RN Health Assessment (BSN 246/ASN 241)

Correct Answer: C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea.

The patient's complaint of being awakened from sleep with shortness of breath is a classic symptom of paroxysmal nocturnal dyspnea (PND), a condition commonly seen in patients with heart failure.  PND occurs when fluid accumulates in the lungs due to decreased cardiac output, typically while the patient is lying down at night. This leads to shortness of breath that wakes the patient from sleep. Assessing for other signs and symptoms of PND (such as orthopnea, edema, or increased weight gain) is crucial to determine if the patient’s condition is worsening and to guide appropriate management.

Why the Other Options Are Wrong:

A) Obtain a detailed history of the patient's allergies and history of asthma:

While asthma and allergies can cause respiratory symptoms, the patient’s history of heart failure and the specific complaint of being awakened with shortness of breath points more directly to paroxysmal nocturnal dyspnea rather than asthma or allergies. A more focused assessment on heart failure symptoms is warranted.

B) Tell the patient to sleep on his or her right side to facilitate ease of respirations:

While positioning can sometimes help with shortness of breath, recommending that the patient sleep on the right side is not a typical solution for PND or heart failure-related symptoms. In fact, many patients with heart failure find relief by sleeping in a semi-Fowler’s position (head of the bed elevated) to reduce fluid accumulation in the lungs. Left-sided heart failure can also cause orthopnea, where patients may be more comfortable sleeping on their right side to reduce pulmonary congestion.

D) Assure the patient that this is normal and will probably resolve within the next week:

This response is inappropriate, as paroxysmal nocturnal dyspnea is a serious symptom that suggests worsening heart failure and needs to be addressed immediately. Ignoring or downplaying the issue could delay necessary intervention, such as adjusting medications or investigating further cardiovascular or pulmonary causes.

Summary:

The most appropriate action is to assess for other signs and symptoms of paroxysmal nocturnal dyspnea (PND), which is a common manifestation of heart failure. This will help determine the severity of the patient's condition and guide further management. Ignoring the symptom or providing inaccurate advice could worsen the patient's condition.

The correct answer is D) Fifth left intercostal space at the midclavicular line.

The apical impulse (also known as the point of maximal impulse, or PMI) is normally palpated in the fifth left intercostal space at the midclavicular line. This location corresponds to the area where the apex of the heart touches the chest wall, and it is where the heart's contraction is strongest and most easily palpable in a healthy adult.

Why the Other Options are Wrong:

A) Third left intercostal space at the midclavicular line: The apical impulse is typically not located at the third intercostal space. This position is too high on the chest and does not align with the apex of the heart.

B) Fourth left intercostal space at the sternal border: The fourth intercostal space at the sternal border is more likely to palpate the heart's right side or may correspond to the aortic or pulmonic areas, but it is not the location of the apical impulse.

C) Fourth left intercostal space at the anterior axillary line: The fourth intercostal space at the anterior axillary line is also too lateral and does not correspond to the position of the apical impulse. This would be outside the area where the PMI is typically felt.

Summary:

The apical impulse is normally palpated in the fifth left intercostal space at the midclavicular line, which is located over the apex of the heart. This area is where the heart's contraction is strongest and easiest to feel in a healthy adult.

Correct Answer is : B) Unequal pupillary constriction in response to light:

Unequal pupillary constriction is abnormal and may indicate neurological issues. Both pupils should constrict symmetrically when exposed to light. If one pupil does not constrict in response to light, this could suggest a problem with the autonomic nervous system or damage to the oculomotor nerve (cranial nerve III). It could also be indicative of more serious conditions such as a brain tumor, stroke, or an aneurysm. This is why unequal constriction is concerning and requires further investigation.

Why the Other Options are Incorrect:

A) A decrease in tear production:

Decrease in tear production is a normal finding in older adults. As people age, the lacrimal glands, responsible for tear production, tend to produce fewer tears. This leads to dry eyes, which is common and not necessarily abnormal unless it becomes severe or symptomatic. This condition is often referred to as age-related dry eye syndrome.

C) The presence of arcus senilis seen around the cornea:

Arcus senilis is a normal, age-related finding in elderly individuals. It appears as a gray or white arc along the edge of the cornea and is caused by lipid (fat) deposits in the eye. It is typically harmless and does not affect vision. While it may sometimes be associated with high cholesterol, it is more commonly just a sign of aging and is not considered abnormal by itself.

D) Loss of the outer hair on the eyebrows due to a decrease in hair follicles:

Loss of eyebrow hair is a normal age-related change. As people age, hair follicles become less active, leading to a thinning of the hair, including on the eyebrows. This is a typical part of the aging process and is not a sign of disease or pathology.

