The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply.
A.Set the room temperature at a comfortable level.
B.Remove distracting objects from the...
The nurse is setting up the physical environment for an interview
with a client and plans to obtain subjective data regarding the client's
health. Which interventions are appropriate? Select all that apply.
A.Set the room temperature at a comfortable level.
B.Remove distracting objects from the interviewing area.
C.Place a chair for the client across from the nurse's desk.
D.Ensure comfortable seating at eye level for the client and nurse.
E.Provide seating for the so that the faces a strong light.
F.Ensure that the distance between the client and the nurse is at least
7 feet. - answer-Correct Answers: A, B, and D
Rationale:When preparing the physical environment for an interview,
the nurse would set the room temperature at a comfortable level.
The nurse would provide sufficient lighting for the client and nurse to
see each other. The nurse would avoid having the client face a strong
light because the client would have to squint into the full light.
Distracting objects and equipment need to be removed from the
interview area. The nurse would arrange seating so that the nurse
and client are seated comfortably at eye level, and the nurse avoids
facing the client across a desk or table, because this creates a barrier.
The distance between the nurse and the client would be set by the
nurse at 4 to 5 feet (1.2 to 1.5 meters). If the nurse places the client
any closer, the nurse will be invading the client's private space and
may create anxiety in the client. If the nurse places the client farther
away, the nurse may be seen as distant and aloof by the client.
,HESI- Health Assessment fully
answered
After performing an initial abdominal assessment on a client with
nausea and vomiting, the nurse would expect to note which finding?
A. Waves of loud gurgles auscultated in all four quadrants.
B. Low-pitched swishing auscultated in one or two quadrants.
C. Relatively high-pitched clicks or gurgles auscultated in one or two
quadrants.
D. Very high pitched, loud rushes auscultated in especially in one or
two quadrants. - answer-Correct Answer: A
Rationale:Although frequency and intensity of bowel sounds vary,
depending on the phase of digestion, normal bowel sounds are
relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi)
indicate hyperperistalsis and are commonly associated with nausea
and vomiting. A swishing or buzzing sound represents turbulent
blood flow associated with a bruit. Bruits are not normal sounds.
Bowel sounds are very high-pitched and loud (hyperresonance) when
the intestines are under tension, such as in intestinal obstruction.
Therefore, options 2, 3, and 4 are incorrect.
The nurse is performing a neurological assessment on a client and
elicits a positive Romberg's sign. The nurse makes this determination
based on which observation?
,HESI- Health Assessment fully
answered
A. An involuntary rhythmic, rapid twitching of the eyeballs.
B. A dorsiflexion of the ankle and great toe with fanning of the other
toes.
C. A significant sway when the client stands erect with feet together,
arms at the side and the eyes closed.
D. A lack of sense of position when the client is unable to return
extended fingers to a point of reference. - answer-Correct Answer: C
Rationale:In Romberg's test, the client is asked to stand with the feet
together and the arms at the sides, and to close the eyes and hold
the position; normally the client can maintain posture and balance. A
positive Romberg's sign is a vestibular neurological sign that is found
when a client exhibits a loss of balance when closing the eyes. This
may occur with cerebellar ataxia, loss of proprioception, and loss of
vestibular function. A lack of normal sense of position coupled with
an inability to return extended fingers to a point of reference is a
finding that indicates a problem with coordination. A positive gaze
nystagmus evaluation results in an involuntary rhythmic, rapid
twitching of the eyeballs. A positive Babinski's test results in
dorsiflexion of the ankle and great toe with fanning of the other toes;
if this occurs in anyone older than 2 years, it indicates the presence
of central nervous system disease.
A client with pneumonia is admitted to the hospital with difficulty
breathing. Which is the best approach for the nurse to use in
obtaining the client's health history?
, HESI- Health Assessment fully
answered
A.Focus only on the physical assessment.
B.Obtain all history information from the family members.
C.Plan short sessions with the client to obtain data.
D.Use the primary healthcare provider's medical history. - answer-
Correct Answer: C
Rationale:The best source of information is the client. Option 1 is
incorrect; the physical examination is not part of the health history.
Option 2 is incorrect because it refers to all information. Option 4 is
incorrect because the primary health care provider's medical history
provides data that are different from the nurse's assessment. All
efforts need to be made to obtain as much information as possible
from the client, using short sessions and closed-ended questions.
The nurse is assessing a client for meningeal irritation and elicits a
positive Brudzinski's sign. Which finding did the nurse observe?
A.The client rigidly extends the arms with pronated forearms and
plantar flexion of the feet.
B.The client flexes a leg at the hip and knee and reports pain in the
vertebral column when the leg is extended.
C.The client passively flexes his hip and knee in response to neck
flexion and reports pain in the vertebral column.
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