NUR 210 RN Health Assessment HESI NGN

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Free NUR 210 RN Health Assessment HESI NGN Questions

1. History and Physical

The client is a 76-year-old female who arrived at the emergency department (ED) via ambulance from an assisted living facility after a fall. The client called for help using her medical alert necklace. Reports feeling dizzy and lightheaded for the past two days. Client is unable to recall the events that led up to the fall and states, "I do not know how long I was down." Past medical history includes chronic obstructive pulmonary disease (COPD), hypertension (HTN), and carotid artery stenosis. Smokes half a pack of cigarettes daily for 40 years. Attempted to quit smoking five years ago after a right carotid endarterectomy.

Nurses' Notes
1620
Received report from triage nurse. Client returning from computed tomography (CT) department. The client is alert and oriented to person, place, time, and situation. Unable to recall details of her fall. Heart rhythm regular. Lung sounds are diminished throughout. Placed on oxygen 1 L/minute via nasal cannula. Bruising noted to left arm and small laceration on the left chin from the fall. Pain rated 3 on a scale of 0 to 10. Carotid ultrasound performed at bedside. Laboratory specimens drawn. Preparing the client for transfer to the stroke unit, calling to ascertain readiness to receive client and room number.

1640
Transferred client to the stroke unit from the ED as prescribed. Situation, background, assessment, recommendation (SBAR) report given.

1655
Received client from emergency department (ED). Admitted and oriented to the stroke unit. Vital signs taken.

Flow Sheet
1600
Vital signs on arrival
· Temperature: 98.9° F (37.1° C) orally
. Heart rate: 101 beats/minute
· Respirations: 22 breaths/minute
· Blood pressure: 156/90 mm Hg
· Oxygen saturation: 92% on room air

1635
Vital signs
· Temperature: 98.6° F (37° C) orally
. Heart rate: 98 beats/minute
. Respirations: 22 breaths/minute
· Blood pressure: 160/92 mm Hg
· Oxygen saturation: 93% on 1 L/minute oxygen via nasal cannula

1700
Vital signs
· Temperature: 98.6° F (37° C) orally
. Heart rate: 100 beats/minute
· Respirations: 21 breaths/minute
· Blood pressure: 166/89 mm Hg
· Oxygen saturation: 94% on 1 L/minute

Orders
. Computed tomography (CT) of the head
· Carotid duplex ultrasound
· Complete blood count (CBC), complete metabolic panel (CMP), prothrombin time/international normalized ratio (PT/INR), partial thromboplastin time (PTT), C-reactive protein (CRP), thyroid stimulating hormone (TSH), low density lipoprotein (LDL), high density lipoprotein (HDL)
· Admit to the stroke unit
· Magnetic resonance imaging (MRI) of brain

Imaging Studies
· Computed tomography (CT) of brain: Negative.
· Carotid ultrasound: Left carotid 80% stenosis.

The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment.
Which assessment(s) should the nurse conduct? Select all that apply.
  • Level of consciousness

  • Romberg’s test

  • Pupil size

  • Glasgow Coma Scale

  • Cranial nerves

  • Muscle tone

  • Brudzinski reflexes

Explanation

A. Level of consciousness: This is one of the most critical components of a neurological assessment. Changes in consciousness may indicate worsening cerebral perfusion or evolving neurological deficits following a possible cerebrovascular event. Monitoring alertness, orientation, and responsiveness provides early clues to deterioration. C. Pupil size: Assessing pupil size, shape, and reactivity to light helps identify cranial nerve (CN) III involvement or increased intracranial pressure. Unequal or sluggish pupils may signal neurological compromise. D. Glasgow Coma Scale: The Glasgow Coma Scale (GCS) objectively measures eye opening, verbal, and motor responses to quantify neurological function. This standardized scale helps track changes in neurological status over time and detect subtle deterioration. E. Cranial nerves: Testing the cranial nerves evaluates brainstem and cerebral function. It identifies deficits such as facial droop, dysarthria, or visual disturbances, which are key indicators of stroke or carotid artery impairment. F. Muscle tone: Assessing muscle tone and strength detects weakness, rigidity, or flaccidity on one side of the body — common in stroke patients. These findings help determine the location and extent of neurological injury.
2.

While the nurse is taking a health history, the client announces, "I don't have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide?

  • Ignore the angry outburst and continue with the history questions.

  • "I am sorry you feel that way. Perhaps you'd like to return when you have more time."

  • "You sound angry. Would you like to tell me about it?"

  • Move closer and place a hand on the client's shoulder to demonstrate concern.

Explanation

The nurse’s response, “You sound angry. Would you like to tell me about it?”, uses therapeutic communication by acknowledging the client’s feelings and inviting discussion in a nonjudgmental way. This approach helps de-escalate emotions, promotes trust, and encourages the client to express underlying frustrations or fears that may be interfering with care. Recognizing and validating the emotion opens the door to effective communication and collaboration.

3.

The nurse is obtaining a health history for a client wishing to obtain a life insurance policy. When evaluating the abdomen, the client reports taking several antacids for heartburn that only occurs at night. Which additional finding associated with gastroesophageal reflux should the nurse ask the client to identify?

  • Small frequent meals cause heartburn to worsen.

  • Heartburn occurs when lying down at night.

  • Bowel movements are light grey and chalky.

