Hesi Rn Fundamental NSG

Correct Answer:

B. Shiny blue skin sacs around anal opening and a linear split.

Explanation:

The most likely cause of bright red blood on the toilet paper after a bowel movement in a client with chronic constipation is the presence of hemorrhoids or an anal fissure. A shiny blue skin sac around the anal opening suggests the presence of hemorrhoids, particularly external hemorrhoids, which are engorged veins that can become swollen, painful, and may bleed, especially after a bowel movement. A linear split refers to an anal fissure, which is a tear in the skin around the anus that can also result in bright red blood, often seen on the toilet paper after straining during bowel movements, a common symptom in individuals with chronic constipation. This finding is consistent with the client’s report of bright red blood after bowel movements.

Why the Other Options Are Incorrect:

A. An anus that is moist, hairless, and has pigmented sphincter folds is a normal anatomical finding and does not suggest any pathology related to bleeding or constipation. There is no indication of hemorrhoids or anal fissures in this description.

C. The presence of dried brown stool around the perianal area can indicate fecal leakage or poor hygiene, but it does not explain the bright red blood reported by the client. This finding is more related to the result of poor wiping or fecal incontinence, which is not consistent with the reported symptoms of bleeding after a bowel movement.

D. A flabby skin sac around the anal orifice that is painless could indicate a hemorrhoid, but without the typical signs of inflammation or bleeding, it is less likely to explain the bright red blood on the toilet paper. Hemorrhoids are often painful, especially if they become thrombosed or inflamed, so this finding may not fully explain the client’s reported symptoms.

Correct Answer:

C. Question her about thoughts of self-harm.

Explanation:

The symptoms described by the adolescent (sleeping excessively, weight loss, and absence of menstruation) are concerning and could indicate depression or an eating disorder. Self-harm is common among adolescents who are experiencing depression or psychological distress, and it's critical to assess for any thoughts of self-harm or suicidal ideation as part of a mental health evaluation. Given the concerning symptoms, it’s essential to ask about self-harm directly to ensure the teen’s safety.

Why the other options are incorrect:

A. Inquire about the use of illicit drugs

While substance abuse is a potential issue in adolescents, the immediate priority based on the symptoms (weight loss, lack of menstruation, fatigue) is to evaluate the possibility of mental health concerns such as depression or eating disorders. The nurse should ask about substance use, but it is not the most urgent assessment to start with.

B. Request a 24-hour dietary recall

Although poor nutrition and eating disorders (e.g., anorexia nervosa) could be contributing to her symptoms, the immediate concern is ruling out more urgent possibilities such as self-harm or suicidal ideation. Once self-harm is ruled out, a dietary recall may help to further assess the teen's physical and mental health, but it’s secondary to immediate safety concerns.

D. Ask the teen if she is sexually active

While this question can be part of a complete assessment, especially if there’s concern about pregnancy or sexually transmitted infections (STIs), it does not directly address the most immediate potential issue — which is the adolescent’s mental health and possible self-harm. It’s more important to first assess for depression and self-harm before addressing sexual activity.

Correct Answer:

C. Apex of the heart at left fifth intercostal space at the midclavicular line.

Explanation:

When a patient describes palpitations that are felt when lying on their left side, this could indicate that they are more aware of their heart's beat due to the position of the heart in the chest. The apex of the heart is located at the left fifth intercostal space along the midclavicular line, which is the point of maximal impulse (PMI). Palpitations are often most pronounced when the heart is closest to the chest wall, which happens when the person is lying on their left side. Auscultating at the apex allows the nurse to better assess the heart sounds, including murmurs or irregular rhythms that might be causing the palpitations.

Why the other options are incorrect:

A. Base of the heart at second intercostal space, right of the sternal border

The base of the heart is located at the top of the heart, where the great vessels are. It is best for auscultating sounds such as the aortic or pulmonic valves, but it is not the ideal location to assess for palpitations, especially if they are felt more strongly near the apex.

B. Left third intercostal space, left lateral sternal border

This location is associated with auscultation of the tricuspid valve area, but it is not the most effective place to listen for heart sounds related to palpitations, which are more often felt near the apex.

D. Second intercostal space, left of the sternal border

This is the location for auscultating the pulmonic valve. While it is an important point for listening to specific valve sounds, it is not the optimal area for assessing palpitations, which are better detected at the apex where the heart's impulse is most prominent.

Correct Answer:

A. Coarse, dry, brittle texture.

Explanation

Frequent hair dyeing, especially with permanent dyes, can damage the hair shaft, leading to a coarse, dry, and brittle texture. Chemical treatments strip natural oils and can weaken the hair structure over time, making this the expected finding on palpation.

Why the other options are incorrect:

B. Excess vellus hair. Vellus hair is soft, fine, and lightly pigmented hair typically found on much of the body, not the scalp. Dyeing does not cause an increase in vellus hair, making this unrelated.

C. Fine, thin, limp texture. While some people naturally have fine or thin hair, dyeing typically makes hair more brittle rather than making it fine or limp. This option does not align with the expected result of frequent dyeing.

