BSN 246 HESI Health Assessment V1
EXAM:PRACTICE QUESTIONS AND
ANSWERS LATEST 2025
The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a chest
measurement of 42 inches, waist measurement of 45 inches, and hip measurement of 50 inches.
What important message should the nurse explain to the client to promote health promotion? -
CORRECT ANSWER-A waist circumference is greater than 35 inches in women puts you at
higher risk for type 2 diabetes and heart disease."
The nurse performs a physical assessment on an older female client. Which change from the
prior exam may be an indication of osteoporosis? - CORRECT ANSWER-Height reduction of
1.5 inches.
While conducting an interview to obtain a health history, the nurse notices that the client pauses
frequently and looks at the nurse expectantly. Which response is best for the nurse to provide? -
CORRECT ANSWER-Sit quietly to allow the client to respond comfortably.
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? - CORRECT ANSWER-Ask the client to
urinate before beginning the examination.
Which respiratory condition should the nurse document after measuring a respiratory rate of 8
breaths/minute? - CORRECT ANSWER-Bradypnea.
The nurse is performing a thoracic assessment on a client with chronic asthma and hyperinflation
of the lungs. Which finding should be expected for this client? - CORRECT ANSWER-Barrel
chest
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel sounds
in the right upper quadrant. What action should the nurse take next? - CORRECT ANSWER-
Note the character and frequency of bowel sounds
During inspection of a client's mouth and pharynx, the nurse places a tongue blade on the back of
the tongue which causes the client to gag. After removing the tongue blade, what action should
the nurse take? - CORRECT ANSWER-Document an intact gag reflex.
When teaching a client how to perform a monthly breast self-assessment, the nurse should tell
the client that it is most important to assess which part of the breast more closely for changes? -
CORRECT ANSWER-Upper outer quadrant.
Which procedure should the nurse use to assessfor a pulse deficit? - CORRECT ANSWER-
Measure the apical pulse and compare it to the peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point of maximal impulse
and the radial pulse palpated at the wrist.
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? - CORRECT
ANSWER-Dull, thud-like.
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? - CORRECT ANSWER-Inspect the hair and
skin.
The nurse is assessing a healthy young adult during an annual physical examination. Which
assessment technique should the nurse implement when palpating the abdominal aorta? -
CORRECT ANSWER-Deep palpation above and to the left of the umbilicus.
The nurse is conducting a family history as part of the assessment interview. Which action
should the nurse take to ensure that sufficient information about the client's blood relatives is
obtained? - CORRECT ANSWER-Document at least 3 generations of the client's family
medical history.
The nurse is testing the client's shoulders for range of motion. What should the nurse document
to record normal internal rotation? - CORRECT ANSWER-Range of 90 degrees when the
hands are placed at the small of the back.
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? - CORRECT ANSWER-
Inspect the scalp looking for nits.
The nurse is assessing a client's range of motion as the client bends the right knee up to the chest
while keeping the left leg straight, but is unable to keep the left thigh on the table. The
assessment is repeated for the left knee, and the client is unable to keep the right thigh on the
table. How should the nurse document this finding? - CORRECT ANSWER-A flexion
deformity referred to as a positive Thomas test.
During a skin asssessment, the nurse notes, round and discrete lesions that are dark red in color
and will not blanch. The lesions range from 1 to 3 mm in size. What is the first question the
nurse should ask the client? - CORRECT ANSWER-Have you notice any irregular bleeding
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? - CORRECT 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 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? - CORRECT
ANSWER-Swelling of the left arm and non-pitting edema.
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? - CORRECT ANSWER-Lying.
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? - CORRECT ANSWER-You have
benign fibroid tumors, a common occurrence in women your age.
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? - CORRECT ANSWER-"My life is
really out of balance."
The nurse is preparing to assess the hearing of a client with a history of prolonged exposure to
occupational noise. Which hearing test provides the most reliable assessment of hearing status? -
CORRECT ANSWER-Audiometry.
