HESI Flashcards
Complete Assessment:
heath history, physical examination. (Purpose to form a baseline)
Subjective
Self care behaviors, history skin disease, medications, environment hazards, changes in pigmentation, mole changes, sore that doesn’t heal
Focused Assessment
focuses on limited or short term problem, such as the clients complaint
Assessment of mental status
Assessed while obtaining subjective data
• Appearance: posture, body movements, dress, hygiene, grooming
• Behavior: LOC, alertness, awareness, ability to interact or follow a command appropriately, facial expression, body language, eye contact, mood and affect, is it consistent with an appropriate situation? speech pattern, cognitive level.
• Inappropriate dress could indicate depression, manic disorder, dementia, organic brain disease,
• Someone who becomes angry or upset, validate their “suffering”!
What do I do if my client is violent, angry or rude?
Be professional, disorder, disease, life changes are stressful!
• Keep a safety margin
• Call for assistance
• Validate the client concerns and repeat back to client you sound like you are upset…..
Cognitive level
- Orientation (A &O x 3): person, place, time, (4-happening)
- Attention Span: Assess concentration
- Recent memory: Recall a current event
- Remote memory: Recall a past event
- New learning: recall words nurse stated 10 minutes ago
- Judgment: clients actions and decisions, are they realistic?
- Thought Process: way client thinks, is it logical, coherent and relevant?
The nurse is interviewing a client to determine the reason for his visit. He is unable to answer the questions appropriately. What interview question is most appropriate at this time?
B) “Do you even know why you came today?”
What is the limitation of utilizing the BMI? (Select all that apply)
A) Athletic persons can be classified as over weight
B) It doesn’t account for cultural differences of body compositions
C) Chinese have been proportionately higher body fat mass
D) There are no inconsistencies to the Body Mass Index Calculation
A) Athletic persons can be classified as over weight
B) It doesn’t account for cultural differences of body compositions
C) Chinese have been proportionately higher body fat mass
The nurse is interviewing a client who came to the ER with Chest pain. What focused questions concerning pain are most appropriate to ask this client? (Select all that apply)
A) “What does the pain feel like”
• B) “What were you doing when the pain started?
” • C) “How are you feeling today?”
• D) “How long have you had this pain?”
• E) “When did the Pain Begin?”
A) “What does the pain feel like”
• B) “What were you doing when the pain started?”
• D) “How long have you had this pain?”
• E) “When did the Pain Begin?”
You are taking the history of a 14 year old girl who has a (BMI) of 18. The girl reports inability to eat, induced vomiting and severe constipation. Which of the following would you most likely suspect?
A. Multiple sclerosis
B. Anorexia nervosa
C. Bulimia
D. Systemic sclerosis
B. Anorexia nervosa
An Arabic speaking client arrives to the emergency room and states that he “no speak English, need interpretation”. What is the best action for this situation? And why?
A) Have the family member interpret for the client
B) Have the receptionist interpret
C) Page the interpreter for the hospital services
D) Obtain a dictionary to assist with the interview
C) Page the interpreter for the hospital services
Assessment order:
” inspection, palpation, percussion, and auscultation.”
EXCEPT abdomen: auscultate before utilizing touch: inspection, auscultation, percussion, and palpation
Percussion sounds:
Normal –over lung tissue resonance
Over-inflation – hyper resonance (emphysema pneumothorax )
Dull -solid or fluid areas
Korotkoff sounds 5 phases
1- period of initiated by the first faint clear, tapping sound
2- period during which the sounds become softer and longer
3- period sounds become crisper and louder
4- period during which sounds become muffled and have soft blowing quality
5- point at which the sound disappears
Objective:
color, temperature, dryness, moisture, turgor, texture, bruising, itching, rash, hair loss, nail abnormalities, scars, birthmarks, edema, capillary filling time. (May inspect with woods lamp/light)
Client Teaching:
Factors harmful to skin Self-inspection of skin monthly
Characteristics of Skin Color
Cyanosis: mottled bluish
Erythema: redness
Pallor: Pale, whitish
Jaundice: yellow
Capillary refill
normal is a return of blood in within 3 seconds
Turgor
poor turgor sign of dehydration, extreme weight loss, check turgor older client on chest
Dehydration in older adult problem:
don’t experience thirst appropriately, or withhold fluid so they don’t have go bathroom in night
May be sign of caregiver neglect, other signs of dehydration: skin dryness, flaking, scaling, tenting, dry mucosa
Vertical nail ridges
are fairly common in older adult.
