HESI V2 HEALTH ASSESSMENT EXAM QUESTIONS AND ANSWERS 100% CORRECT!!, Exams of Nursing

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HESI V2 HEALTH ASSESSMENT EXAM

QUESTIONS AND ANSWERS 100% CORRECT!!

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" - ANSWER 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. - ANSWER Correct answer is D, brisk 4+ response is correlated with hyperactive response.

The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating the spleen? A. Pain notes when palpating McBurney's point. B. Tip of spleen palpable when client is asked to forcefully exhale. C. Rebound tenderness with compression over right upper quadrant. D. Firm mass palpated at bottom of left rib cage. - ANSWER Correct answer is D. McBurney's point is related to appendicitis and not spleen.

In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the stethoscope at which location? - ANSWER *under mandible towards lymph nodes. transverse to trachea

A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?

D. Note any change in the color of the ulcer when the leg is moved - ANSWER Correct answer is C. Location and appearance of the ulcer would give us the type (venous vs arterial) In observing a client's face, which assessment finding requires the most immediate intervention by the nurse? A. Eyelids are matted and crusted. B. Cornea are jaundiced. C. Oral mucosa is cyanotic. D. Face is flushed and diaphoretic. - ANSWER Answer is C. Blue lips occur when the skin on the lips takes on a bluish tint or color. This generally is due to either a lock of oxygen in the blood or to extremely cold temperatures. When the skin becomes a bluish color, the symptom is called cyanosis. Most commonly, blue lips are caused by a lack of oxygen in the blood. Most causes of cyanosis are serious and symptom of your body not getting enough oxygen. Over time, this condition will become life-threatening. It can lead to respiratory failure, heart failure, and even death, if left untreated.

While obtaining a health history, a male client tells the nurse that he sometimes experiences shortness of breath. The nurse determines that the client's respirators are regular and deep, and his respiratory rate is 14 breaths/minutes. What is the best nursing action? A. Ask the client to perform light exercise and observe the respiratory effect. B. Document "dyspnea on exertion" in the client's medical record. C. Ask the client to describe the episodes of dyspnea in more detail. D. Explain to the client the possible causes of dyspnea or "shortness of breath." - ANSWER Correct answer is C. Both respiratory rate and breath sounds are normal. Further assessment is needed by asking the client to describe his SOB

When assessing a male client's respiratory status, which technique should the nurse use to assess his anterior- posterior (AP) chest diameter? A. Auscultation. B. Percussion. C. Palpation. D. Observation. - ANSWER Correct answer is D. Observation is the way to detect barrel chest which is associated with COPD

Which assessment finding supports the client statement, "My feet swell all the time?" A. 2+ pitting edema of ankles bilaterally. B. Capillary refill both feet > 3 seconds. C. Pedal pulses weak and thread. D. Positive Homan's sign bilaterally. - ANSWER Correct answer is A. 2+ pitting edema indicate swelling in the lower extremities. Homans's sign is often used in the diagnosis of deep venous thrombosis of the leg. A positive Homans's sign (calf pain at dorsiflexion of the foot) is thought to be associated with the presence of thrombosis.

The nurse is performing a cranial nerve exam on an 87-year-old client. The nurse notes that the client has a reduced upward gaze, a decreased corneal reflex, a high frequency hearing loss, and a reduced gag reflex. What action should the nurse take next? A. Review past history for any episodes of a cerebral cortex lesion. B. Implement neuro vital signs every 2 hours to detect Cushing's Triad. C. Continue the assessment to the next pairs of cranial nerves. D. Assess the spinal reflexes for demyelination symptoms. - ANSWER Correct answer is C. Full cranial nurses assessment should be completed before considering the other options.

When performing a neurologic assessment on an alert client, the nurse observes that the client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment? A. PERRL. B. GCS of 15. C. PERLA. D. Neuro status intact - ANSWER Correct answer is A. "Pupils Equal, Round, and Reactive to Light".

Which assessment technique provides the nurse with the best data related to the client's level of peripheral perfusion? - ANSWER correct answer C. Capillary refill test

The nurse is assessing a female client who states that her hemorrhoids are inflamed and hurt constantly. Which intervention is best for the nurse to complete a focused assessment? A. Ask the client how long she has experienced discomfort related to hemorrhoids. B. Place the client in a standing position, leaning over the exam bed for inspection. C. Determine if the client uses any over-the-counter preparation for hemorrhoids. D. Position client in left lateral position to inspect perianal area for fissures or sacs. - ANSWER Correct answer is D. A focused assessment collects relevant information pertaining to the current condition of the patient after a change or new symptom develops.