The nurse is performing a routine physical examination on an adult client. When gathering a
health history, which question is included in the CAGE questionnaire? - CORRECT
ANSWER-Have you ever felt guilty about your drinking?
*CAGE is the acronym for Cut down, Annoyed, Guilty, and Eye-opener. Nurse can use it to
assess for possible alcohol abuse.
The nurse is examining the hip joint of a client who reports hip pain. Which other assessment is
most helpful in determining the cause of the client's pain? - CORRECT ANSWER-Knee joint
evaluation.
The nurse performs a series of cranial nerve tests on a client with a head injury. Which test
should the nurse use to assess damage to the first cranial nerve? - CORRECT ANSWER-
Occlude one nostril and have the client identify various odors.
The client reports to the nurse a recent exposure to the mumps. Which assessment finding
suggests the client has contracted the mumps? - CORRECT ANSWER-Swelling anterior to the
ear lobe on one side of the face
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.) - CORRECT ANSWER-Be open to people who are different.
Have a curiosity about people.
Become culturally competent.
Which findings can the nurse determine by palpating a client's skin? (Select all that apply.) -
CORRECT ANSWER-Diaphoresis.
Scaling.
Which question should the nurse ask in order to test a client's remote memory? - CORRECT
ANSWER-What is your date of birth?
While assessing level of consciousness, the nurse finds that a client localizes to pain, is confused
during conversation, and opens the eyes to sound. How should the nurse document the Glasgow
score of this client? - CORRECT ANSWER-12.
The Glasgow Coma Scale is used to establish baseline data based on eye opening, motor
response, and verbal response. The lowest possible score is 3 and thehighest is 15. This client's
Glasgow Coma Scale (GCS) score is 12: Opening eyes to sound is a score of 3, localizing to pain
is a 5, and confusion during a conversation is a 4 (3 + 5 + 4 = 12).
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?
- CORRECT ANSWER-Family history of colon cancer on mother's side.
An adult client is in the clinic for a regular physical examination. The nurse is assessing the
client's hydration status by pinching then releasing the client's skin. Which finding is indicative
of good hydration status? - CORRECT ANSWER-The skin immediately returns to normal
position.
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? - CORRECT ANSWER-Level of consciousness.
While palpating a client's breasts, the nurse detects a nontender, solitary, round lobular mass that
is solid and firm and slides easily through the breast tissue . The findings of this breast exam are
consistent with which condition? - CORRECT ANSWER-Fibroadenoma.
The client is experiencing severe pruritus and small papules and burrows on areas over one hand
and the inner thighs. Which assessment data best explains the condition the client is
experiencing? - CORRECT ANSWER-The client works in a daycare setting that has had a
scabies outbreak.
When assessing facial nerve function of a 96-year-old, the nurse asks the client to smile in an
exaggerated manner. Which finding is most important for the nurse to further asses? -
CORRECT ANSWER-Only one side of the mouth moves when smiling.
When performing range of motion exercises on the joints of an older adult client, the nurse notes
that joint range is greater with passive ranging than with active ranging. A goniometer indicates
that this difference is as much as 15% in some joints. How should this finding be documented? -
CORRECT ANSWER-Abnormal.
Which action should the registered nurse (RN) implement to complete an assessment for a client
while using an interpreter? - CORRECT ANSWER-Maintain eye contact with the client while
listening to the translation.
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? - CORRECT ANSWER-Have you experienced sudden weight loss?
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? - CORRECT ANSWER-"What effect do you think your use of alcohol may
have on you?"
Which part of the body should the nurse examine when assessing for peripheral edema in a client
with heart failure? - CORRECT ANSWER-Ankles.
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? -
CORRECT ANSWER-Use of vitamin and iron supplements.
What is the best place for the nurse to hear lower lobe lung sounds with a stethoscope? -
CORRECT ANSWER-Posterior chest below the 3rd intercostalspace.
A registered nurse (RN) is performing a mini-mental state examination (MMSE) for a client who
is being admitted to an assisted living community. Which communication techniques should the
RN implement to decrease anxiety in the client? (Select all that apply.) - CORRECT
ANSWER-Use simple sentences during the examination.
