CNS Vital Signs Assessment

HESI RN · CNS Vital Signs Assessment

Question 1 of 64

The nurse is assessing a patient's mental status. Which question best evaluates the patient's recent memory?

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HESI RN · CNS Vital Signs Assessment

Question 2 of 64

A 60-year-old woman with a history of breast cancer presents with a complaint of a new mass in her left breast. On examination, the mass is firm, non-tender, and fixed to the underlying tissue. What is the most likely diagnosis?

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HESI RN · CNS Vital Signs Assessment

Question 3 of 64

A 25-year-old woman presents with a complaint of fatigue and muscle weakness. On examination, she has ptosis and weakness of the proximal muscles of the upper limbs. Her vital signs are stable, and laboratory tests reveal a positive anti-acetylcholine receptor antibody test. Which of the following is the most likely diagnosis?

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HESI RN · CNS Vital Signs Assessment

Question 4 of 64

A blood pressure reading consists of a top number, or , and bottom number, or

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HESI RN · CNS Vital Signs Assessment

Question 5 of 64

The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true?

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HESI RN · CNS Vital Signs Assessment

Question 6 of 64

What is the function of the Lisfranc ligament?

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HESI RN · CNS Vital Signs Assessment

Question 7 of 64

Which of the following is a contraindication for spinal traction?

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HESI RN · CNS Vital Signs Assessment

Question 8 of 64

The nurse has received a status report on the following patients admitted with head injuries, which patient should the nurse assess first?

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HESI RN · CNS Vital Signs Assessment

Question 9 of 64

An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. The nurse would need to know additional information that includes which of these?

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HESI RN · CNS Vital Signs Assessment

Question 10 of 64

A 72-year-old teacher comes to your clinic for an annual examination. She is concerned about her risk for peripheral vascular disease and states that there is a place in town that does tests to let her know her if she has this or not. Which of the following disease processes is a risk factor for peripheral vascular disease?

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HESI RN · CNS Vital Signs Assessment

Question 11 of 64

You feel a small mass that you think is a lymph node. It is mobile in both the up-and-down and side-to-side directions. Which of the following is most likely?

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HESI RN · CNS Vital Signs Assessment

Question 12 of 64

When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulsus:

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HESI RN · CNS Vital Signs Assessment

Question 13 of 64

The patient is being admitted to the emergency department with complaints of shortness of breath. The patient has had chronic lung disease for many years but still smokes. The nurse should

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HESI RN · CNS Vital Signs Assessment

Question 14 of 64

Factors important during an interview include: Select all that apply.

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HESI RN · CNS Vital Signs Assessment

Question 15 of 64

A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. During the tests of cognitive function, the nurse would expect that he:

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HESI RN · CNS Vital Signs Assessment

Question 16 of 64

During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning:

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HESI RN · CNS Vital Signs Assessment

Question 17 of 64

A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with this patient?

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HESI RN · CNS Vital Signs Assessment

Question 18 of 64

During a skin assessment, the nurse observes a patient's mole and notes that it has an irregular border, varied colors, and a diameter of 8 mm. What is the appropriate action?

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HESI RN · CNS Vital Signs Assessment

Question 19 of 64

A nurse is assessing a client's blood pressure. Which of the following should the nurse use to measure blood pressure accurately?

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HESI RN · CNS Vital Signs Assessment

Question 20 of 64

A 23-year-old graduate student comes to your clinic for evaluation of a urethral discharge. As the provider, you need to get a sexual history. Which one of the following questions is inappropriate for eliciting the information?

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HESI RN · CNS Vital Signs Assessment

Question 21 of 64

A patient returns to your postoperative unit following surgery for right shoulder rotator cuff repair. The licensed practical nurse (LPN) reports that she had difficulty obtaining the patient's heart rate from his right radial pulse. What is your best response?

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HESI RN · CNS Vital Signs Assessment

Question 22 of 64

A nurse responds to an order to place an infant in an overhead radiant heater. Which of the following are recommended guidelines the nurse should follow?

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HESI RN · CNS Vital Signs Assessment

Question 23 of 64

The nurse is performing a neurological assessment and asks the patient to walk in a straight line. The patient sways significantly and loses balance. What does this finding suggest?

