To assess a female client for hirsutism, which action should the nurse take? Assess
the appearance of the clients face
A nurse is completing the health history for a 25 year old male client who reports that he
is allergic to penicillin. Which question should the nurse ask after receiving the
...
a client who recently underwent a routine surgical
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HESI Study Guide -Health Assessment Q&A To assess a female client for hirsutism, which action should the nurse take? ✅Assess the appearance of the clients face A nurse is completing the health history for a 25 year old male client who reports that he is allergic to penicillin. Which question should the nurse ask after receiving the information? ✅What happens to you when you take penicillin? A client who recently underwent a routine surgical procedure made a clinic appointment. To elicit the most information which question is best for the nurse to ask the client? ✅What type of surgery did you have? The nurse reorients a male client to the correct time, day, date, and location, but he is only able to remember his name and where he is. Based on these findings, which should the nurse document? ✅Oriented x 2 Which finding, obtained during a skin assessment, should the school nurse report to the healthcare provider? ✅Red, swollen, painful nodule located on upper back on a school -aged boy The nurse observes that the lower legs of a client with diabetes mellitus are shiny, and with no hair growth. To obtain additional data to support these findings, what assessment should the nurse perform? ✅Palpate the clients dorsalis pedis pulses When assessing a client's abdomen, the nurse uses auscultation to assess for which possible findings? ✅Bruits To compare arterial circulation in a client's lower extremities, what assessment should the nurse complete? ✅Palpate the volume of the pedal pulses The nurse completes percussion of the abdomen on an adult client. Which finding is considered normal for this client? ✅Musical and drum -like During an abdominal assessment, a client with a temperature of 103 F (39.4 C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement? ✅Nothing by mouth When assessing a client's mouth, which findings requires immediate follow -up by the nurse? ✅Fruity odor of the breath A nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual's nutritional status? ✅Condition of hair, nails, and skin When entering a client's room, the nurse observes that the client is using pursed -lip breathing. It is most important for the nurse to monitor the client for which problem? ✅Syncope While assessing a client, the nurse notes an audible expiratory wheeze and a respiratory rate of 30 breaths per minute. What action should the nurse implement? ✅Auscultate all lobes of the client's lungs When assessing an older client with a history of cardiovascular disease, dyspnea, and peripheral edema, which method is best for the nurse to use to assess the client's pulse rate? ✅Auscultate the apical pulse at the point of maximal impulse The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding? ✅Hematocrit During an admission assessment, which approach should the nurse use to assess a client's speech patterns? ✅... When conducting a physical examination, the nurse uses a tuning fork to assess for which condition? ✅Hearing Loss When interviewing an elderly client, the nurse observes that the client's hands tremble uncontrollably while reaching for a glass of water how should the nurse document the finding? ✅Intention tremor The nurse is performing a mental status examination and asks the client to interpret a familiar proverb. When the client is unable to interpret the proverb the nurse implements? ✅... In assessing an adult client, the nurse calculates the BMI (body mass index) as 14 kg/m2. what nursing problem should be included in this client's plan of care? ✅Unbalanced nutrition, less than body needs Which area of the body should the nurse examine to best reveal the presence of petechiae in a dark -skinned person? ✅Mucous membranes While conducting a physical assessment, the nurse shines a pen light into a client's right eye and moves the light source to check the client's left eye. Which finding indicates the need for further evaluation? ✅.. An elderly client with history of heart failure comes to the clinic complaining of awakening during the night in a cold sweat, accompanied by difficulty breathing and rapid heartbeat. Which assessment should the nurse complete first? ✅... The nurse is assessing a client for goiter and is unable to observe the thyroid gland. Which action should the nurse take? ✅Ask the client to swallow while palpating along the sides of the trachea In obtaining a client's health history related to smoking cigarettes, the nurse plans to determine the client's smoking pack years. What information should the nurse obtain for this calculation? a. Number of years the client smoked b. Number of attempts to quit smoking c. Packs of cigarettes smoked per day d. Client's current age e. Age when the client started smoking ✅A. Number of years the client smoked C. Pack of cigarettes smoked per day In assessing a client's sensory nerve function, the nurse prepares to assess the client's response to temperature. What action should the nurse include during this assessment? ✅Instruct the client to close both eyes During assessment of a client's abdomen, the nurse observes that the client's umbilicus is depressed and below the surface of the abdomen. What action should the nurse take in response to this observation? ✅Document the normal finding
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