Reduce environmental detractors during the examination.
Ask questions one at a time to decrease confusion.
The nurse is interviewing a client who reports having a persistent, productive cough during the
winter caused by bronchitis. Which additional finding should the nurse assess for bronchitis? -
CORRECT ANSWER-Phlegm production and wheezing.
The nurse is assessing the posterior pharynx during a physical examination. Which technique
should the nurse use? - CORRECT ANSWER-Press the tongue down one side at a time with a
tongue depressor.
The nurse is assessing a client who has a history of mitral stenosis. How should the nurse assess
this client with a stethoscope to listen for this condition? - CORRECT ANSWER-Place the bell
on the 5th intercostal space, left midclavicular line.
Which statement is accurate about assessing the spleen? - CORRECT ANSWER-It must be
enlarged at least three times normal size for it to be palpable.
During an external examination of the eyes, the nurse gently palpates the eyes while the client's
eyelids are closed. The eyes are both very firm and resist movement back into the orbit. How
should the nurse document this finding? - CORRECT ANSWER-Abnormal finding.
Which tool should the nurse use when assessing the neurological status of a client with traumatic
brain injury? - CORRECT ANSWER-Glasgow Coma Scale.
The nurse is assessing a client with liver disease who is jaundice and exhibits scleral edema.
During the health assessment, the nurse should implement which technique to determine
evidence of hepatomegaly? - CORRECT ANSWER-Use a bouncing motion to tap the middle
finger placed within boundaries of the liver.
What is the best nursing response to an older client who has not mentioned incontinence during a
genitourinary assessment? - CORRECT ANSWER-Ask the client specifically about any
leakage of urine.
The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during
conversations. How should the RN assess this client's response? - CORRECT ANSWER-The
client is treating the nurse with respect.
The nurse is assessing a client for a hip flexion contracture. Which finding indicates a negative
Thomas test when the client's right knee is brought toward the chest? - CORRECT ANSWER-
The left leg remains on the table
*The Thomas test is performed by having the client bring one knee toward the chest while the
other leg remains extended on the table. A positive Thomas test is elicited when the extended leg
rises off the table when the opposite leg's knee is brought up to the client's chest, indicating hip
flexor contracture. If the extended leg (the left leg, in this example) remains on the table, the test
is negative.
The nurse is assessing a client who has a history of aortic regurgitation. Where should the nurse
place the stethoscope diaphragm to listen for this condition? - CORRECT ANSWER-2nd
intercostal space along the right sternal border.
The nurse is assessing a client who has experienced a sudden onset of hearing loss in the right
ear. Which finding should alert the nurse to a potentially serious medical condition that requires
further evaluation? - CORRECT ANSWER-There is no sign of associated infection.
Which information should the nurse obtain to identify the client's self-perception of health
status? - CORRECT ANSWER-Health history
During the initial assessment, the nurse notes that a client has blurred vision with cloudy lenses.
Which condition should the nurse document? - CORRECT ANSWER-Cataracts.
Which condition is indicated by a fluorescent, yellow-green color when the nurse uses a Wood's
lamp toexamine a client's skin lesions? - CORRECT ANSWER-Fungal infection.
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? - CORRECT ANSWER-
Change in consistency.
A client reports pain when taking a deep breath. Which lung auscultation sound should the nurse
anticipate hearing? - CORRECT ANSWER-Pleural friction rub
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? - CORRECT ANSWER-24-
hour dietary recall
The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings
should the RN document that are consistent with diminished peripheral circulation? (Select all
that apply.) - CORRECT ANSWER-Diminished hair on legs.
Skin cool to touch.
The nurse is completing a physical assessment of a client who feel from a tree. The client's
abdomen is soft with hyperactive bowel sounds in all four quadrants. Which assessment
technique should the nurse implement when evaluating the client's spleen? - CORRECT
ANSWER-Percuss the splenic area as the client takes a deep breath.
The nurse enters an examination room to conduct a routine health assessment on an adolescent
female client, who is accompanied by her mother. Which action by the nurse is likely to facilitate
accurate responses to personal and social history questions? - CORRECT ANSWER-Request
that the mother leave the exam room.
