BSN 246 HESI HEALTH ASSESSMENT V1 QUESTIONS AND ANSWERS 100% CORRECT!!, Exams of Nursing

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BSN 246 HESI HEALTH ASSESSMENT V

QUESTIONS AND ANSWERS 100%

CORRECT!!

The nurse is performing a thoracic assessment on a client with chronic asthma and hyperinflation of the lungs. Which finding should be expected for this client? - ANSWER Barrel chest

The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel sounds in the right upper quadrant. What action should the nurse take next? - ANSWER Note the character and frequency of bowel sounds

During inspection of a client's mouth and pharynx, the nurse places a tongue blade on the back of the tongue which causes the client to gag. After removing the tongue blade, what action should the nurse take? - ANSWER Document an intact gag reflex.

When teaching a client how to perform a monthly breast self-assessment, the nurse should tell the client that it is most important to assess which part of the breast more closely for changes? - ANSWER Upper outer quadrant.

The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a chest measurement of 42 inches, waist measurement of 45 inches, and hip measurement of 50 inches. What important message should the nurse explain to the client to promote health promotion? - ANSWER A waist circumference is greater than 35 inches in women puts you at higher risk for type 2 diabetes and heart disease."

The nurse performs a physical assessment on an older female client. Which change from the prior exam may be an indication of osteoporosis? - ANSWER Height reduction of 1.5 inches.

While conducting an interview to obtain a health history, the nurse notices that the client pauses frequently and looks at the nurse expectantly. Which response is best for the nurse to provide? - ANSWER Sit quietly to allow the client to respond comfortably.

A client is in the clinical for a yearly physical examination. Which action should the nurse take when preparing to examine the client's abdomen? - ANSWER Ask the client to urinate before beginning the examination.

Which respiratory condition should the nurse document after measuring a respiratory rate of 8 breaths/minute? - ANSWER Bradypnea.

Which procedure should the nurse use to assessfor a pulse deficit? - ANSWER Measure the apical pulse and compare it to the peripheral pulse.

A postmenopausal female client is undergoing a routine physical examination. She has reported nothing out of the ordinary. When performing the examination of the genitourinary system, the nurse finds an irregularly enlarged uterus with firm, mobile, painless nodules in the uterine wall. How should the nurse explain this finding to the client? - ANSWER You have benign fibroid tumors, a common occurrence in women your age.

A client is reporting chest pain. What statement made by the client, helps the nurse to understand this client has a naturalistic belief in the cause of illness? - ANSWER "My life is really out of balance."

The nurse is preparing to assess the hearing of a client with a history of prolonged exposure to occupational noise. Which hearing test provides the most reliable assessment of hearing status? - ANSWER Audiometry.

The nurse is performing a routine physical examination on an adult client. When gathering a health history, which question is included in the CAGE questionnaire? - ANSWER Have you ever felt guilty about your drinking?

*CAGE is the acronym for Cut down, Annoyed, Guilty, and Eye-opener. Nurse can use it to assess for possible alcohol abuse.

The nurse is examining the hip joint of a client who reports hip pain. Which other assessment is most helpful in determining the cause of the client's pain? - ANSWER Knee joint evaluation.

The nurse performs a series of cranial nerve tests on a client with a head injury. Which test should the nurse use to assess damage to the first cranial nerve? - ANSWER Occlude one nostril and have the client identify various odors.

The client reports to the nurse a recent exposure to the mumps. Which assessment finding suggests the client has contracted the mumps? - ANSWER Swelling anterior to the ear lobe on one side of the face

A nurse is working in a healthcare facility that serves a diverse population. What action(s) by the nurse will allow the nurse to empathize with and understand this population? (Select all that apply.) - ANSWER Be open to people who are different. Have a curiosity about people.

Become culturally competent.

Which findings can the nurse determine by palpating a client's skin? (Select all that apply.) - ANSWER Diaphoresis. Scaling.

Which question should the nurse ask in order to test a client's remote memory? - ANSWER What is your date of birth?

While assessing level of consciousness, the nurse finds that a client localizes to pain, is confused during conversation, and opens the eyes to sound. How should the nurse document the Glasgow score of this client? - ANSWER 12.

