While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include in the history?
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HESI RN · Assessing Vital Signs ATI
Question 2 of 62
Vital signs are based on....
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Question 3 of 62
Shoulder ROM involves 180° of flexion, 180° of abduction, 60° of extension, and 60° of adduction. How many degrees of scapulothoracic motion is involved in shoulder abduction?
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Question 4 of 62
Structures passing through the carpal tunnel into the hand include which of the following?
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Question 5 of 62
A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. The nurse recognizes that he:
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Question 6 of 62
During a physical assessment, the nurse observes that a client's blood pressure is 160/100 mmHg. What action should the nurse take?
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Question 7 of 62
A home health nurse is visiting a patient who recently was hospitalized for repair of a fractured hip. The patient tells the nurse, I have had a lot of pain in my abdomen. What type of assessment would the nurse conduct?
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Question 8 of 62
A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, 'You don't smoke, drink, or take drugs, do you?' This question is an example of:
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Question 9 of 62
The nurse is assessing a patient for signs of heart failure. Which finding is most consistent with this condition?
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Question 10 of 62
During a respiratory assessment, the nurse observes that the patient's chest moves asymmetrically during inspiration. What is the most likely cause?
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Question 11 of 62
Josh is a 14-year-old boy who presents with a sore throat. On examination, you notice dullness in the last intercostal space in the anterior axillary line on his left side with a deep breath. What does this indicate?
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Question 12 of 62
The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use?
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Question 13 of 62
While assessing vital signs of a patient with a head injury and increased intracranial pressure (IICP), a nurse notes that the patients respiratory rate is 8 breaths/min. How will the nurse interpret this finding?
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Question 14 of 62
The nurse is assessing the abdomen of a patient and notes visible peristalsis. What does this finding most likely indicate?
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Question 15 of 62
Which of the following examples represents a subjective finding?
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Question 16 of 62
When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. Next, the nurse should:
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Question 17 of 62
The patient wants to monitor blood pressure at home and asks the nurse's advice about how to purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient?
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Question 18 of 62
A nurse is helping at a health fair at a local mall. When taking blood pressures on a variety of people, the nurse keeps in mind that:
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Question 19 of 62
The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say?
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Question 20 of 62
The electrical stimulus of the cardiac cycle follows which sequence?
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Question 21 of 62
During percussion of the abdomen, the nurse notes a dull sound over the liver. What does this indicate?
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Question 22 of 62
A newborns temperature should be:
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Question 23 of 62
The nurse is auscultating a patient's heart sounds and notes a high-pitched, blowing sound during systole. What is the most likely cause of this finding?
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Question 24 of 62
During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for approximately 2 weeks. In trying to find the cause of the rash, which question would be important for the nurse to ask?
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Question 25 of 62
A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient's skin?
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Question 26 of 62
The nurse is assessing the patient's ability to stand on one leg with their eyes closed. Which aspect of neurological function is being tested?
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Question 27 of 62
Which assessment finding is most consistent with left-sided heart failure?
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Question 28 of 62
The nurse is assessing a patient's cranial nerve II (optic nerve) function. Which test is most appropriate?
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Question 29 of 62
A nurse is assessing a client's pulse rate and finds it to be irregularly irregular with no discernible pattern. What action should the nurse take?
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Question 30 of 62
A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to the hospital ED. His wife tells you that he fell down the stairs about a month ago but 'he didn't have a scratch afterward.' She feels that he has become gradually less active and sleepier over the last 10 days or so. Which of the following collaborative interventions will you implement first?
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Question 31 of 62
The nurse is performing a respiratory assessment and notes that the patient has an increased work of breathing. What is the priority action?
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Question 32 of 62
A 17-year-old high school senior presents to your clinic in acute respiratory distress with sudden right-sided chest pain and severe shortness of breath. On auscultation you hear no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe.
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Question 33 of 62
You are examining a newborn and note that the right testicle is not in the scrotum. What should you do next?
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Question 34 of 62
The nurse is performing a neurological assessment and asks the patient to touch their nose with their finger. Which aspect of neurological function is being tested?