While performing a mental status exam (MSE), the nurse asks a client to remember three
unrelated words and repeat them later. The client was able to repeat the words as directed. Which
computer documentation is accurate? - CORRECT ANSWER-"Short-term memory is intact."
Which technique should the nurse implement when performing a Weber test? - CORRECT
ANSWER-Place a vibrating tuning fork midline on top of the head
Which technique should the nurse use to assess a client for scoliosis? - CORRECT ANSWER-
Observe spine while the client is erect and bent forward
Which term should the nurse use to document in the client's medical record for a high-pitched
scratchy sound during auscultation of the heart? - CORRECT ANSWER-Friction rub
While performing a head-to-toe assessment, the nurse assesses the client's pupillary
accommodation. During the second portion of the test, the nurse notes that the client's pupils
constrict and there is convergence of the axes of the eyes. What action should the nurse
implement next? - CORRECT ANSWER-Document a normal finding.
The nurse performs the Weber and Rinne tests to assess which cranial nerve? - CORRECT
ANSWER-VIII - vestibulocochlear
The nurse uses a tongue depressor to assess a client's mouth. Which structure should the nurse be
able to visualize? - CORRECT ANSWER-Pharynx
As a part of a routine health assessment, the nurse assesses the kidneys as part of the abdominal
assessment. Which assessment finding should the nurse conclude is normal when palpating the
client's right kidney? - CORRECT ANSWER-A round smooth mass that slides between the
fingers.
A client reports lower abdominal pain and a feeling of pressure in the bladder. Which assessment
finding indicates acute urinary retention? - CORRECT 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.
The nurse examines the skin of an older adult client. Which skin variation is considered a normal
finding for a client in this age group? - CORRECT ANSWER-Lentigines.
*Lentigines or commonly referred to as liver spots are irregularly shaped dark spots on the skin
caused by aging and extensive sun exposure. This skin variation is a normal finding in an older
adult client.
During a client's routine well-woman physical exam, the nurse examines the breasts. Which
assessment technique should the nurse implement to evaluate for any abnormal lumps? -
CORRECT ANSWER-With both arms at client's side, lift one arm and palpate the axilla.
The nurse is completing a physical exam on an adult client. Which thyroid finding is considered
normal? - CORRECT ANSWER-Gland is not palpable.
How should the nurse assess for lower extremity edema in a client who has been diagnosed with
heart failure? - CORRECT ANSWER-Measure bilateral ankle circumference with a non-
stretchable tape measure.
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? -
CORRECT ANSWER-Have you had sudden and severe pain in the toes or feet?
During the interview portio of the health assessment, a nurse notes the person's posture, physical
appearance, and ability to converse. How should the nurse document these findings? -
CORRECT ANSWER-Objective.
The nurse is assessing a client who reports having shoulder pain. Which sign is the best indicator
of a rotator cuff tear? - CORRECT ANSWER-Inability to slowly lower the arm when abducted.
During cardiac auscultation, the nurse hears a split in the second heart sound when listening at
the second left intercostal space of a male client. To assess this sound more fully, what action
should the nurse implement? - CORRECT ANSWER-Listen to the sound while observing the
client's respirations.
An older client has just returned to the room following a surgical procedure. Which pain scale
should the nurse use when assessing the client's pain level? - CORRECT ANSWER-Verbal
descriptor scale.
The nurse observes peristaltic movement in the left lower quadrant of a client's abdomen. Which
further assessment of the area should the nurse perform? - CORRECT ANSWER-Observe the
direction of movement.
The nurse is assessing a client's middle lung lobe. What is the best location for the nurse to place
a stethoscope diaphragm to hear normal lung sounds in this lobe? - CORRECT ANSWER-4th
intercostal space, right midclavicular line.