The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. What question should the nurse ask first? "Have you A. Been depressed lately?" B. Had everything to eat in the last 24 hours?" C. Ever had problems with you blood sugar?" D. Been sleeping well?" - ANSWER Correct answer is D. To rule out symptoms for lack of sleep, asking the client if he slept well would help determining why he has the presented symptoms.

After checking a client's pupillary response to light, the practical nurse (PN) tells the nurse that the client's pupils are constricted with minimal response to light. Before verifying the PN's findings, which action should the nurse take? A. Brighten the light in the client's room. B. Assess the client's visual fields. C. Review the client's medication list. D. Administer PRN saline eye solution. - ANSWER Correct answer is B. PERRLA:

D. Serum pre-albumin - ANSWER Correct answer is C. Hemoglobin is the main lab value to check for anemia. Anemia is a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues. Having anemia can make you feel tired and weak. There are many forms of anemia, each with its own cause. Anemia can be temporary or long term, and it can range from mild to severe.

A male client returns to the clinic for a follow-up visit after being treated for a bladder infection. While examining the client, which finding indicated an expected response to the treatment? A. Orange sized prostate gland. B. Post-voided residual volume of 50 mL. C. Pain score of 1 out of 10 with urination. D. Decreasing sperm cell count. - ANSWER C

The nurse completes palpitation of the abdomen on an older adult client. Which finding is considered normal for the client? A. Non-tender. B. Gallop. C. Thrill. D. Peristaltic waves. - ANSWER Correct answer is D. The small intestine undergoes segmental contractions and peristaltic waves Segmental contractions occur for short distances only along the small intestine Peristaltic waves occur for variable distances to cause the chyme to move along the small intestine.

The nurse has just completed palpitation maneuvers for lymph nodes on a 75-year-old female client. Which findings are considered normal for this elderly client? A. Nodes are non-palpable. B. Axillary nodes feel soft and fatty. C. Nodes feel ropey and rubbery. D. Inguinal nodes are enlarged and warm to the touch. - ANSWER Correct answer is A. Normal lymph nodes are non-palpable.

A women comes to the clinic for her first prenatal visit. The nurse is conducting a health history and the women begins to cry when asked about previous pregnancies. Which response is best for the nurse to provide? A. "Why don't I come back in a few minutes after you are more composed." B. Offer a tissue and sit quietly until the crying subsides. C. Allow the client to compose herself then change the subject. D. "I'm so sorry that I made you cry. I didn't mean to upset you." - ANSWER Correct answer C. Try always to listen to the patient when she is in a bad mood or wants to express her feeling.

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take? A. Apply warm blankets to both feet. B. Palpate pulse points with legs dependent. C. Notify the healthcare provider. D. Use a doppler ultrasonic stethoscope. - ANSWER Correct answer is D. Doppler ultrasonic stethoscope is used when the nurse couldn't palpate a pedal pulse of a client.

A homeless male client with a history of alcohol abuse had a cerebrovascular accident (CVA) 10 years ago that resulted in left hemiparesis. Today he is complaining of pain in his left leg, is afebrile, has 4+ pitting edema in the lower left leg, and minimal swelling of the right leg. Which action should the nurse implement first? A. Inspect legs for infection of trauma. B. Obtain a blood alcohol level. C. Complete a mental status exam. D. Inquire about dietary salt intake. - ANSWER Correct answer is A. Since it is a single leg, the nurse has to rule out any trauma of infection especially the left side for the patient is awakened.

The nurse is assessing a client for goiter and is unable to observe the thyroid gland. Which action should the nurse take? A. Defer the thyroid exam and observe the client for signs of myxedema. B. Document that thyroid gland size is normal with no visible goiter. C. Ask the client to swallow while palpating along the sides of the trachea. D. Palpate deeply and firmly over the location of the thyroid gland. - ANSWER Correct answer is C. To palpate a client thyroid gland: Use one hand to slightly retract the sternocleidomastoid muscle while using the other to palpate the thyroid. Have the patient swallow a sip of water as you palpate, feeling for the upward movement of the thyroid gland.

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perineal area and anus. Which findings indicates a normal appearance of the anus? A. Increased pigmentation and coarse skin. B. Flap of tissue at sphincter. C. Hypotonic tone of the anal sphincter. D. Dimpled area above anus. - ANSWER Correct answer is A

Which focused assessment technique should the nurse use for a client admitted with possible dehydration?

