessment finding supports the client statement, "My feet swell all the time?" (Ans- 2+ pitting edema of ankles bilaterally.The nurse is performing a cranial nerve exam on an 87-year-old client. The nurse notes that the client has a reduced upward gaze, a decreased corneal reflex, a high frequency hearing loss, and a reduced gag reflex. What action should the nurse take next? (Ans- Continue the assessment to the ne