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? - CORRECT ANSWER-Request a male
nurse or healthcare provider to perform the exam.
cultural issues to assess to prepare client for discharge - CORRECT ANSWER-language,
education level, lifestyle, financial resources,
Assessments to identify and document that are consistent with PUD (peptic ulcer disease) -
CORRECT ANSWER-hematemsis, gastric pain, intolerance of spicy foods
steatorrhea - CORRECT ANSWER-fatty stool- not associated with peptic ulcer disease (PUD)
Common complications of systemic lupus erythematosus - CORRECT ANSWER-weight loss,
anorexia, depressed mood, break in tissue integrity
Systemic lupus erythematosus (SLE)- complications that should be reported immediately -
CORRECT ANSWER-fever related to infection- secondary infections are a major concern due
to use of corticosteroids and chemotherapeutic agents that suppress the immune system
Common symptoms of viral gastroenteritis (stomach flu) - CORRECT ANSWER-dehydration
(from diarrhea and throwing up), dizziness when ambulating due to fluid volume deficit, poor
skin turgor, dry mucous membranes and lips
Rebound abdominal tenderness over right lower quadrant - CORRECT ANSWER-could be an
indication of appendicitis- notify provider. It is not common for those with gastroenteritis
weak pedal pulse and what else is consistent with diminished peripheral circulation -
CORRECT ANSWER-diminished hair on legs, skin cool to touch (decreased arterial blood
flow)
Common complications of immobility include - CORRECT ANSWER-- stiff joints (early
warning of contractures and atrophy)
- osteoporosis, decreased flexibility
- DVT, PE
- orthostatic hypotension
- atelectasis and pneumonia
- retention, UTIs, kidney stones
- pressure ulcers
- depression, anxiety, cognitive decline
Early signs of hypovolemic shock - CORRECT ANSWER-- lethargy, AMS
- tachycardia,
- cool, clammy, pale or mottled skin
tachypneic
decreased urine output (oliguria)
- delayed cap refill
Blood pressure doesn't decrease until later stages
asthma treated with Beta 2 receptor expected response - CORRECT ANSWER-rapid resolution
of wheezing
improved pulse ox
esophageal varices - CORRECT ANSWER-abnormally dilated veins in lower esophagus.
Caused by portal hypertension most common cause is liver cirrhosis. high risk of rupturing.
- usually asymptotic until they rupture-
signs of bleeding
- hematemesis, melena (black tarry stools), anemia, hypovolemic shock
nursing intervention most important for esophageal varices - CORRECT ANSWER-monitoring
infusing IV fluids and replacement blood products- patient at risk of fluid volume deficit and
hypovolemic shock if varices rupture
important maintain hemodynamic stability
why do we combo drug therapies for TB? - CORRECT ANSWER-development of resistant
strains of TB is decreased with combo drugs and ensure efficacy of treatment
What should the nurse prepare a patient for immediately after chest tube removal? - CORRECT
ANSWER-a chest xray- ensure that lung expansion has been maintained after removal
diverticulosis - CORRECT ANSWER-small pouch like sacs form in the colon- can be caused
by chronic constipation (straining weakens colon wall), low fiber diet, obesity, lack of exercise,
smoking
how does liver cirrhosis lead to varicose veins in the esophagus? - CORRECT ANSWER-
increased portal pressure- shunts blood glow to esophageal vessels
paroxysmal nocturnal dyspnea (PND) - CORRECT ANSWER-sudden and severe SOB that
occurs at night most common cause is left-sided heart failure
left-sided heart failure - CORRECT ANSWER-left ventricle fails to pump blood efficiently-
leads to fluid build up in the lungs (pulmonary edema)- when lying down the fluid that usually
collects in the legs shifts to the lungs leading to PND
IBS - CORRECT ANSWER-chronic functional GI disorder- abdominal pain and altered bowel
habits (diarrhea, constipation, or both)
Diverticulitis - CORRECT ANSWER-abd pain, fever, nausea vomiting, constipation, rectal
bleeding
Chrohn's disease - CORRECT ANSWER-chronic inflammatory process involving any portion
of the GI tract from the mouth to the anus- abd pain, bloating, frequent loose stools, malnutrition,
mouth sores. Flares up and has remissions
Ulcerative colitis - CORRECT ANSWER-limited to colon and rectum (Chrohns is whole GI
tract). S&S tenesmus (frequent urge to go to the bathroom but being unable to) frequent diarrhea,
rectal bleeding, abd cramping, dehydration
Mini-Mental State Examination (MMSE) - CORRECT ANSWER-Brief 30-point questionnaire
test that is used to screen for cognitive impairment; commonly used to screen for dementia.
