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PN 135 HESI STUDY GUIDE EXAM QUESTIONS AND VERIFIED ANSWERS
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PN 135 HESI STUDY GUIDE EXAM QUESTIONS AND VERIFIED ANSWERS...
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What would you notice in a patient with abdominal guarding?Sometimes patients will guard a tender area, which means they tighten up
abdominal muscles when the area is touched.
grimacing and other facial expressions
What are you looking for/at when looking for symmetry in the abdomen?
Even shape, no bulges, and a centrally located belly button
What do you do when you note an abnormality in abdomen symmetry?
Examine it further, check for pain, listen for bowel sounds, and consider
diagnostic tests.
In what position is an abdominal assessment conducted in?
The abdominal assessment is performed while the patient is in the supine
position with a pillow behind the head and knees.
How will you assess muscle strength on a patient?
manual muscle test
ROM
In reviewing a patients home meds, what are you looking for?
interactions
duplicates
consistency
Where are all the places you might assess a pulse.
carotid, femoral, popliteal, and pedal pulses, apical and radial pulse
What makes assessing an apical pulse different
, the apical pulse must be assessed for a full minute
How do you assess for JVD
-have patient lay flat
-Note the highest point of pulsation in the jugular vein.
-If the vein is distended more than 3-4 centimeters above the sternal angle
(the angle of Louis), it indicates JVD.
Looking at the legs, what might you note in a focused assessment?
color, temperature, moisture, swelling
What is the difference between peripheral vascular disease and venous
insufficiency?
> Peripheral Vascular Disease is a broad term that includes any disorder of
the blood vessels outside the heart and brain. It often refers to Peripheral
Artery Disease (PAD), which involves narrowing or blockage of the arteries
that supply blood to the legs
> Venous Insufficiency is a condition where the veins in the legs cannot
effectively return blood to the heart, leading to blood pooling in the vein
_________ bowel sounds. Loud, gurgling borborygmi often accompanies
increased motility of the bowel, such as with diarrhea
Increased bowel sounds
____________ bowel sounds. Diminished or absent bowel sounds accompany
inhibition of bowel motility.
Decrease bowel sounds
______________ bowel sounds are irregular, high-pitched, and gurgling and
occur every 5 to 15 seconds.
Normal bowel sounds
________________ bowel sounds tend to be loud, high-pitched, and rushing;
they are commonly heard with diarrhea or inflammatory disorders.
Hyperactive bowel sounds
_______________ bowel sounds are slow and sluggish, with occurrence of
less than five sounds per minute.
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