Summary:

Correct Answer: B) Unequal pupillary constriction in response to light – This is abnormal and can indicate serious neurological issues, such as cranial nerve damage or brain injury. The most concerning finding among the options is unequal pupillary constriction, which could point to a serious neurological problem. The other findings are typical age-related changes and do not indicate pathology.

Correct Answer: Monitor the client's vital signs every 4 hours

Acute glomerulonephritis (AGN) is an inflammatory condition affecting the glomeruli of the kidneys, often triggered by a streptococcal infection. It leads to fluid retention, hypertension, hematuria, and decreased urine output.

Why Monitoring Vital Signs is Critical:

Hypertension Risk – AGN can cause fluid overload and increased blood pressure, leading to complications like hypertensive encephalopathy or heart failure. Regular BP monitoring every 4 hours helps detect and manage hypertension early.

Edema & Fluid Imbalance – Monitoring vital signs, including heart rate and respiratory status, helps assess fluid retention and potential pulmonary complications.

Early Detection of Complications – Changes in temperature, pulse, or respiratory rate may indicate infection, worsening renal function, or cardiovascular strain.

Why the Other Options Are Incorrect:

 Provide large high-protein meals

 Incorrect because protein restriction is often recommended in AGN to reduce kidney workload and minimize nitrogenous waste buildup.

 Monitor intake and output every 2 hours 

While I&O monitoring is necessary, doing so every 2 hours is excessive unless the patient is in critical condition. A routine schedule (e.g., every shift) is typically sufficient unless there are signs of acute deterioration.

 Allow constant family visits to improve the client's mood

 Emotional support is beneficial, but constant visits can cause fatigue and stress, which may increase blood pressure and fluid retention.

Summary:

The most appropriate nursing intervention for acute glomerulonephritis is to monitor the patient’s vital signs every 4 hours to detect and manage hypertension, fluid overload, and other complications promptly.

The correct answer is B) Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex.

When auscultating heart sounds, the nurse should listen to all heart valves in a systematic pattern to ensure that no sounds are missed. The correct technique involves moving the stethoscope across the chest in a rough Z pattern, starting at the base of the heart, moving across the top of the heart, down toward the left lower side, and then over to the apex. This ensures that the nurse listens to heart sounds from the aortic, pulmonic, tricuspid, and mitral valve areas, which are the main points of auscultation.

Why the Other Options are Wrong:

A) Listen to the sounds at the aortic, tricuspid, pulmonic, and mitral areas: This is partly correct in terms of the locations, but it doesn't specify the correct method for auscultation. Simply stating the areas doesn't explain the importance of moving the stethoscope systematically.

C) Listen to the sounds only at the site where the apical pulse is felt to be the strongest: The apical impulse is a useful guide for locating the mitral valve, but auscultation should cover all heart valve areas, not just the one where the apical pulse is strongest. This would miss important heart sounds in other areas.

D) Listen for all possible sounds at a time at each specified area: This is incorrect because it suggests that the nurse should listen for all sounds simultaneously at each area. Instead, auscultation should be done gradually by moving the stethoscope to each of the valve areas in sequence, allowing time to listen to the various heart sounds in each area.

Summary:

The correct technique for auscultating heart sounds involves moving the stethoscope in a rough Z pattern across the heart, from the base to the apex. This approach ensures that heart sounds from all four main valve areas—aortic, pulmonic, tricuspid, and mitral—are heard clearly.

Correct Answer: Phlegm production and wheezing

Phlegm production is a hallmark symptom of bronchitis, particularly chronic bronchitis. The inflammation in the bronchial tubes leads to increased mucus production, which causes a productive cough. The nurse should assess the quantity, consistency, and color of the sputum (mucus), as these can provide insights into the severity and type of bronchitis (e.g., bacterial vs. viral). Wheezing often accompanies bronchitis because inflammation and mucus can narrow the airways, making it harder for air to flow freely, particularly during exhalation.

Why the other options are incorrect:

Smoking history: Although smoking is a significant risk factor for chronic bronchitis, the question specifically asks for additional findings related to the symptoms of bronchitis. Smoking history is important for the overall assessment and diagnosis of chronic obstructive pulmonary disease (COPD) or chronic bronchitis, but it’s not the most direct symptom or finding that would indicate bronchitis during the examination.