MMSE- what finding is found by counting down from 7 - CORRECT ANSWER-attention to
detail and calculation
Client history that can cause possible interaction with an over-the-counter decongestant -
CORRECT ANSWER-closed angle glaucoma
chronic hypertension
OTC decongestants can cause increase in intraocular pressure and increase HR and BP
ABG - CORRECT ANSWER-normal ranges
pH 7.35-7.45
pCO2 35-45
HCO3 21-28
pO2 80-100
respiratory acidosis and ABGs - CORRECT ANSWER-low pH (<7.35), high pCO2 (>45),
normal HCO3 (21-28)
Respiratory alkalosis and ABGs - CORRECT ANSWER-high pH (>7.45), low pCO2 (<35),
incomplete fractures - CORRECT ANSWER-part of bone is splintered or bent but has not gone
completely through
Acute Coronary Syndrome (ACS) - CORRECT ANSWER-acute reduction of blood flow to
heart muscle
elevated troponin - CORRECT ANSWER-indicates myocardial damage
normal range of urine output - CORRECT ANSWER-40mL/hour
2 hour postprandial (post eating) blood glucose levels - CORRECT ANSWER-should be less
than 140 for young adults
fasting blood glucose normal - CORRECT ANSWER-70-99 mg/dL
sarcoidosis - CORRECT ANSWER-systemic inflammatory disease- more common in African
American women
normal WBC count - CORRECT ANSWER-4,000-10,000/mm3
bradykinesia - CORRECT ANSWER-slow movement
Dystonia - CORRECT ANSWER-a condition of abnormal muscle tone that causes the
impairment of voluntary muscle movement- can be caused by a sudden adverse effect to psych
meds
Somatization - CORRECT ANSWER-the expression of psychological distress through physical
symptoms
Akathisia - CORRECT ANSWER-motor restlessness
Initial dose of haloperidol- assess for - CORRECT ANSWER-dystonia
Liver Biopsy performed- most important nursing interventions - CORRECT ANSWER-- VS q
10-20 min for 2 hours (liver is highly vascular, assess for bleeding)
- position on right side with pillow under costal margin to support biopsy site
- bedrest for hours after to decrease risk of bleeding
Communication techniques for cognitive impairments - CORRECT ANSWER-- simple
sentences
- no environmental distractions
- direct questions, 1 at a time
acute pancreatitis - CORRECT ANSWER-activation of pancreatic enzymes that digest the
pancreas itself
- elevated serum amylase and lipase
emphysema and pursed lip breathing - CORRECT ANSWER-promotes CO2 elimination
alcohol detox patient at highest risk for - CORRECT ANSWER-injury
Ipratropium - CORRECT ANSWER-bronchodilator- headache nausea, blurred vision, and
insomnia are symptoms of excessive use- withhold and notify provider
sphygmomanometer - CORRECT ANSWER-instrument to measure blood pressure
Thyroid replacing therapy (levothyroxine and hypothyroidism) and the effect of warfarin -
CORRECT ANSWER-enhances the effect of warfarin so dose would need to be reduced
positions to help with dyspneic episodes - CORRECT ANSWER-anything to allow for
complete expansion of the chest wall- sitting and leaning on a table, sitting with hands on knees,
standing leaning against the wall (sitting is the best for safety but leaning should be ok)
positioning for a lumbar puncture - CORRECT ANSWER-side lying, legs pulled up to chest
and head bent to chest- helps open up between vertebrae
Discontinuing an NG tube - CORRECT ANSWER-have patient take a deep breath and hold
while pulled out slowly (prevents aspiration)
ABG low pH, low pCO2, and low HCO3 - CORRECT ANSWER-metabolic acidosis with resp
compensation
diabetic ketoacidosis - CORRECT ANSWER-acidity of the blood caused by the presence of
ketone bodies produced when the body is unable to burn sugar; thus, it must burn fat for energy.