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HESI RN · CNS Vital Signs Assessment

Question 24 of 64

The nurse needs to take the temperature of a patient who had a cardiac arrest. Which route will the nurse use?

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HESI RN · CNS Vital Signs Assessment

Question 25 of 64

A physical therapist evaluates a patient with adhesive capsulitis of the shoulder. Which intervention is MOST appropriate to improve range of motion?

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HESI RN · CNS Vital Signs Assessment

Question 26 of 64

Vital signs are measurements of...

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HESI RN · CNS Vital Signs Assessment

Question 27 of 64

A school nurse is preparing to test the auditory function of grade school students. What equipment will be needed for this examination?

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HESI RN · CNS Vital Signs Assessment

Question 28 of 64

The nurse is performing a musculoskeletal assessment and notes that the patient has a decreased range of motion in the shoulder with pain on movement. What is the most likely cause of this finding?

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HESI RN · CNS Vital Signs Assessment

Question 29 of 64

What site for taking body temperature with a glass thermometer is contraindicated in patients who are unconscious?

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HESI RN · CNS Vital Signs Assessment

Question 30 of 64

The nurse is performing a neurological assessment and asks the patient to walk heel-to-toe. The patient staggers and loses balance. What does this finding suggest?

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HESI RN · CNS Vital Signs Assessment

Question 31 of 64

A nurse is assessing a client's pulse oximetry reading and notices that the waveform is irregular and inconsistent. What action should the nurse take?

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HESI RN · CNS Vital Signs Assessment

Question 32 of 64

During the examination, which action by the nurse helps reduce patient anxiety?

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HESI RN · CNS Vital Signs Assessment

Question 33 of 64

What causes BoutonniÃƒÆ’Ã‚Â¨re deformity?

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HESI RN · CNS Vital Signs Assessment

Question 34 of 64

The nurse is assessing a patient's gait. Which finding indicates a normal gait?

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HESI RN · CNS Vital Signs Assessment

Question 35 of 64

The nurse is assessing a patient's peripheral circulation. Which finding suggests arterial insufficiency?

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HESI RN · CNS Vital Signs Assessment

Question 36 of 64

Surface and Core:

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HESI RN · CNS Vital Signs Assessment

Question 37 of 64

The nurse knows that a normal finding when assessing the respiratory system of an older adult is:

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HESI RN · CNS Vital Signs Assessment

Question 38 of 64

When performing a physical assessment, the first technique the nurse will always use is:

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HESI RN · CNS Vital Signs Assessment

Question 39 of 64

A 32-year-old white male comes to your clinic, complaining of aching on the right side of his testicle. He has felt this aching for several months. He states that as the day progresses the aching increases, but when he wakes up in the morning he is pain-free. He denies any pain with urination and states that the pain doesn't change with sexual activity. He denies any fatigue, weight gain, weight loss, fever, or night sweats. His past medical history is unremarkable. He is a married hospital administrator with two children. He notes that he and his wife have been trying to have another baby this year but have so far been unsuccessful despite frequent intercourse. He denies using tobacco, alcohol, or illegal drugs. His father has high blood pressure but his mother is healthy. On examination you see a young man appearing his stated age with unremarkable vital signs. On visualization of his penis, he is circumcised with no lesions. He has no scars along his inguinal area, and palpation of the area shows no lymphadenopathy. On palpation of his scrotum you feel testes with no discrete masses. Upon placing your finger through the right inguinal ring you feel what seems like a bunch of spaghetti. Asking him to bear down, you feel no bulges. The left inguinal ring is unremarkable, with no bulges on bearing down. His prostate examination is unremarkable. What abnormality of the scrotum does he most likely have?

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HESI RN · CNS Vital Signs Assessment

Question 40 of 64

The nurse is assigned to care for a client with complete right-sided hemiparesis. The nurse plans care knowing that this condition:

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HESI RN · CNS Vital Signs Assessment

Question 41 of 64

A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur?

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HESI RN · CNS Vital Signs Assessment

Question 42 of 64

Which assessment finding is most consistent with a diagnosis of arterial insufficiency?

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HESI RN · CNS Vital Signs Assessment

Question 43 of 64

Which respiratory disease causes a restrictive, parenchymal pattern of illness?

