Chapter 12 Vital Signs Assessment

HESI RN · Chapter 12 Vital Signs Assessment

Question 1 of 63

The nurse is assessing a patient's pupillary response and observes that both pupils constrict when light is directed into one eye. What does this finding indicate?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 2 of 63

The differential diagnosis of trigger finger includes which of the following?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 3 of 63

A patient reports severe abdominal pain. The nurse begins with:

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HESI RN · Chapter 12 Vital Signs Assessment

Question 4 of 63

You observe a nursing student taking a blood pressure (BP) on a patient. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. The student used a BP cuff that was too narrow for the patient. Which of the following BP readings made by the student is most likely caused by the incorrect choice of BP cuff?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 5 of 63

A nurse is assessing a client's respiratory rate and finds it to be 8 breaths per minute. What action should the nurse take first?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 6 of 63

For a client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to:

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HESI RN · Chapter 12 Vital Signs Assessment

Question 7 of 63

The nurse is performing a neurological assessment and asks the patient to touch their nose with their finger and then touch the nurse's finger. Which aspect of neurological function is being tested?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 8 of 63

Suzanne, a 25-year-old, comes to your clinic to establish care. You are the student preparing to go into the examination room to interview her. Which of the following is the most logical sequence for the patient-provider interview?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 9 of 63

The nurse is assessing a patient's cranial nerve function and asks the patient to stick out their tongue. Which cranial nerve is being tested?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 10 of 63

During an interview, a patient reveals that she is pregnant. She states that she is not sure whether she will breastfeed her baby and asks for some information about this. Which of these statements by the nurse is accurate?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 11 of 63

A patient presents with ear pain. She is an avid swimmer. The history includes pain and drainage from the left ear. On examination, she has pain when the ear is manipulated, including manipulation of the tragus. The canal is narrowed and erythematous, with some white debris in the canal. The rest of the examination is normal. What diagnosis would you assign this patient?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 12 of 63

Which statement is true regarding the arterial system?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 13 of 63

A 40-year-old woman presents with complaints of fatigue and muscle weakness. On examination, she has ptosis and weakness of the proximal muscles of the upper limbs. What is the most likely diagnosis?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 14 of 63

A nurse is conducting a health history for a patient with a chronic respiratory problem. What question might the nurse ask to assess for orthopnea?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 15 of 63

A 35-year-old man is brought to the emergency department after a motorcycle accident. He is conscious but has pain in his chest. His vital signs are as follows: BP 100/60 mm Hg, pulse 120 bpm, and respiratory rate 22 breaths/min. Physical examination reveals bruising and tenderness over the left side of his chest. Which of the following is the most likely cause of his pain?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 16 of 63

Which of the following symptoms is relevant to the genitourinary system?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 17 of 63

The normal temperature for an adult is:

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HESI RN · Chapter 12 Vital Signs Assessment

Question 18 of 63

The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that:

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HESI RN · Chapter 12 Vital Signs Assessment

Question 19 of 63

Evidence-based nursing practice is:

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HESI RN · Chapter 12 Vital Signs Assessment

Question 20 of 63

A 50-year-old woman with a history of alcohol use presents with jaundice, abdominal pain, and ascites. Her serum bilirubin and liver enzymes are elevated. What is the most likely diagnosis?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 21 of 63

Mr. Martin is a 72-year-old smoker who comes to you for his hypertension visit. You note that with deep palpation you feel a pulsatile mass which is about 4 centimeters in diameter. What should you do next?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 22 of 63

A 52-year-old man presents with a complaint of chest pain. The pain is crushing and radiates to his left arm. He has a history of hypertension and diabetes mellitus. His vital signs are as follows: BP 150/90 mm Hg, pulse 105 bpm, and respiratory rate 20 breaths/min. What is the most likely diagnosis?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 23 of 63

The following information is recorded in the health history: 'Patient denies chest pain, palpitations, orthopnea, and paroxysmal nocturnal dyspnea.' Which category does it belong to?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 24 of 63

The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the:

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HESI RN · Chapter 12 Vital Signs Assessment

Question 25 of 63

The five primary vital signs routinely monitored by both caregivers and medical professionals and highlighted in this training, include the following:

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HESI RN · Chapter 12 Vital Signs Assessment

Question 26 of 63

In Erb's palsy, what part of the brachial plexus is affected?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 27 of 63

When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 28 of 63

A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to:

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HESI RN · Chapter 12 Vital Signs Assessment

Question 29 of 63

The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is _____ comparison.

