Exam (elaborations)
246 HESI EXAM STUDYGUIDE 2024
- Course
- Institution
246 HESI EXAM STUDYGUIDE 2024...
[Show more]
Content preview
246 HESI EXAM STUDYGUIDE 2024A 29 year old male client informs the nurse that he came to the clinic
to see if, "Maybe I have lung cancer or something," and wants to get
checked out since, "I can't seem to get rid of this body-wracking dry
cough that has been hanging around for the last six weeks." Which
computer documentation of this client's concerns should the nurse
enter?
A. Presents with a hacking non-productive cough of 6 weeks
duration.
B. Describe having a "body-wracking dry cough" of 6 weeks
duration.
C. Expresses concern of "lung cancer" symptoms for the last 6
weeks.
D. Young adult male presents with fears that he has "lung cancer" -
ANSWER -ANSWER- Correct answer is B, an assessment process
includes chief complaint which is how the patient describe why he is
here in the hospital or clinic and can't include diagnosis.
A 75-year-old client with a recent history of a cerebrovascular
accident (CVA) presents with right hemiparesis. The nurse tests the
deep tendon reflexes on the right side and elicits a brisk 4+
response. Which interpretation of this finding is accurate?
A. A normal reflex response.
B. Absent or sluggish response consistent with a lower motor neuron
lesion.
C. Flaccid paralysis.
D. Hyperactive response consistent with an upper motor neuron
disorder. - ANSWER - ANSWER- Correct answer is D, brisk 4+
,response is correlated with hyperactive response
The nurse examines a client's abdomen. Which finding indicates an
abnormal response when palpating the spleen?
A. Pain notes when palpating McBurney's point.
B. Tip of spleen palpable when client is asked to forcefully exhale.
C. Rebound tenderness with compression over right upper quadrant.
D. Firm mass palpated at bottom of left rib cage. - ANSWER -
ANSWER- Correct answer is D. McBurney's point is related to
appendicitis and not spleen
A male client arrives at the clinic for follow-up health assessment
after recent antibiotic treatment for pneumonia without
hospitalization. Which technique should the nurse implement to
assess for adventitious lung sounds?
A. Use the bell of the stethoscope to listen to the lung fields over
lower lobes.
B. Have the client lay flat while listening to the anterior surface of the
chest.
C. Press the stethoscope's diaphragm firmly on the skin over each
lung field.
D. Shave all chest hair that may distort sounds heard through the
diaphragm. - ANSWER - ANSWER- Correct answer is C. The nurse
should listen to all lungs fields during assessment and move from
side to side during auscultation
A client with streptococcus pharyngitis reports high fever, difficulty
swallowing and a muffled voice. Which complication should the nurse
suspect?
A. Foreign body obstruction.
B. Laryngeal polyps.
,C. Peritonsillar abscess.
D. Nasal polyps. - ANSWER . - ANSWER- Correct answer is C. Since
infections are associated with abscesses and pus
The nurse is obtaining a health history for a client prior to a
scheduled cholecystectomy. While interviewing the client, which
assessment technique should the nurse use when asking about the
client's use of illegal drugs and alcohol?
A. Obtain a drug using screen to verify legitimacy of client's stated
history.
B. Allow the client to decline answering social questions.
C. Ask specifically about alcohol, marijuana, cocaine, heroin, and
amounts.
D. Use the term illegal or illicit to describe street drugs - ANSWER -
ANSWER- Correct answer is C. When interviewing the patient,
questions should be clear and specific
The nurse applies pressure over an area of the lower abdomen
where the client reports pain. The client denies pain upon palpation,
but reports pain when the pressure is released. What action should
the nurse implement?
A. Offer to administer a laxative prescribed for PRN use.
B. Obtain a prescription to catheterize the client's bladder.
C. Instruct the client in distraction and relation techniques.
D. Notify the healthcare provider of the rebound tenderness -
ANSWER - ANSWER- Correct answer is D. As this could be a sign of
appendicitis
The nurse is assessing an ulcer on a client's lower extremity, which is
likely the result of either venous or arterial insufficiency. Which
assessment technique should the nurse use to differentiate the
pathophysiology causing the ulcer?
, A. Measure the degree of join range of motion in the extremity.
B. Compare the skin turgor of the client's upper and lower leg.
C. Observe the specific location and appearance of the ulceration.
D. Note any change in the color of the ulcer when the leg is moved -
ANSWER - ANSWER-Correct answer is C. Location and appearance
of the ulcer would give us the type (venous vs arterial) Venous:
develop on the inner lower leg, shallow wounds that are large and
irregular edges that slope, red with granular tissue, discoloration
with yellow slough present, shiny skin warm or scaly Arterial: occur
most often on the foot, on the heels and around lateral malleolus,
round shaped, well-defined edges, yellow, brown or black in color,
skin pale and non granulating, deep but may also appear shallow in
early stages, skin is thin, smooth, taut, and dry. Loss of hair on the
leg is also common
The nurse is conducting a physical assessment of a young adult.
Which information provides the best indication of the individual's
nutritional status?
A. Status of current appetite.
B. A 24-hour diet history.
C. History of a recent weight loss.
D. Condition of hair, nails, and skin - ANSWER - ANSWER- Correct
answer is D. Hair, nail, and skin are the most important reflection of
nutritional status
The nurse is assessing a healthy adult male during an annual
physical examination. The nurse auscultates the client's abdomen
and hears gurgling sound every ten seconds. What action should the
nurse take in response to this finding?
A. Document this normal bowel sound activity in the record.
B. Encourage increased consumption of fiber in the diet.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Boostertips. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $14.99. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
77254 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now