Hesi V2 Health Assessment (Exam Questions With Correct Answers) || Graded A+ Updated

HESI V2 health assessment (EXAM QUESTIONS WITH CORRECT ANSWERS) || GRADED A+ UPDATED A client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin 0.4 mg sublingually. Five minutes later, the client is still experiencing chest pain. If the blood pressure is still stable, the nurse should take which action next? - ANSWER Administer another nitroglycerin tablet. The health care provider is discharging a client with a diagnosis of chronic heart failure. Which health maintenance instructions should the nurse reinforce in the discharge teaching plan? Select all that apply. - ANSWER 1. Obtain annual influenza vaccination. 3. Avoid adding salt to foods or in cooking. 4. Report a weight gain of 3 or more pounds in a week. The nurse is preparing for a health fair about tobacco use and the development of coronary heart disease. Which information should the nurse include? Select all that apply. - ANSWER 1. Nicotine decreases oxygen to the heart. 2. Hypnosis may be helpful to stop smoking. 3. Avoid exposure to environmental tobacco smoke The nurse is caring for a client with a new onset of atrial fibrillation. Which prescribed treatments should the nurse expect? Select all that apply. - ANSWER 2. Digoxin (Lanoxin) 3. Warfarin (Coumadin) 4. Electrical cardioversion A client with hyperlipidemia is seen in the clinic for a follow-up visit. Which dietary modifications should the nurse include to lower the risk of coronary heart disease? Select all that apply. - ANSWER 1. Use liquid vegetable oil. 2. Increase intake of fruits. 3. Choose whole grain foods. 4. Remove skin from poultry. The LPN/LVN is caring for a client with left-sided heart failure. Which clinical signs are most important for the nurse to communicate to the health care provider? Select all that apply. - ANSWER 1. Pink-tinged frothy sputum 2. Increase in respiratory rate 5. Auscultation of crackles throughout the lungs The nurse is admitting a client with acute pericarditis who reports chest pain. When planning the client's care, which position should the nurse encourage the client to assume to alleviate the chest pain? Select all that apply. - ANSWER 3. Sitting up and leaning forward 5. Head of bed elevated to 45 degrees The health care provider is discharging a client with a diagnosis of primary hypertension. Which health maintenance instructions should the nurse reinforce in the discharge teaching plan? Select all that apply. - ANSWER 1. Monitor the blood pressure at home. 2. Restrict sodium intake as prescribed. 4. Eye examinations with an ophthalmoscope should be routine. 5. Follow-up appointments for blood pressure checks are important The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care? - ANSWER Prevent infection. The LPN/LVN is conducting an osteoporosis screening clinic at a health fair. What information should the nurse provide to individuals who are at risk for osteoporosis? (Select all that apply.) - ANSWER 1.Encourage alcohol and smoking cessation. 3.Promote regular weight-bearing exercises. 4.Implement a home safety plan to prevent falls. An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked and his eyeballs appear sunken into his head. Which nursing intervention is indicated? - ANSWER Help the client determine ways to increase his fluid intake. The nurse is assessing a client who presents with jaundice. Which assessment finding is most important for the nurse to follow up? - ANSWER Elevated serum amylase and lipase levels Which content about self-care should the LPN/LVN include in the teaching plan of a female client who has genital herpes? (Select all that apply.) - ANSWER 1.Encourage annual physical and Pap smear. 2.Take antiviral medication as prescribed. 3.Use condoms to avoid transmission to others. 4.Warm sitz baths may relieve itching. The LPN/LVN is interviewing a client who is taking interferonalfa-2a (Roferon-A) and ribavirin (Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. Which action should the nurse implement first? - ANSWER Review the medication actions and interactions. A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. In what position should the nurse immediately place the client to promote maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg? - ANSWER Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound. The nurse assesses a client who has been prescribed furosemide (Lasix) for cardiac disease. Which electrocardiographic change would be a concern for a client taking a diuretic? - ANSWER Presence of a U wave When a nurse assesses a client receiving total parenteral nutrition (TPN), which laboratory value is most important for the nurse to monitor regularly? - ANSWER Glucose A 62-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor most likely contributed to the fracture in the proximal end of her femur? - ANSWER Osteoporosis resulting from declining hormone levels A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I have lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this body-wracking dry cough that has been hanging around for the last six weeks." Which computer documentation of this client's concerns should the nurse enter? A. Presents with a hacking non-productive cough of 6 weeks duration. B. Describe having a "body-wracking dry cough" of 6 weeks duration. C. Expresses concern of "lung cancer" symptoms for last 6 weeks. D. Young adult male presents with fears that he has "lung cancer" - ANSWER Correct answer is B, as assessment process includes chief complaint which is how the patient describe why he is here in the hospital or clinic and can't include diagnosis. A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response. Which interpretation of this finding is accurate? A. A normal reflex response. B. Absent or sluggish response consistent with a lower motor neuron lesion. C. Flaccid paralysis. D. Hyperactive response consistent with an upper motor neuron disorder. - ANSWER Correct answer is D, brisk 4+ response is correlated with hyperactive response.