The Glasgow Coma Scale is used to establish baseline data based on eye opening, motor response, and verbal response. The lowest possible score is 3 and thehighest is

15. This client's Glasgow Coma Scale (GCS) score is 12: Opening eyes to sound is a score of 3, localizing to pain is a 5, and confusion during a conversation is a 4 (3 + 5 + 4 = 12).

A client is in the clinic and is reporting lower abdominal pain and constipation. Which information is of greatest concern to the nurse when obtaining the health history from this client? - ANSWER Family history of colon cancer on mother's side.

An adult client is in the clinic for a regular physical examination. The nurse is assessing the client's hydration status by pinching then releasing the client's skin. Which finding is indicative of good hydration status? - ANSWER The skin immediately returns to normal position.

A client comes to the clinic with a report of fever and a recent exposure to someone who was diagnosed with meningitis. Which nursing assessment should be completed during the initial examination of this client? - ANSWER Level of consciousness.

While palpating a client's breasts, the nurse detects a nontender, solitary, round lobular mass that is solid and firm and slides easily through the breast tissue. The findings of this breast exam are consistent with which condition? - ANSWER Fibroadenoma.

The client is experiencing severe pruritus and small papules and burrows on areas over one hand and the inner thighs. Which assessment data best explains the condition the client is experiencing? - ANSWER The client works in a daycare setting that has had a scabies outbreak.

Ask questions one at a time to decrease confusion.

The nurse is interviewing a client who reports having a persistent, productive cough during the winter caused by bronchitis. Which additional finding should the nurse assess for bronchitis? - ANSWER Phlegm production and wheezing.

The nurse is assessing the posterior pharynx during a physical examination. Which technique should the nurse use? - ANSWER Press the tongue down one side at a time with a tongue depressor.

The nurse is assessing a client who has a history of mitral stenosis. How should the nurse assess this client with a stethoscope to listen for this condition? - ANSWER Place the bell on the 5th intercostal space, left midclavicular line.

Which statement is accurate about assessing the spleen? - ANSWER It must be enlarged at least three times normal size for it to be palpable.

A client with progressive hearing loss appears distressed when the registered nurse (RN) asks open-ended questions about the client's health history. Which forms of communication should the RN use? - ANSWER Face the client so the client can see the RN's mouth. Check if the client's hearing aides are working properly. Reduce environmental noise surrounding the client.

A client states that she had a mastectomy of her left breast last year and now experiences lymphedema. What should the nurse expect to find when examining the client? - ANSWER Swelling of the left arm and non-pitting edema.

A client has just returned from the recovery room and asks to get out of bed to go to the bathroom. The nurse decides to obtain orthostatic vital signs first. How will the nurse position the client to begin this procedure? - ANSWER Lying.

The nurse is assessing a client for a hip flexion contracture. Which finding indicates a negative Thomas test when the client's right knee is brought toward the chest? - ANSWER The left leg remains on the table

*The Thomas test is performed by having the client bring one knee toward the chest while the other leg remains extended on the table. A positive Thomas test is elicited when the extended leg rises off the table when the opposite leg's knee is brought up to

the client's chest, indicating hip flexor contracture. If the extended leg (the left leg, in this example) remains on the table, the test is negative.

The nurse is assessing a client who has a history of aortic regurgitation. Where should the nurse place the stethoscope diaphragm to listen for this condition? - ANSWER 2nd intercostal space along the right sternal border.

The nurse is assessing a client who has experienced a sudden onset of hearing loss in the right ear. Which finding should alert the nurse to a potentially serious medical condition that requires further evaluation? - ANSWER There is no sign of associated infection.

Which information should the nurse obtain to identify the client's self-perception of health status? - ANSWER Health history

During the initial assessment, the nurse notes that a client has blurred vision with cloudy lenses. Which condition should the nurse document? - ANSWER Cataracts.

Which condition is indicated by a fluorescent, yellow-green color when the nurse uses a Wood's lamp toexamine a client's skin lesions? - ANSWER Fungal infection.