Hemoptysis: Hemoptysis (coughing up blood) is not a typical symptom of bronchitis. While it can occur in severe cases or with complications like infection, it's more commonly associated with conditions like tuberculosis, pneumonia, or lung cancer. The presence of blood in sputum should be immediately investigated, but it is not a characteristic feature of uncomplicated bronchitis.

Night sweats: Night sweats are generally associated with conditions like tuberculosis, infective endocarditis, or lymphoma. While a severe respiratory infection (like pneumonia) could cause night sweats, bronchitis itself doesn’t typically result in this symptom. Thus, night sweats are not a primary finding associated with bronchitis.

Summary:

When assessing a client with bronchitis, the key findings to focus on are phlegm production and wheezing. These symptoms directly result from the inflammation and increased mucus production in the airways. A smoking history is important for long-term risk assessment, but it's not a current symptom to assess. Hemoptysis and night sweats are less common in bronchitis and are more indicative of other, more severe respiratory conditions.

The correct answer is C. Document the presence of borborygmi.

Borborygmi refers to loud, high-pitched, and almost continuous gurgling sounds that are typically heard during the auscultation of bowel sounds, especially when the stomach and intestines are actively moving and processing food. This can be normal and indicate increased intestinal motility, which can occur after eating, during digestion, or in certain gastrointestinal conditions. The nurse should document this finding, as it is often a normal, benign observation, unless other abnormal findings are present.

Why the other options are wrong:

A. Use the bell of the stethoscope to auscultate again: The bell of the stethoscope is used for listening to low-pitched sounds such as heart murmurs, not for bowel sounds. For bowel sounds, the diaphragm of the stethoscope is the appropriate tool to use, as it amplifies higher-pitched sounds, which is ideal for detecting borborygmi.

B. Elevate the head of the client's bed immediately: There is no indication in this scenario that the client’s position is causing a problem. Borborygmi, or normal bowel sounds, do not typically require a positional change unless there are additional symptoms like discomfort or respiratory distress, which are not mentioned here.

D. Auscultate the remaining two quadrants: It is important to auscultate all four quadrants of the abdomen when assessing bowel sounds to get a comprehensive view of the client's gastrointestinal activity. However, the nurse has already auscultated two quadrants and observed borborygmi. This finding can be documented at this point, and further auscultation may not be necessary unless more information is needed or abnormal findings are suspected in other quadrants.

Summary:

The nurse should document the presence of borborygmi, which refers to the loud, high-pitched, continuous gurgling sounds heard during bowel auscultation. These sounds can be normal, especially in certain contexts such as digestion. The nurse should ensure that the full abdominal assessment is documented accurately.

The correct answer is D. Place the dorsum of the hand on the client's forehead.

Placing the dorsum of the hand on the client's forehead is an effective way to gauge if the client has a fever before using a thermometer. The dorsum (back) of the hand is more sensitive to temperature changes than the palm, allowing the nurse to feel if the client’s forehead is warmer than usual, which is an indication of a possible fever. This action provides a quick and preliminary check, which can be followed by taking the temperature to confirm the fever.

Why the other options are wrong:

A. Ask the client to describe any other related symptoms: While asking about symptoms is important for a thorough assessment, it does not objectively confirm the presence of fever. The nurse would still need to take the client’s temperature for an accurate diagnosis.

B. Use both hands to hold and palpate the client's hands: Palpating the hands may be helpful for assessing circulation or skin temperature, but it is not an effective method to assess fever. The hands may feel warm due to other factors, like environmental conditions or local circulation, which don't necessarily indicate a fever.

C. Lightly pinch a fold of skin over the client's sternum: This technique is typically used for assessing skin turgor (hydration status) and is not related to detecting fever. It doesn't provide objective information regarding body temperature.

Summary:

To objectively confirm the presence of fever, placing the dorsum of the hand on the client’s forehead is a simple and effective preliminary action, which can be followed by confirming the temperature with a thermometer.

Correct Answer: A. 140 mg/dL

Explanation of Correct Answer:

According to standard OGTT guidelines, a two-hour postprandial glucose level less than 140 mg/dL is considered normal. Values between 140 and 199 mg/dL indicate impaired glucose tolerance (pre-diabetes). A value of 200 mg/dL or higher suggests diabetes mellitus.

Why the Other Options are Incorrect:

B. 160 mg/dL and C. 180 mg/dL indicate impaired glucose tolerance and are not normal.

D. 200 mg/dL or above meets criteria for diabetes and is abnormal.

Summary:

A two-hour postprandial glucose result of 140 mg/dL or less is considered normal during an OGTT. Therefore, the RN should recognize 140 mg/dL as the normal value among the options.