Wgu rn hesi health assessment

Question 1: View

Exhibits

Which assessment(s) should the nurse conduct? Select all that apply.

A. Muscle tone B. Level of consciousness C. Cranial nerves D. Brudzinski reflexes E. Pupil size F. Glasgow coma scale G. Romberg's test

Explanation

A. Muscle tone: Assessing muscle tone is important to evaluate for motor deficits or neurological impairments that may have contributed to the fall or been caused by a cerebrovascular event.

B. Level of consciousness: The client’s inability to recall the events leading to the fall requires an assessment of mental status and level of consciousness to identify potential cognitive or neurological issues.

C. Cranial nerves: A cranial nerve assessment can detect focal neurological deficits indicative of stroke or other neurological conditions.

D. Brudzinski reflexes: This reflex is assessed for meningitis and would not be relevant in this scenario as the client does not exhibit symptoms such as fever, nuchal rigidity, or photophobia.

E. Pupil size: Changes in pupil size and reactivity may indicate increased intracranial pressure or other neurological changes.

F. Glasgow Coma Scale (GCS): This scale is crucial for assessing the client’s neurological status and level of consciousness, especially given the fall and dizziness.

G. Romberg's test: This test evaluates balance and proprioception, but it is less appropriate in the acute setting when the priority is to assess for neurological deficits related to the fall or potential cerebrovascular event.

Question 2: View

When assessing a client's range of motion, the nurse notes crepitation with movement of the left knee. Which information in the client's history is most likely related to this finding?

A. Needle aspiration of the synovial space. B. Knee arthroplasty surgery. C. Degenerative disease. D. History of a fractured patella.

Explanation

A. Needle aspiration of the synovial space: This procedure is typically diagnostic or therapeutic and does not cause crepitation directly.

B. Knee arthroplasty surgery: Post-surgical complications could cause limited motion, but crepitation is more likely linked to degenerative processes.

C. Degenerative disease: Crepitation is often a result of degenerative joint disease (e.g., osteoarthritis) caused by the breakdown of cartilage and bone rubbing together.

D. History of a fractured patella: While this can affect joint function, crepitation is less commonly associated unless significant degenerative changes have occurred.

Question 3: View

While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?

A. Borborygmi sounds. B. Hypoactive bowel sounds. C. Normal bowel sounds. D. Hyperactive bowel sounds.

Explanation

A. Borborygmi sounds: These are loud, prolonged gurgles heard during increased peristalsis, typically associated with conditions like diarrhea.

B. Hypoactive bowel sounds: These occur less frequently than every 5 to 10 seconds, typically associated with conditions like ileus.

C. Normal bowel sounds: Normal bowel sounds consist of intermittent gurgles occurring every 5 to 15 seconds in all quadrants.

D. Hyperactive bowel sounds: These are high-pitched, frequent sounds occurring more often than every 5 seconds and may indicate obstruction or increased motility.

Question 4: View

The nurse is assessing a client with gallstones for jaundice. Which action should the nurse perform to confirm this information?

A. Review recent serum bilirubin levels. B. Assess conjunctival sacs of lower lids for pallor. C. Observe the client's urine for dark orange color. D. Examine client's sclera for icterus.

Explanation

A. Review recent serum bilirubin levels: This is an indirect confirmation but not part of a physical assessment.

B. Assess conjunctival sacs of lower lids for pallor: This checks for anemia, not jaundice.

C. Observe the client's urine for dark orange color: This may suggest jaundice but is not definitive or diagnostic.

D. Examine the client's sclera for icterus: Scleral icterus is the most reliable physical sign of jaundice and directly reflects elevated bilirubin levels.

Question 5: View

A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

A. Advise the client to see his healthcare provider for immediate evaluation. B. Offer to teach a family member how to monitor the skin around the mole. C. Encourage the client to keep checking the mole with a magnifying mirror. D. Ask the client if he often spends time outside in the sun without a shirt.

Explanation

A. Advise the client to see his healthcare provider for immediate evaluation: A mole that has changed color and size may indicate melanoma, which requires urgent evaluation.

B. Offer to teach a family member how to monitor the skin around the mole: This is not a priority action and delays necessary evaluation.

C. Encourage the client to keep checking the mole with a magnifying mirror: Monitoring is insufficient for a mole with suspicious changes.

D. Ask the client if he often spends time outside in the sun without a shirt: While UV exposure is a risk factor, this is not relevant to the immediate concern.

Question 6: View

The nurse is obtaining a health history for a client being admitted for new onset seizures. Which action should the nurse implement to accurately record the health history findings?

A. Enter the information in the electronic medical record at the client's bedside. B. Document the assessment findings on the computer at the nursing station. C. Document the client's history that is directly related to current admission diagnoses. D. Enter subjective data in the note section of the client's electronic medical record.

Explanation

A. Enter the information in the electronic medical record at the client's bedside: This ensures accuracy and allows for real-time clarification with the client.

B. Document the assessment findings on the computer at the nursing station: Delaying documentation may lead to errors or omissions.

