BSN 246 HESI Health Assessment Complete Exam Preparation: Questions & Answers:HESI Health Assessment Test Bank: Guaranteed A+ Score Guide

The registered nurse (RN) reviews the new prescription, phenelzine, a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is most important for the RN to assess? A. Consumption of any alcohol or tyramine-rich foods. B. Complaints of nausea or vomiting. C. Therapeutic serum drug levels. D. Blood pressure and pulse prior to taking each dose. (Ans- A All alcohol (A) and any foods that contain tyramine should be avoided while taking an MAO inhibitor, which interact to cause a hypertensive crisis. (B and C) should be discussed, but are not as important as (A). Although assessing blood pressure and pulse may be indicated, it is not necessary prior to taking each dose (D). A female client is recently diagnosed with Sarciodosis. The client tells the registered nurse (RN) that she does not understand why she has this. When teaching about the occurrence of sarcoidosis, the RN should include that sarcoidosis most commonly occurs with which ethnic group of women? A. African American women B. Caucasian women C. Asian women D. Hispanic women (Ans- A Sarcoidosis, an autoimmune inflammatory disease affecting multiple organs, has shown presence in relatives due to multiple genes that together to increase the susceptibility of developing the disease, which most commonly occurs in African American women and women of Northern European heritage (A). (B, C, and D) have a lower percentage of women affected by sarcoidosis than African American women. A client who uses ipratropium reports having nausea, blurred vision, headaches, and insomnia after using the inhaler. Which action should the registered nurse (RN) implement first? A. Withhold medication and report symptoms and vital signs to healthcare provider. B. Give PRN medication for nausea and vomiting and evaluate client in 30 minutes. C. Reassure client that the ipratropium given will alleviate the symptoms. D. Delay administration of ipratropium until next maintenance medication is scheduled. (Ans- A Headache, nausea, blurred vision and insomnia are symptoms of excessive use of ipratropium, so withholding the medication (A) until the healthcare provider is notified should be initiated to maintain client safety. If the symptoms continue and are not addressed immediately, then (B, C, and D) may place the client in imminent danger. A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the registered nurse (RN) anticipate to be elevated if the client experienced myocardial damage? A. Creatine Kinase (CK-MB) B. Serum troponin C. Myoglobin D. Ischemia modified albumin (Ans- B Troponin (B) is the most sensitive and specific test for myocardial damage. Troponin elevation is more specific than CK-MB (A). (C) can be elevated when there is skeletal muscle damage. (D) can be elevated nonspecifically and create false positives, so is not a reliable choice. The registered nurse (RN) is caring for an older client who recently experienced a fractured pelvis from a fall. Which assessment finding is most important for the RN to report to the healthcare provider? A. Lower back pain B. Headache of 7 on scale of 1 to 10 C. Blood pressure of 140/98 D. Dyspnea (Ans- D A client with a large bone fracture is at risk for intramedullary fat leaking into the blood stream and becoming embolic. Dyspnea is an indication of fat embolism to the lungs and should be reported to the healthcare provider immediately. (A, B, and C) are expected findings after a fall and do not require immediate notification of a healthcare provider. While caring for a client who has esophageal varices, which nursing intervention is most important for the registered nurse (RN) to implement? A. Monitor infusing IV fluids and any replacement blood products B. Prepare for esophagogastroduodenoscopy (EGD) C. Maintain a client on strict bedrest D. Insert a nasogastric tube (NGT) for intermittent suction (Ans- A Maintaining hemodynamic stability in a client with esophageal varices can precipitate a life-threatening crisis if esophageal varies leak or rupture and can result in hemorrhage. The priority is assessing and monitoring infusions of IV fluids and any replacement blood products (A). The healthcare provider should be present during (B and D) in the event the client's esophageal varies rupture and bleed profusely. Bedrest (C) is not a priority at this time. The registered nurse (RN) is caring for an older client who has been bedridden for two weeks. Which assessment findings indicate to the RN that the client is developing a complication related to immobility? A. Decreased pedal pulses B. Edema in upper extremities C. Loss of appetite for food D. Stiffness in right ankle joint (Ans- D Stiffness in joints is an early sign of contractures and muscle atrophy (D) related to inactivity and immobility. Decreased pedal pulses (A), upper extremity (B) and a loss of appetite (C) are not directly related to immobility. An 82-year-old client is admitted with pneumonia. Which of the following actions should be the nurse's first priority as she performs this client's admission assessment? A. Having the client sign the admission forms B. Establishing rapport with the client C. Obtaining the necessary equipment D. Taking the client's vital signs (Ans- B The first priority of a successful physical assessment is establishing rapport with the client. Having the client sign the admission forms, taking his vital signs, and obtaining equipment are also important but aren't the nurse's first priority in most cases. An 86-year-old client is admitted with a diagnosis of syncope. He tells the nurse, "When I get up in the morning, I feel dizzy." The nurse replies, "You feel dizzy when you get out of bed in the morning?" What communication strategy is this nurse using? A. Reflection B. Facilitation C. Confirmation D. Summarization (Ans- A Reflection is a technique that involves repeating something the client has just said. It can help the nurse obtain more specific information. Facilitation involves using phrases that encourage the client to continue with his story. Confirmation helps clear misconceptions. Summarization restates the information that the client has given. An occupational health nurse is performing a physical assessment on a prospective company employee. Which assessment should she perform first? A. Vital signs B. Presence of skin lesions C. Anthropometric measurements D. Appearance (Ans- D After assembling the necessary equipment, the nurse should perform the first part of the assessment-forming an initial impression of the client by observing his appearance. Vital signs should follow this initial observation. Assessment for skin lesions and anthropometric measurements should occur later in the assessment process. A 52-year-old client is admitted with unstable angina. The nurse assigned to the client notes an irregular rhythm when assessing his pulse. To further assess the irregular pulse, the nurse knows she must determine the client's pulse deficit. Which pulses help identify pulse deficit? A. Carotid and apical B. Apical and radial C. Radial and brachial D. Carotid and radial (Ans- B When determining a pulse deficit, the nurse should palpate the radial pulse while auscultating the apical pulse. The apical pulse rate minus the radial pulse rate equals the pulse deficit. Pulse deficit isn't identified using the carotid or brachial pulses.