BSN 246 HESI Health Assessment V1The 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...
BSN 246 HESI Health Assessment V1
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.
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.
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.
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