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Question 35 of 62
The nurse is counting an infant's respirations. Which technique is correct?
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Question 36 of 62
A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. The nurse suspects:
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Question 37 of 62
During a staff meeting, nurses discuss problems with accessing research studies to incorporate EBP into their practice. Which suggestion by the nurse manager would best help these problems?
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Question 38 of 62
A 30-year-old man presents with a complaint of shortness of breath and a cough. He has a history of asthma. On examination, he has wheezing and use of accessory muscles during respiration. What is the most likely diagnosis?
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Question 39 of 62
During a cardiac assessment, the nurse notes a pulse deficit. How is this finding assessed?
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Question 40 of 62
A nurse assesses the rectal temperature of a patient who is postoperative following oral surgery. What patient assessment needs to be made before taking this temperature?
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Question 41 of 62
The nurse is assessing a patient's cranial nerves. How is cranial nerve II (optic nerve) tested?
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Question 42 of 62
A woman in her 26th week of pregnancy states that she is 'not really short of breath' but feels that she is aware of her breathing and the need to breathe. What is the nurse's best reply?
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Question 43 of 62
What is the normal range of motion for plantar flexion of the ankle?
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Question 44 of 62
The nurse is caring for an infant and is obtaining the patient's vital signs. The best site for the nurse to obtain the infant's pulse would be the artery.
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Question 45 of 62
Heberden's nodes are found in which condition?
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Question 46 of 62
A 22-year-old advertising copywriter presents for evaluation of joint pain. The pain is new, located in the wrists and fingers bilaterally, with some subjective fever. The patient denies a rash; she also denies recent travel or camping activities. She has a family history significant for rheumatoid arthritis. Based on this information, which of the following pathologic processes would be the most correct?
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Question 47 of 62
The nurse is assessing the mental status of a child. Which statement about children and mental status is true?
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Question 48 of 62
Susanne is a 27-year-old who has had headaches, muscle aches, and fatigue for the last 2 months. You have completed a thorough history, examination, and laboratory workup but have not found a cause. What would your next action be?
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Question 49 of 62
While assessing breath sounds, a nurse hears crackles. What causes these abnormal sounds?
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Question 50 of 62
The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, "I think she is getting her first tooth because she has started drooling a lot." The nurse's best response would be:
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Question 51 of 62
On visual confrontation testing, a stroke patient is unable to see your fingers on his entire right side with either eye covered. Which of the following terms would describe this finding?
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Question 52 of 62
Which of the following is the most effective type of transcutaneous electrical nerve stimulation (TENS) stimulator?
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Question 53 of 62
The following information is recorded in the health history: 'The patient has had abdominal pain for 1 week. The pain lasts for 30 minutes at a time; it comes and goes. The severity is 7 to 9 on a scale of 1 to 10. It is accompanied by nausea and vomiting. It is located in the mid-epigastric area.' Which of these categories does it belong to?
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Question 54 of 62
A patient has been transferred to your unit from the respiratory intensive care unit, where he has been for the past 2 weeks recovering from pneumonia. He is receiving oxygen via 4 L nasal cannula. His respiratory rate is 26 breaths/min, and his oxygen saturation is 92%. In planning his care, which information is most helpful in determining your priority nursing interventions?
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Question 55 of 62
When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?
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Question 56 of 62
When examining an older adult, the nurse should:
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Question 57 of 62
The nurse is working the night shift on a surgical unit and notices that the patient's temperature is 96.8°F (36°C), whereas at 4:00 PM the preceding day, it was 98.6°F (37°C). What should the nurse do?
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Question 58 of 62
The nurse is assessing a patient's lungs and hears wheezing during exhalation. What is the most likely cause of this finding?
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Question 59 of 62
Which of the following symptoms is most likely to be documented under the neurological system in the review of systems?
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Question 60 of 62
Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as:
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Question 61 of 62
The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal?
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Question 62 of 62
Which of the following findings during palpation of the abdomen is considered abnormal?
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