  • Hyperactive bowel sounds are present in all quadrants.

Explanation

Heartburn that worsens when lying down at night is a hallmark symptom of gastroesophageal reflux disease (GERD). In this position, gravity no longer helps keep gastric contents in the stomach, allowing acid to flow back into the esophagus. This causes burning discomfort in the chest or throat and may be accompanied by a sour taste or regurgitation. Asking about nighttime reflux helps confirm GERD and guides further evaluation and lifestyle modifications.

4.

To assess a female client for hirsutism, which action should the nurse take?

  • Observe the hair shafts on the client's scalp.

  • Lightly palpate over the client's entire scalp.

  • Assess the appearance of the client's face.

  • Apply and release light pressure to the skin.

Explanation

Hirsutism refers to excessive, male-pattern hair growth in women—commonly appearing on the face, chest, and back. To assess for hirsutism, the nurse should observe areas where coarse, dark terminal hair typically appears in women with hormonal imbalances such as elevated androgen levels. Assessing facial hair distribution (chin, upper lip, sideburns) helps identify abnormal patterns that may suggest conditions like polycystic ovary syndrome (PCOS) or adrenal dysfunction.

5.

The nurse is performing a health interview for a client who does not speak fluent English and has obtained an interpreter. Which action should the nurse implement?

  • Use an interpreter throughout the client’s hospitalization.

  • Maintain eye contact with the client when questions are asked.

  • Ask the interpreter to tell the client to write down questions.

  • Give the interpreter a form that lists the interview questions.

Explanation

When communicating through an interpreter, the nurse should maintain direct eye contact and speak to the client, not the interpreter. This demonstrates respect, promotes rapport, and ensures the client feels directly included in the conversation. The interpreter’s role is to facilitate accurate translation, but the therapeutic connection must remain between the nurse and the client. The nurse should speak slowly, use simple language, and pause frequently to allow for accurate interpretation.

6.

When inspecting a client's skin, the nurse observes an area of erythema on the arm. Which follow-up assessment should the nurse complete?

  • Measure the degree of skin elasticity.

  • Observe the appearance of the nailbeds.

  • Determine the client's oxygen saturation.

  • Palpate the area for warmth and swelling.

Explanation

Erythema refers to redness of the skin caused by increased blood flow to superficial capillaries, often due to inflammation, infection, or irritation. The nurse should palpate the area for warmth, tenderness, and swelling to determine whether inflammation or infection is present. Warmth and edema confirm that erythema is likely inflammatory in nature rather than simply a skin color variation.

7.

The nurse is assessing a client with type 2 diabetes mellitus and observes an abnormal response when using a monofilament. Which finding should the nurse document that is consistent with an abnormal finding?

  • Inequality in muscle contraction.

  • An intention tremor.

  • Slowed capillary refill.

  • Loss of peripheral sensation.

Explanation

A monofilament test is used to assess peripheral sensation, particularly in clients with diabetes mellitus, who are at risk for peripheral neuropathy. An abnormal finding is the client’s inability to feel the monofilament when it lightly touches the skin, indicating a loss of protective sensation. This loss increases the risk of foot ulcers and injury due to the client’s inability to detect pressure or pain. The nurse should document this and report it to the healthcare provider for further evaluation and preventive care planning.

8.

A woman comes to the clinic for her first prenatal visit. The nurse is conducting a health history and the woman begins to cry when asked about previous pregnancies. Which response is best for the nurse to provide?

  • "I'm so sorry that I made you cry. I didn't mean to upset you."

  • "Why don't I come back in a few minutes after you are more composed."

  • C Offer a tissue and sit quietly until the crying subsides.

  • Allow the client to compose herself then change the subject.

Explanation

The best therapeutic response is to offer a tissue and remain present in silence while the client cries. This demonstrates empathy, compassion, and emotional support, allowing the client to express feelings freely without interruption or judgment. Silence is a powerful therapeutic communication technique that gives the client space to process emotions while maintaining trust and rapport.

9.

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

  • White blood cell count (WBC).

  • Blood urea nitrogen (BUN).

  • Hematocrit.

  • Glucose.

Explanation

Melena refers to black, tarry stools caused by digested blood from an upper gastrointestinal (GI) bleed. This condition can result in blood loss and anemia, making it essential for the nurse to monitor the client’s hematocrit (and hemoglobin) to evaluate the extent of blood loss and the risk of hypovolemia. A declining hematocrit level indicates ongoing bleeding or inadequate replacement of lost blood volume.

10.

The nurse assesses a male client who is brought to the emergency department (ED) by his family who believes he is having a heart attack. Which finding is the best indicator that a client is experiencing an acute myocardial infarction (AMI)?

  • Pain in the neck, jaw, or medial side of the left arm.

  • Anterior thorax pain that radiates between the scapulae.

  • Localized sternal border pain intensified by palpation.

  • Chest pain that intensifies upon chest excursion.

Explanation

Classic symptoms of an acute myocardial infarction (AMI) include chest pressure or discomfort radiating to the neck, jaw, shoulder, or left arm, especially the medial aspect. This type of pain is caused by myocardial ischemia due to reduced coronary blood flow. It may be accompanied by shortness of breath, diaphoresis, nausea, or anxiety. The radiation pattern of pain is a hallmark sign that distinguishes cardiac pain from musculoskeletal or respiratory causes.

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