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HESI RN · CNS Vital Signs Assessment

Question 44 of 64

A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?

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HESI RN · CNS Vital Signs Assessment

Question 45 of 64

A 9-year-old girl is in the clinic for a sport physical examination. After some initial shyness she finally asks, "Am I normal? I don't seem to need a bra yet, but I have some friends who do. What if I never get breasts?" The nurse's best response would be:

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HESI RN · CNS Vital Signs Assessment

Question 46 of 64

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would:

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HESI RN · CNS Vital Signs Assessment

Question 47 of 64

The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the ________ of the underlying tissue.

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HESI RN · CNS Vital Signs Assessment

Question 48 of 64

Which of the following findings is most concerning during a neurological assessment?

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HESI RN · CNS Vital Signs Assessment

Question 49 of 64

A 45-year-old woman presents with a complaint of a persistent cough for the past 3 weeks. She denies any fever, chills, or chest pain but reports some shortness of breath. What is the most likely diagnosis?

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HESI RN · CNS Vital Signs Assessment

Question 50 of 64

The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find:

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HESI RN · CNS Vital Signs Assessment

Question 51 of 64

What does FABERE (Patrick's test) test for?

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HESI RN · CNS Vital Signs Assessment

Question 52 of 64

A middle-aged man comes in because he has noticed multiple small, blood-red, raised lesions over his anterior chest and abdomen for the past several months. They are not painful and he has not noted any bleeding or bruising. He is concerned this may be consistent with a dangerous condition. What should you do?

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HESI RN · CNS Vital Signs Assessment

Question 53 of 64

The nurse is auscultating the lungs and hears low-pitched, soft sounds over the peripheral lung fields. How should this finding be documented?

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HESI RN · CNS Vital Signs Assessment

Question 54 of 64

A 55-year-old married homemaker comes to your clinic, complaining of 6 months of vaginal itching and discomfort with intercourse. She has not had a discharge and has had no pain with urination. She has not had a period in over 2 years. She has no other symptoms. Her past medical history consists of removal of her gallbladder. She denies use of tobacco, alcohol, and illegal drugs. Her mother has breast cancer and her father has coronary artery disease, high blood pressure, and Alzheimer's disease. On examination she appears healthy and has unremarkable vital signs. There is no lymphadenopathy with palpation of the inguinal nodes. Visualization of the vulva shows dry skin but no lesions or masses. The labia are somewhat smaller than usual. Speculum examination reveals scant discharge and the vaginal walls are red, dry, and bleed easily. Bimanual examination is unremarkable. The KOH whiff test produces no unusual odor and there are no clue cells on the wet prep. What form of vaginitis is this patient most likely to have?

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HESI RN · CNS Vital Signs Assessment

Question 55 of 64

Which vein(s) is(are) responsible for most of the venous return in the arm?

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HESI RN · CNS Vital Signs Assessment

Question 56 of 64

A 45-year-old woman with a history of hypertension presents with a complaint of headache, blurred vision, and nausea. Her blood pressure is 200/120 mm Hg. What is the most likely diagnosis?

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HESI RN · CNS Vital Signs Assessment

Question 57 of 64

Which of the following anatomic landmark associations is correct?

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HESI RN · CNS Vital Signs Assessment

Question 58 of 64

Which physical assessment finding is most indicative of chronic hypoxia?

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HESI RN · CNS Vital Signs Assessment

Question 59 of 64

What is the primary reason for performing a Romberg test during a neurological assessment?

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HESI RN · CNS Vital Signs Assessment

Question 60 of 64

A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an "unexplained" weight loss of 10 pounds over the last 6 weeks. The nurse knows that:

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HESI RN · CNS Vital Signs Assessment

Question 61 of 64

The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman:

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HESI RN · CNS Vital Signs Assessment

Question 62 of 64

A nurse assesses an oral temperature for an adult patient and records that the patient is afebrile. What would be the nurses best response to this finding?

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HESI RN · CNS Vital Signs Assessment

Question 63 of 64

The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient?

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HESI RN · CNS Vital Signs Assessment

Question 64 of 64

Which of the following is considered to be the greatest single modifiable risk factor for cardiac disease?

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Practice results