HESI Health Assessment and Physical Examination

HESI Health Assessment and Physical Examination

A 29 year old male client informs the nurse that he came to the clinic to see if,
"Maybe I have lung cancer or something," and wants to get checked out since, "I
can't seem to get rid of this body-wracking dry cough that has been hanging around
for the last six weeks." Which computer documentation of this client's concerns
should the nurse enter?
A. Presents with a hacking non-productive cough of 6 weeks duration.
B. Describe having a "body-wracking dry cough" of 6 weeks duration.
C. Expresses concern of "lung cancer" symptoms for last 6 weeks.
D. Young adult male presents with fears that he has "lung cancer"
(- Correct answer is B, as assessment process includes chief complaint which is
how the patient describe why he is here in the hospital or clinic and can't include
diagnosis.
A 75-year-old client with a recent history of a cerebrovascular accident (CVA)
presents with right hemiparesis. The nurse tests the deep tendon reflexes on the
right side and elicits a brisk 4+ response. Which interpretation of this finding is
accurate?
A. A normal reflex response.
B. Absent or sluggish response consistent with a lower motor neuron lesion.
C. Flaccid paralysis.
D. Hyperactive response consistent with an upper motor neuron disorder.
(- Correct answer is D, brisk 4+ response is correlated with hyperactive response.