Health Assessment Hesi Questions and Answers 100% Pass

Health Assessment Hesi Questions and Answers 100% Pass Which of the following statements from a patient's history is it most important to investigate further? a. "I have an allergy to peanuts." b. "I have lost 30 pounds over the last 4 months." c. "I don't like many vegetables so I take multivitamins." d. "I drink 2 cups of coffee each morning." ANS: B The statement in option "b is most important to investigate further because any significant weight loss may indicate a serious problem. The statement about an allergy to peanuts is not the most important piece of information, although the nurse would want to investigate and document any food allergies. Option "c" is not the most significant statement; however, the nurse should investigate the types and amounts of vegetables the patient eats. Two cups of coffee is considered fairly typical and the patient is not consuming an excessive amount of caffeine. Your patient complains of pruritus. You should examine the patient for which of the following associated signs and symptoms? a. rash and edema b. coolness and pallor c. cyanosis and coolness d. ecchymosis and purpura ANS: A Pruritus or itching of the skin is associated with the following manifestations: rashes, lesions, edema, angioedema, anaphylaxis, excoriation or ulcers as a result of scratching, lichenification or thickening of the skin, and systemic disease. As a result of scratching the skin due to pruritus, the skin would most likely be warm and red, not pale, cool, or cyanotic. Ecchymosis is a violaceous discoloration, also called a black-and-blue mark. Purpura is a condition characterized by the presence of confluent petechiae or confluent ecchymosis. Neither of these is associated with pruritus. ____ 3. Your patient asks you about the small, reddish purple discolorations of the skin, less than 0.5 cm in diameter. You inform the patient that this is known as which of the following? a. ecchymoses c. purpura b. petechiae d. spider telangiectasia ANS: B Petechiae are violaceous (red-purple) discolorations of less than 0.5 cm in diameter. Petechiae do not blanch. They can indicate an increased bleeding tendency or embolism; causes include intravascular defects and infections. Ecchymosis is a violaceous discoloration of varying size, also called a black-and-blue mark. It is caused by extravasation of blood into the skin as a result of trauma; heparin or Coumadin use; or liver dysfunction. Purpura is a condition characterized by the presence of confluent petechiae or confluent ecchymosis over any part of the body. Purpura is caused by hemorrhage into the skin and can be the result of decreased platelet formation. Spider angiomas, a type of telangiectasia, are bright red and star-shaped. Most often these lesions are found on the face, neck, and chest. There is often a central pulsation noted with pressure, and this results in blanching in the extensions. Your patient expresses concern about a mole on her right leg that has recently started itching. Which accompanying finding most likely indicates a developing cancerous lesion? a. regular and distinct border c. edema in both feet b. multiple colorations d. inflammation of periungual tissue ANS: B Developing cancerous lesions may have multiple colorations such as brownish, tan, red, white, blue, pink, purple, or gray. Other signs in potentially cancerous lesions include the following: 1) rapid change in size; 2) change in coloration; 3) irregular or butterfly-shaped border; 4) elevation in a previously flat mole; 5) multiple colorations in a lesion; 6) change in surface characteristics, such as oozing; 7) change in sensation, such as pain, itching, or tenderness; 8) change in surrounding skin, such as inflammation or induration; and 9) bleeding or ulcerative appearance in a mole. These lesions are not associated with edema or inflammation of the area around the fingernails or the toenails. After releasing the pressure of your thumb on your patient's lower legs, ankles, and feet, you observe a 4 mm depression of the skin that disappears in 10 to 15 seconds. You would report this finding as which of the following? a. 1+ pitting edema c. 3+ pitting edema b. 2+ pitting edema d. 4+ pitting edema ANS: B Edema is the accumulation of fluid in the intercellular spaces. Pitting edema is rated on a 4-point scale: 0+ = no pitting edema. 1+ = mild pitting edema; 2 mm depression that disappears rapidly. 2+ = moderate pitting edema; 4 mm depression that disappears in 10 to 15 seconds. 3+ = moderately severe pitting edema; 6 mm depression that can last more than 1 minute. 4+ = severe pitting edema; 8 mm depression that can last more than 2 minutes. The nurse checks the capillary refill of a new patient. The amount of time for the nail color to return after the pressure is released on the patient's nail should not exceed which of the following? a. 1-2 seconds c. 3-4 seconds b. 2