precipitating factors- infection
ABG- all low- metabolic acidosis
signs and symptoms of DKA - CORRECT ANSWER-fatigue, polydipsia, polyuria, N/V,
change in LOC, dehydration, fruity breath, hypotension, tachycardia, tachypnea, ketones in
urine, potassium imbalance (high)
C-reactive protein - CORRECT ANSWER-A nonspecific protein, produced in the liver, that
becomes elevated during episodes of acute inflammation or infection. (elevated with infection-
like covid)
D-dimer - CORRECT ANSWER-blood clot test (increased= risk of clots- happens with covid)
hypothyroidism if super low could cause - CORRECT ANSWER-myxedema coma- fever, ams,
body swelling
positive for HIV, acquired PCP, CD4 count below 200 - CORRECT ANSWER-patient has
developed AIDS
Normal CD4 count - CORRECT ANSWER-800-1200
prophylactic measures for HIV - CORRECT ANSWER-pneumococcal vaccine, flu vaccine,
hep b vaccine
NOT varicella zoster immune globulin (live vaccine) or any antibiotics (like trimethoprim
sulfamethoxazole)
enlarged cervical lymph nodes with HIV - CORRECT ANSWER-expected finding
acute infection lab results - CORRECT ANSWER-increased band neutrophils (immature)
MRSA - CORRECT ANSWER-community acquires is worse, resistant to methicillin and
penicillin
Incompetent valve- heart murmur heard as - CORRECT ANSWER-blowing or swooshing
sound
pericardial friction rub - CORRECT ANSWER-scratchy leathery heart sound
pulmonary edema- pink frothy sputum leads to what breathsounds - CORRECT ANSWER-
crackles
normal sinus rhythm - CORRECT ANSWER-60-100bpm
PR 0.12-0.20
QRS 0.04-0.10
hx of headaches - CORRECT ANSWER-auscultate carotid artery sounds
patient in MVA, severe abdominal pain, suspected arterial damage. What assessment? -
CORRECT ANSWER-auscultate bruits- identifies turbulent blood flow indicates arterial
damage
hyperthyroidism complications - CORRECT ANSWER-fever, nausea, tremors, confusion
Thyroid storm - CORRECT ANSWER-a relatively rare, life-threatening condition caused by
exaggerated hyperthyroidism. elevated temp, HR, nausea, tremors, confusion, restlessness,
anxiousness,
S&S of hyperthyroidism - CORRECT ANSWER-tachy, hypertension, hair loss, weight loss,
GCS - CORRECT ANSWER-not accurate for intubated or aphasic patients
Brudzinski's sign- suspected meningitis - CORRECT ANSWER-pain with resistance and
involuntary flex of hip/knee when neck is flexed to chest when lying supine
Kernig's sign - CORRECT ANSWER-a diagnostic sign for meningitis marked by the person's
inability to extend the leg completely when the thigh is flexed upon the abdomen and the person
is sitting or lying down
Decorticate posturing - CORRECT ANSWER-characterized by upper extremities flexed at the
elbows and held closely to the body and lower extremities that are externally rotated and
extended. occurs when the brainstem is not inhibited by the motor function of the cerebral
cortex.
Acute COPD exacerbation, expected assessment findings - CORRECT ANSWER-
hyperinflated chest on x ray and flattened diaphragm
decreased O2 with mild exercise
use of accessory muscles
hypercapnia (increased PCO2)
decreased vital capacity
best indicator for acute renal failure - CORRECT ANSWER-serum creatinine (elevated
indicates renal failure)
- BUN could be caused by multiple things (dehydration, injury, GI bleed, and renal failure
Serum creatinine normal levels - CORRECT ANSWER-0.6-1.3 mg/dL
conditions that can cause acute abdominal pain - CORRECT ANSWER-gastroenteritis, ectopic
pregnancy, GI bleed, IBS, inflammatory bowel disease
peritonitis - CORRECT ANSWER-inflammation of the peritoneum (membrane lining the
abdominal cavity and surrounding the organs within it)
rebound tenderness, hard abdomen, severe continuous pain that's worse with movement, patient
lies still shallow breaths with tachypnea, fever, tachycardia
Secondary amenorrhea - CORRECT ANSWER-the absence of menstruation after a period of
normal menses.