D. Receding front hairline. Hair dyeing alone does not generally cause a receding hairline. A receding hairline is more commonly associated with genetic factors, androgenic alopecia, or hormonal changes, not chemical hair treatment

Correct Answer:

Opioid analgesic received one hour ago.

Explanation:

Opioids commonly cause sedation, dizziness, or impaired coordination, especially shortly after administration. These side effects significantly increase the risk of falls and must be addressed in the plan of care through fall precautions and close monitoring.

Why Other Options are Wrong:

Expressed feelings of depression.

Depression may affect activity levels but is not a direct or immediate risk factor for falls unless accompanied by psychomotor retardation or medication effects.

Recent serum hemoglobin level of 16 g/dL (160 g/L).

This is a normal hemoglobin level, indicating good oxygen-carrying capacity. It does not contribute to fall risk.

Stooped posture with a steady gait.

Posture alone does not necessarily indicate instability or fall risk, especially if the gait remains steady.

Correct Answer:

B. Measure ankle-brachial index (ABI).

Explanation:

Measuring the ankle-brachial index (ABI) is a highly reliable, noninvasive method for assessing the presence and severity of peripheral vascular disease. It compares the blood pressure in the ankle with the blood pressure in the arm to determine how well blood is flowing to the limbs. An ABI below 0.90 is generally indicative of PVD. This test not only confirms the diagnosis but also helps monitor disease progression and guide treatment decisions.

Why the Other Options are Incorrect:

A. Documenting thickened toenails can suggest chronic poor circulation but is not diagnostic and does not quantify the degree of vascular impairment.

C. Dependent ankle edema is more commonly associated with venous insufficiency or heart failure than with arterial PVD.

D. Palpating distal pulses is important and often done first during a physical exam, but it is subjective and less precise than ABI in quantifying blood flow reduction.

Correct Answer:

C. Hematocrit

Explanation:

Melena, or black, tarry stools, suggests gastrointestinal bleeding, typically from the upper GI tract, where blood is digested and turns black. This bleeding can lead to a drop in red blood cells and hemoglobin as the blood is lost, which in turn causes a decrease in hematocrit levels. Monitoring hematocrit is important because it reflects the percentage of red blood cells in the blood and can indicate blood loss, including in the case of melena. A decrease in hematocrit will show that the body is losing blood, potentially due to an ongoing GI bleed.

Why the Other Options Are Incorrect:

A. White blood cell count (WBC): While an elevated WBC count may suggest an infection or inflammation, it is not directly related to the presence of melena or bleeding. It is not the most helpful laboratory test in the case of GI bleeding.

B. Blood urea nitrogen (BUN): Although BUN can increase with gastrointestinal bleeding due to the digestion and absorption of blood, it is not the most immediate indicator of blood loss when compared to hematocrit. BUN can also be influenced by other factors like kidney function and hydration status.

D. Glucose: Glucose levels are unrelated to gastrointestinal bleeding and melena. They are more relevant in conditions like diabetes or in assessing for hypoglycemia or hyperglycemia, but not for melena.

Correct Answer:

D. Inspect the external ear canals.

Explanation:

When a client reports hearing best in one ear with muffled sounds, particularly in settings with background noise such as a social gathering, the nurse should first consider the possibility of conductive hearing loss. Conductive hearing loss often results from obstructions such as cerumen (earwax), fluid, or foreign bodies in the external auditory canal. Inspecting the external ear canals allows the nurse to identify visible causes like impacted cerumen, which is a common and easily correctable issue. This is a fundamental and non-invasive initial step in hearing assessment.

Why the other options are incorrect:

A. Determine ability to maintain balance with eyes closed: This evaluates vestibular function related to the inner ear and is not typically relevant to a complaint of muffled hearing in one ear unless balance problems are also reported.

B. Differentiate ability to hear high and low pitched sounds: This may help evaluate sensorineural hearing loss, but it is not the priority initial step when a more likely and easily identifiable cause, such as blockage of the external canal, could be present.

C. Ask client if he has tinnitus: Tinnitus, or ringing in the ears, is more commonly associated with sensorineural hearing loss. While relevant in a comprehensive auditory evaluation, it does not directly address the client’s primary complaint of muffled hearing in one ear.

Correct Answer:

C. Trains for competition and runs 12 miles every day.

Explanation:

Amenorrhea (absence of menstruation) in a young female with a low BMI can be caused by excessive physical activity, especially when paired with low body fat. This is commonly seen in athletes, particularly those involved in endurance sports such as distance running. The physical stress of intense training, combined with inadequate caloric intake to meet energy demands, can disrupt the hypothalamic-pituitary-ovarian axis, resulting in functional hypothalamic amenorrhea. This is a known and expected physiological response in female athletes with significantly low BMI.

Why the Other Options are Incorrect:

A. Increased calcium intake is generally beneficial for bone health but does not cause or explain amenorrhea.

B. A history of UTIs does not correlate with menstrual irregularities or amenorrhea.

D. While IUDs can sometimes alter menstrual patterns, amenorrhea shortly after insertion is more common with hormonal IUDs, not all types. Additionally, this would not explain the low BMI and intense training pattern, which is more clinically relevant.