A client with dark skin is reporting a painful and itching area on the lower left leg. What should the nurse look for when assessing this client's skin for inflammation? - ANSWER Change in consistency.

A client reports pain when taking a deep breath. Which lung auscultation sound should the nurse anticipate hearing? - ANSWER Pleural friction rub

A nurse is completing a nutritional assessment with a client. What is the easiest method for the nurse to use to get information about the client's nutritional intake? - ANSWER 24-hour dietary recall

The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply.) - ANSWER Diminished hair on legs. Skin cool to touch.

The nurse is completing a physical assessment of a client who feel from a tree. The client's abdomen is soft with hyperactive bowel sounds in all four quadrants. Which

A client reports lower abdominal pain and a feeling of pressure in the bladder. Which assessment finding indicates acute urinary retention? - ANSWER Dull sound percussed over bladder.

*Clients with acute urinary retention may present with lower abdominal pain and bladder distension. Percussion (tapping on the body wall) is performed to detect differences in pitch. A dull sound produced when percussing a distended urinary bladder is an indication of urinary retention.

During an external examination of the eyes, the nurse gently palpates the eyes while the client's eyelids are closed. The eyes are both very firm and resist movement back into the orbit. How should the nurse document this finding? - ANSWER Abnormal finding.

Which tool should the nurse use when assessing the neurological status of a client with traumatic brain injury? - ANSWER Glasgow Coma Scale.

The nurse is assessing a client with liver disease who is jaundice and exhibits scleral edema. During the health assessment, the nurse should implement which technique to determine evidence of hepatomegaly? - ANSWER Use a bouncing motion to tap the middle finger placed within boundaries of the liver.

What is the best nursing response to an older client who has not mentioned incontinence during a genitourinary assessment? - ANSWER Ask the client specifically about any leakage of urine.

The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response? - ANSWER The client is treating the nurse with respect.

During the interview portio of the health assessment, a nurse notes the person's posture, physical appearance, and ability to converse. How should the nurse document these findings? - ANSWER Objective.

The nurse is assessing a client who reports having shoulder pain. Which sign is the best indicator of a rotator cuff tear? - ANSWER Inability to slowly lower the arm when abducted.

During cardiac auscultation, the nurse hears a split in the second heart sound when listening at the second left intercostal space of a male client. To assess this sound more

fully, what action should the nurse implement? - ANSWER Listen to the sound while observing the client's respirations.

An older client has just returned to the room following a surgical procedure. Which pain scale should the nurse use when assessing the client's pain level? - ANSWER Verbal descriptor scale.

The nurse observes peristaltic movement in the left lower quadrant of a client's abdomen. Which further assessment of the area should the nurse perform? - ANSWER Observe the direction of movement.

The nurse is assessing a client's middle lung lobe. What is the best location for the nurse to place a stethoscope diaphragm to hear normal lung sounds in this lobe? - ANSWER 4th intercostal space, right midclavicular line.

A Muslim male client refuses to let the female registered nurse (RN) listen to his breath sounds during the examination. How should the RN respond? - ANSWER Request a male nurse or healthcare provider to perform the exam.

The nurse examines the skin of an older adult client. Which skin variation is considered a normal finding for a client in this age group? - ANSWER Lentigines.

*Lentigines or commonly referred to as liver spots are irregularly shaped dark spots on the skin caused by aging and extensive sun exposure. This skin variation is a normal finding in an older adult client.

During a client's routine well-woman physical exam, the nurse examines the breasts. Which assessment technique should the nurse implement to evaluate for any abnormal lumps? - ANSWER With both arms at client's side, lift one arm and palpate the axilla.

The nurse is completing a physical exam on an adult client. Which thyroid finding is considered normal? - ANSWER Gland is not palpable.

How should the nurse assess for lower extremity edema in a client who has been diagnosed with heart failure? - ANSWER Measure bilateral ankle circumference with a non-stretchable tape measure.

A client has come to the clinic for a routine health assessment. What is the best assessment question for the nurse to ask a client after observing tophi on the client's ear cartilage? - ANSWER Have you had sudden and severe pain in the toes or feet?