C. Document the client's history that is directly related to current admission diagnoses: While focused documentation is important, all relevant history should be recorded.

D. Enter subjective data in the note section of the client's electronic medical record: Subjective data should be documented, but this is not the primary action for obtaining a health history.

Question 7: View

The nurse assesses a young adult female who was brought to the emergency department (ED) by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?

A. Sudden onset of severe anxiety, fear, and concern. B. Periumbilical pain localizing to right lower quadrant. C. Anorexia progressing to nausea, vomiting, and fever. D. Diffuse abdominal pain with elevated neutrophil count.

Explanation

A. Sudden onset of severe anxiety, fear, and concern: These symptoms are not indicative of appendicitis.

B. Periumbilical pain localizing to the right lower quadrant: This is a classic sign of appendicitis due to inflammation irritating surrounding tissues.

C. Anorexia progressing to nausea, vomiting, and fever: While common in appendicitis, these findings are non-specific.

D. Diffuse abdominal pain with elevated neutrophil count: Appendicitis pain typically localizes rather than remaining diffuse.

Question 8: View

To assess for the presence of egophony, which instruction should the nurse give the client who has a lung abscess?

A. Repeat the number "99" during a systematic auscultation of the thorax B. Whisper "one, two, three" in sequence during auscultation of the thorax. C. Repeat vocalizing the letter "E" while the thorax is auscultated. D. Breathe in and out while all lobes of both lungs are auscultated.

Explanation

A. Repeat the number "99": This test is for bronchophony, not egophony.

B. Whisper "one, two, three": This tests for whispered pectoriloquy.

C. Repeat vocalizing the letter "E": Egophony is assessed by having the client say "E" while auscultating the thorax. In areas of lung consolidation (e.g., a lung abscess), "E" sounds may be heard as "A."

D. Breathe in and out: This assesses general breath sounds, not egophony.

Question 9: View

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Explanation

Potential Condition: Lobar pneumonia

Actions to take:

Auscultate the lungs for adventitious breath sounds
Inspect the chest for lag on the affected side

Parameters to monitor

Crackles
Respiratory rate and pulse

Rationale:

Potential Condition: Lobar pneumonia

The client presents with worsening breathing difficulty, a mild fever, elevated respiratory rate, and borderline hypoxemia, which are indicative of pneumonia. The chest X-ray order supports the suspicion of a lung infection, such as lobar pneumonia.

Actions to Take:

Auscultate the lungs for adventitious breath sounds: Lobar pneumonia often produces abnormal lung sounds, such as crackles or bronchial breath sounds, over the affected lobe. This assessment helps confirm consolidation in the lung.

Inspect the chest for lag on the affected side: Chest lag may indicate reduced ventilation of the affected lobe, a hallmark of pneumonia.

Parameters to Monitor:

Crackles: A common finding in pneumonia, crackles result from the movement of air through fluid-filled alveoli. Monitoring for resolution or worsening crackles can assess treatment efficacy.

Respiratory rate and pulse: Both are essential indicators of respiratory and cardiovascular status. An increasing respiratory rate or tachycardia may signal worsening oxygenation or sepsis.

Rationale for Incorrect Options:

Other Conditions

Pleural effusion: While it can cause respiratory symptoms, pleural effusion typically presents with dullness to percussion and diminished breath sounds, not crackles or lobar consolidation.

Atelectasis: Usually presents with diminished or absent breath sounds and often resolves with deep breathing exercises or incentive spirometry.

Acute bronchitis: This condition is associated with a productive cough, wheezing, and diffuse lung involvement, not localized findings like in lobar pneumonia.

Other Actions:

Assess for tactile fremitus: Fremitus is reduced in pleural effusion or pneumothorax, but pneumonia typically increases fremitus over the affected lobe.

Assess for muffled heart sounds: This is associated with cardiac tamponade, not pneumonia.

Assess for prolonged expiration: This is more relevant in obstructive conditions like asthma or COPD.

Other Parameters to Monitor:

Loud bronchial breathing: Although it may occur, it is less specific and not always present in pneumonia.

Cyanosis: This would indicate advanced hypoxemia, which is not present in this client (oxygen saturation is 94% on room air).

Wheezing: More commonly associated with bronchospasm or asthma, not lobar pneumonia.

Question 10: View

When assessing an older adult 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?

A. Palpate the radial pulses in both arms for a deficit. B. Feel the volume of the dorsalis pedis and posterior tibialis pulses. C. Use the stethoscope to listen over the carotid artery. D. Auscultate the apical pulse at the point of maximal impulse.

Explanation

A. Palpate the radial pulses: This may not reveal irregularities or provide an accurate heart rate, especially in clients with conditions like atrial fibrillation.

B. Feel the dorsalis pedis and posterior tibialis pulses: These assess peripheral circulation, not the heart rate.

C. Use the stethoscope over the carotid artery: While it assesses blood flow in the carotid artery, it is not the best method for determining pulse rate.

D. Auscultate the apical pulse: This provides the most accurate assessment of heart rate and rhythm, especially in clients with cardiac disease.