HEALTH ASSESSMENT HESI

HEALTH ASSESSMENT HESI For a client admitted with metabolic acidosis, which two body systems would the nurse assess for compensatory changes? A. Skeletal and nervous B. Circulatory and urinary C. Respiratory and urinary D. Muscular and endocrine - AnswersC. Respiratory and urinary Kidney and lungs When providing care for a client with diarrhea, in which clinical indicator would the nurse anticipate a decrease? A. Pulse rate B. Tissue turgor C. Specific gravity D. Body temperature - AnswersB. Tissue turgor Dehydration The nurse notes a client has dependent edema around the area of the feet and ankles. To characterize the severity of the edema, the nurse presses the medial malleolus area, noting an 8-mm depression after release. In which way would the nurse document the edema? A. 1+ B. 2+ C. 3+ D. 4+ - AnswersD. 4+ Dependent edema around the area of feet and ankles often indicates right sided heart failure or venous insufficiency. 1+ = 2mm 2+ = 4mm 3+ = 6mm 4+ = 8mm Which Korotkoff sound represents the diastolic pressure for children? A. First B. Second C. Fourth D. Fifth - AnswersC. Fourth For a client suspected of having a prostate disorder, which client position would facilitate a rectal examination by the registered nurse? A. Left lateral recumbent position HEALTH ASSESSMENT HESI B. Prone position C. Dorsal recumbent position D. Lateral recumbent position - AnswersA. Left lateral recumbent position While assessing a client with dehydration, the nurse notices diminished skin elasticity. Which portion of the nurse's hand would the nurse use to perform this assessment? A. Fingertips, B. Pads of fingertips C. Ulnar surface of hand D. Palmer surface of finger pds - AnswersA. Fingertips, A client with a family history of diabetes has been following a diet regimen recommended by the dietician and walking for 45 minutes daily for the past 8 months. Based on the transtheoretical model of health behavior change, which stage would the nurse document for this client? A. Action B. Preparation C. Maintenance D. Contemplation - AnswersC. Maintenance Maintenance = 6 mos after action A client reports right ear hearing loss. When performing a Weber test with a tuning fork, the client hears the sound better with the right ear. Which condition would the nurse suspect from these results? A. Normal hearing B. Mixed hearing loss C. Conduction hearing loss D. Sensorineural hearing loss - AnswersC. Conduction hearing loss In conduction hearing loss, the client can hear the tuning fork better on the impaired ear. Sensorineural, you hear better with the normal ear. Mixed is both ^^ When an African American client with renal failure reports the illness is punishment for sins, which cultural health belief is the client communicating? A. Yin/Yang balance B. Biomedical belief C. Determinism belief D. Magicoreligious belief - AnswersD. Magicoreligious belief While assessing the eyes of a client, a health care provider notices there is an obstruction to the outflow of aqueous humor. Which additional finding would support a diagnosis of glaucoma? HEALTH ASSESSMENT HESI A. Blurred central vision B. Increased opacity of the lens C. Elevated intraocular pressure D. Changes in retinal blood vessels - AnswersC. Elevated intraocular pressure The nurse providing care for a client who underwent cardiac catherization, found the client's skin was cool, tender to touch, with edema of 15.2 cm (1-6 inches) at the site of catheterization. Which condition would the nurse suspect? A. Phlebitis B. Infection C. Infiltration D. Circulatory overload - AnswersC. Infiltration After performing an optical assessment on a client, a primary health care provider notices impaired near vision. Which other finding would confirm the client's diagnosis as presbyopia? A. Loss of elasticity of the lens B. Increased opacity of the lens. C. Elevated intraocular pressure D. Noninflammatory changes in eyes - AnswersA. Loss of elasticity of the lens Presbyopia is defined as impaired near vision caused by a loss of elasticity of the lens. This condition is reported in middle-aged and older adults. Which skin condition would the nurse associate with a client whose skin pathophysiology involves increased visibility of oxyhemoglobin caused by an increased blood flow due to capillary dilation? A. Pallor B. Vitiligo C. Cyanosis D. Erythema - AnswersD. Erythema More RBCs would make an area RED After an eye assessment the nurse finds that the client's eyes are not focusing on an object simultaneously and appear crossed. Which potential cause would the nurse associate with this condition? A. Loss of elasticity of the lens B. Impairment of the extraocular muscles C. Obstruction of the aqueous humor outflow D. Progressive degeneration of the center of the retina - AnswersB. Impairment of the extraocular muscles Strabismus = cross eyed