Vertical nail ridges extend from the cuticle to the tip of the nail.
Vertical nail ridges often become more numerous or prominent with age, possibly due to variations in cell turnover within the nail.
Nail pitting
small depressions in the nails. Nail pitting is most common in people who have psoriasis — a condition characterized by scaly patches on the skin. Nail pitting can also be related to connective tissue disorders, such as Reiter’s syndrome, and alopecia areata — an autoimmune disease that causes hair loss
Nail clubbing
is sometimes the result of low oxygen in the blood and could be a sign of various types of lung disease. (chronic cardiopulmonary disease) Nail clubbing is also associated with inflammatory bowel disease, cardiovascular disease, pulmonary disease, COPD, cor-pumonale, liver disease and AIDS. (Cor pulmonale is an increase in bulk of the right ventricle of the heart, generally caused by chronic diseases or malfunction of the lungs. This condition can lead to heart failure) more info on next slide. Angel between skin and nail base is over 160 degrees
Spoon nails (koilonychias)
are soft nails that look scooped out. (Concave)The depression usually is large enough to hold a drop of liquid. Often, spoon nails are a sign of iron deficiency anemia or a liver condition
• Beau’s lines run across the nails
The indentations can appear when growth at the area under the cuticle is interrupted by injury or severe illness. Conditions associated with Beau’s line: diabetes, peripheral vascular disease, scarlet fever, measles, mumps and pneumonia. Beau’s lines can also be a sign of zinc deficiency
Petechiae
- small pinpoint red flat spots, frequently occurs with anticoagulation therapy, difficult to detect in darker skin, do not blanch, Causes: fragile capillaries, septicemias, liver disease, vitamin C and K deficiency •
Purpura
various sizes, red blue flat irregular shaped, from scurvy, capillary fragility in older adult.
The Nurse is caring for a client who states that a mole on his back has gotten bigger and is itchy. The nurse recognizes the changes in a mole are often associated with which disease? A) Impetigo • B) Tinea Corporis • C) Gyrate • D) Skin Cancer
D) skin cancer
Gyrate describes a lesion coiled and twisted
Impetigo bacterial skin infection
Tinea corporis fungal infection on the body
Skin cancer is often described as a long existing growth that suddenly changes in character
During an interview the nurse ask the client if she utilizes bleach, color, perms and chemicals to straighten her hair. The nurse recognizes that use of these products may cause which of the following symptoms?
A) Telogen effluvium
B) Peeling nails from protein deficiency
C) Oily scalp and infections behind the ears
D) Hair and scalp damage and possible hair loss
D) Hair and scalp damage and possible hair loss
Which of the following individuals is least likely to be at risk of developing psoriasis?
• a. A 32 year-old-African American
• b. A woman experiencing menopause
• c. A client with a family history of the disorder
• d. An individual who has experienced a significant amount of emotional distress
• a. A 32 year-old-African American
Psoriasis occurs equally among women and men, although the incidence is lower in darker skinned races and ethnic groups. A genetic predisposition has been recognized in some cases. Emotional distress, trauma, systemic illness, seasonal changes, and hormonal changes are linked to exacerbations
The nurse is assigned to care for a female client with herpes zoster. Which of the following characteristics would the nurse expect to note when assessing the lesions of this infection?
• a. Clustered skin vesicles
• b. A generalized body rash
• c. Small blue-white spots with a red base
• d. A fiery red, edematous rash on the cheeks
• a. Clustered skin vesicles
When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which of the following?
• a. An irregular shaped lesion
• b. A small papule with a dry, rough scale
• c. A firm, nodular lesion topped with crust
• d. A pearly papule with a central crater and a waxy border
a. An irregular shaped lesion
Nurse Carl reviews the client’s chart and notes that the physician has documented a diagnosis of paronychia. Based on this diagnosis, which of the following would the nurse expect to note during the assessment?