Causes: primary ovarian insufficiency, PCOS, hypothalamic disorder, hyperprolactemia
normal breath sounds - CORRECT ANSWER-loud high pitched resembling air blowing
through a hollow pipe (bronchial)
Soft, low pitched gentle rustling sound heard over all except major bronchi (vesicular)
Medium-pitched sounds hear anteriorly over mainstem bronchi on either side of sternum
(bronchovesicular)
abnormal lung sounds - CORRECT ANSWER-bronchophony- repeat "99" and can be heard
whispered pectoriloquy- whispers 1,2,3 and can be heard clearly
Rebound tenderness - CORRECT ANSWER-peritoneal inflammation
Melena - CORRECT ANSWER-black tarry stool
Cushing's syndrome - CORRECT ANSWER-caused by prolonged exposure to high levels of
cortisol
findings- periorbital edema, moon face, purplish-red marks on abdomen (striae), hypertension
conductive hearing loss - CORRECT ANSWER-hearing impairment caused by interference
with sound or vibratory energy in the external canal, middle ear, or ossicles,
patient may hear better in a noisy environment, speaks softly because own voice seems loud,
hearing aid may help
cranial nerve XII - CORRECT ANSWER-Hypoglossal- tongue movement, speech, swallow
vesicular lung sounds - CORRECT ANSWER-normal
rhonchi - CORRECT ANSWER-Coarse, low-pitched breath sounds heard in patients with
chronic mucus in the upper airways when breathing OUT- COPD, bronchitis, fluid or mucus in
the airways
wheeze - CORRECT ANSWER-high-pitched, musical, squeaking adventitious lung sound
when breathing IN AND OUT. asthma, copd, bronchitis, allergies, anaphylaxis
stridor - CORRECT ANSWER-strained, high-pitched sound heard on inspiration caused by
obstruction in the pharynx or larynx when breathing IN- upper airway obstruction, croup
sensorineural hearing loss - CORRECT ANSWER-hearing loss caused by damage to the
cochlea's receptor cells or to the auditory nerves; also called nerve deafness
- hears sound but does not understand speech
- hearing aid may not help, makes sounds louder but not clearer
Cranial nerve I - CORRECT ANSWER-Olfactory (smell)
Cranial Nerve II - CORRECT ANSWER-Optic - vision
Cranial Nerve III - CORRECT ANSWER-oculomotor nerve
Cranial Nerve IV - CORRECT ANSWER-trochlear nerve- eye movement down and in
Cranial nerve V - CORRECT ANSWER-trigeminal nerve- sensation to the face
cranial nerve VI - CORRECT ANSWER-Abducens- abduction eye movement (outward)
Cranial nerve VII - CORRECT ANSWER-facial nerve- taste, face movements,
cranial nerve VIII - CORRECT ANSWER-Vestibulocochlear- hearing and balance
cranial nerve IX - CORRECT ANSWER-Glossopharyngeal- taste, and gag reflex
cranial nerve X - CORRECT ANSWER-vagus- swallow, speech, cough, and regulates HR and
digestion
Cranial Nerve XI - CORRECT ANSWER-accessory- head and shoulder movements
crackles (rales) - CORRECT ANSWER-Short and intermittent clicking, rattling, or popping
sounds heard during inhalation when air is forced through an airway narrowed by fluid.
pneumonia, pulmonary edema, bronchiectasis
pleural rub - CORRECT ANSWER-scratchy sound produced by pleural surfaces rubbing
against each other. pneumonia, pleurisy, PE, autoimmune disease