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HESI RN · Chapter 12 Vital Signs Assessment

Question 30 of 63

An adolescent comes to a community health clinic with complaints of vaginal itching and discharge. She believes it is from having sex with her boyfriend. Which of the following responses should the nurse use during the health history to elicit information?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 31 of 63

A patient is experiencing pyrexia. Which piece of equipment will the nurse obtain to monitor this condition?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 32 of 63

The patient is found to be unresponsive and not breathing. To determine the presence of central blood circulation and circulation of blood to the brain, the nurse checks the patient's pulse.

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HESI RN · Chapter 12 Vital Signs Assessment

Question 33 of 63

The nurse is performing an abdominal assessment and notes that the patient has a distended abdomen with tympany on percussion. What is the most likely cause of this finding?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 34 of 63

A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 35 of 63

Which of the following best describes the general survey component of the physical examination?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 36 of 63

The nurse notes a drumlike percussion sound over the abdomen. This indicates:

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HESI RN · Chapter 12 Vital Signs Assessment

Question 37 of 63

A nurse is assessing a client's respiratory rate. Which technique should the nurse use to accurately measure the respiratory rate?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 38 of 63

The true leg length should be measured between which of the following points?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 39 of 63

The nurse is conducting an interview with a woman who has recently learned that she is pregnant and who has come to the clinic today to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, which statement does the nurse know to be most accurate? The woman is:

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HESI RN · Chapter 12 Vital Signs Assessment

Question 40 of 63

A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous examination, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 41 of 63

While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 42 of 63

When assessing the abdomen, which assessment technique is used last?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 43 of 63

The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 44 of 63

A 68-year-old retired postman presents with dull, intermittent left-sided chest pain over several weeks, occurring after physical activity. The pain radiates to the left jaw and resolves with rest.

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HESI RN · Chapter 12 Vital Signs Assessment

Question 45 of 63

A mother brings her 28-month-old daughter into the clinic for a well-child visit. At the beginning of the visit, the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to 'warm up' and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 46 of 63

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 47 of 63

The nurse is preparing to assess a patient's deep tendon reflexes. Which tool is most appropriate for this assessment?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 48 of 63

The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 49 of 63

A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 50 of 63

The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to:

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HESI RN · Chapter 12 Vital Signs Assessment

Question 51 of 63

The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is:

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HESI RN · Chapter 12 Vital Signs Assessment

Question 52 of 63

A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. The nurse's best response would be:

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HESI RN · Chapter 12 Vital Signs Assessment

Question 53 of 63

During an abdominal examination, the nurse hears high-pitched, tinkling bowel sounds. What is the most likely cause of this finding?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 54 of 63

Which of the following findings during a cardiovascular assessment would require immediate intervention?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 55 of 63

If a burn patient is splinted in a comfortable position for grafted burns to heal, the patient is at risk for which of the following complications?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 56 of 63

A patient informs the nurse that she still uses a mercury thermometer to take the temperature of her children when they are sick. Which of the following is a recommended teaching guideline for patients using these types of thermometers?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 57 of 63

What is the primary purpose of palpating the costovertebral angle during an abdominal assessment?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 58 of 63

The nurse is assessing a patient's visual fields by confrontation. This test evaluates which cranial nerve?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 59 of 63

A 29-year-old woman comes to your office. As you take the history, you notice that she is speaking very quickly, and jumping from topic to topic so rapidly that you have trouble following her. You are able to find some connections between ideas, but it is difficult. Which describes this thought process?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 60 of 63

The nurse is caring for a patient who reports feeling light-headed and 'woozy.' The nurse checks the patient's pulse and finds that it is irregular. The patient's blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 61 of 63

A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this cough may indicate:

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HESI RN · Chapter 12 Vital Signs Assessment

Question 62 of 63

What is the primary purpose of using the Snellen chart during a physical examination?

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HESI RN · Chapter 12 Vital Signs Assessment

Question 63 of 63

In performing a voice test to assess hearing, which of these actions would the nurse perform?

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