- a. Red shiny skin around the nail bed
- b. White taut skin in the popliteal area
- c. White silvery patches on the elbows
- d. Swelling of the skin near the parotid gland
- A Red shiny around the nail bed
* Paronychia is infection of the skin adjacent to the nail caused by bacteria or fungi • Red, swollen, painful, pus
A female client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding most accurately using which of the following terms? • a. Purpura • b. Petechiae • c. Ecchymosis • d. Erythema
- C- Ecchymosis
- Ecchymosis is a type of purpuric lesion and also is known as a bruise. Purpura is an umbrella term that incorporates ecchymoses and petechiae. Petechiae are pinpoint hemorrhages and are another form of purpura. Erythema is an area of redness on the skin.
- The nurse is caring for a dark skin client with Vitamin K and Vitamin C deficiency. During the assessment of the skin the nurse realizes that Petechiae is a common occurrence with these decencies. The nurse expects to find what characteristics of this clients skin assessment regarding petechiae?
- A) Bright red radiating blood vessels
- B) Flat reddish blue, irregularly shaped patches
- C) Petechiae is never visible in a dark skin client
- D) Possible visible petechiae in the oral mucosa
- E) Blanching Petechiae on the feet and hands
Answer is D) Possible visible petechiae in the oral mucosa
• Dark skin clients may have petechiae visible, more likely in oral mucosa or conjunctiva, but difficult to detect and do not blanch. • Petechiae are flat red or purple rounded 1-3 cm seen back, buttocks mostly
Changes in Skin Pallor: Dark and Light Skin
Light Skin • White skin: loses rosy tones • Natural yellow: appears more yellow
• Dark Skin • Black Skin: Loses red undertones and appears ash-gray • Brown Skin: Yellow tinged, dull
Changes in Skin Cyanosis Dark and Light Skin
Light skin skin lips mucous membrane look blue tinged conjunctiva and nail beds blue
• Dark Skin • Appear shade darker, difficult to see in skin. lips tongue, oral mucosa nail beds appear pale or blue tinged
The nurse is assessing for the presence of cyanosis in a male dark-skinned client. The nurse understands that which body area would provide the best assessment? • a. Lips • b. Sacrum • c. Earlobes • d. Back of the hands
lips
Pitting Edema
1+ Barely perceptible pit 2mm 2+ Deeper pit, rebounds in a few seconds 4mm 3+ Deep pit, rebounds in 10-20 seconds 6mm 4+ Deeper pit rebounds in > 30 seconds 8mm
Temporal artery
– above cheek bone between eye and top of the ear
• Periorbital swelling
– swelling around the eye
• Thyroid gland
moves up with sip of water
• Lymph nodes are enlargement
of lymph nodes (lymphadenopathy) are due to infection, allergy, or a tumor, infections that cause enlarged lymph nodes are usually tender to touch
• Auscultate the thyroid
– presence of bruit is abnormal and is an indication of increased blood flow
• Abnormalities in lymph nodes,
irregular border, non movable fibrous stringy (attached), enlarged
Hypothyroidism –
iodine deficiency gives rise to goiter, problem in areas where no iodine is in the diet • Goiter can occur in hyper, hypo thyroid
Sign and symptoms of hypothyroidism
- Rough scaly skin, pale
- Fatigue, weakness
- Weight gain
- Constipation
- Memory impairment
- Intolerance to cold
- Depression
- Horse voice
- Brittle finger nails and hair, decreased hair growth
- Heavier mensuration
Sign and symptoms of Hyperthyroidism
Smooth velvety skin • Irritability/nervousness • Muscle weakness • Amenorrhea • Sudden weight loss • Tachycardia and palpitations • Insomnia • Enlarged thyroid glad • Sweating • Heart sensitivity • Visual disturbance • Increased sensitivity to heat • Bowel changes, more frequent bowel movement
Ptosis –
eye drooping
• Exophthalmos-
eye protrusion, bulging eyes
• Sclera
white