In assessing a client's sensory nerve function, the nurse prepares to assess the client's response to temperature. What action should the nurse include during this assessment? A. Darken the client's room environment. B. Cover the client with a warmed blanket. C. Measure the client's body temperature. D. Instruct the client to close both eyes. - ANSWER Correct answer is B

The nurse is obtaining a health history for a client during an annual physical examination. When evaluating the client for menopausal symptoms, which finding indicates the client is perimenopausal? A. Drenching night sweats. B. Excessive vaginal moisture. C. Increase in sexual desire. D. Cessation of menstruation. - ANSWER correct answer is A

A client sustained a subconjunctival hemorrhage. The presence of which set of symptoms indicate that the client needs to be seen for further evaluation by an ophthalmologist? A. Acute pain, change in visual acuity, and foreign body sensation. B. Frequent burning, irritation and tearing of the eyes. C. Bilateral itchy, red eyes with watery discharge D. Diminished ability to focus on close work and excessive illumination required. - ANSWER Correct answer is D. Diminished ability to focus on close work could be a sign of cranial nerve damage and could lead to reduced visual acuity, due to a reduced ability of the lens in the eye to focus light on the retina, results in images that appear blurry.

To assess a female client for hirsutism, which action should the nurse take? A. Lightly palpate over the client's entire scalp. B. Apply and release light pressure to the skin. C. Assess the appearance of the client's face. D. Observe the hair shafts on the client's scalp - ANSWER Correct answer is C. Hirsutism is a condition in women that results in excessive growth of dark or coarse hair in a male-like pattern like face, chest and back.

After a young adult woman describes feeling palpitations when she lies on her left side it is most important for the nurse to auscultate heart sounds at which anatomical location? A. Second intercostal space, left of the sternal border. B. Left third intercostal space, left lateral sternal border. C. Base of the heart at second intercostal space, right of the sternal border. D. Apex of the heart at the left fifth intercostal space at the midclavicular line - ANSWER Correct answer is D. The apex beat or apical impulse is the palpable cardiac impulse

farthest away from the sternum and farthest down on the chest wall, usually caused by the LV and located near the midclavicular line (MCL) in the fifth intercostal space

While assessing the legs of a female client, the nurse observes leathery-looking skin. The client reports aching tired legs that swell if she stands for long periods of time. To screen for venous insufficiency, the nurse should ask the client if she has experienced which subject finding? A. Decreased pain when legs are elevated. B. Deep, continuous pain in the calf muscles. C. Cool, pale skin below the knees. D. Painful symptoms alleviated by warmth. - ANSWER Correct answer is A. Elevation of the legs decreases welling and helps with blood flow.

During an abdominal assessment, a client with a temperature of 103 F (39.4 C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement? A. Electrocardiogram. B. Complete bed rest. C. Monitor urinary output. D. Nothing by mouth. - ANSWER Correct answer is D.

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high pitched almost continuous gurgling in two quadrants. What action should the nurse implement? A. Use the bell of the stethoscope to auscultate again. B. Elevate the head of the client's bed immediately. C. Document the presence of borborygmi. D. Auscultate the remaining two quadrants. - ANSWER Correct answer is D. Full assessment of all parts of the lungs, side by side, should be performed before taking any other action or document the findings.

To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take? A. Ask the client to describe any other related symptoms. B. Use both hands to hold and palpate the client's hands. C. Lightly pinch a fold of skin over the client's sternum. D. Place the dorsum of the hand on the client's forehead. - ANSWER Correct answer is B.

D. Observe the client's eye movements through the cardinal fields of vision. - ANSWER correct answer B.

Which question by the nurse is likely to elicit the most information regarding a client's use of medications to treat a chronic cough? A. What medications are you currently taking? B. Have you tried any generic brands of cough syrup? C. Have you been prescribed any medications for your cough? D. What medications have you used for your cough? - ANSWER Correct answer is A. The nurse should always ask general questions about medication which include OTC and herbal products. Also, there might be other medications that cause cough like ACE inhibitors so the nurse should assist the who image.

The school nurse is interviewing a 13-year-old girl who wants to go home from school because of "back pain". Which question should the nurse ask the adolescent first? A. "Have you taken any medications to relieve the pain?" B. "What were you doing when you first noticed the problem?" C. "Do you remember ever having this type of pain in the past?" D. "Does changing your position make the pain worse?" - ANSWER Correct answer is C. Scoliosis (a severe curvature of the spine) is a possible cause of back pain, especially in adolescent girls. Your pediatrician evaluates your child's posture during regular well-child visits to make sure her back is straight and she's growing normally.

During a health assessment for a young adult female client's gynecological annual screening, the client reports amenorrhea. The nurse calculates the client body mass index (BMI) as 16. Which finding should the nurse document in the electronic medical record that indicates an expected rationale for this condition? A. Increased calcium intake with 3 glasses if non-fat milk daily. B. Reports a history of chronic urinary tract infections. C. Trains for competition and runs 12 miles every day. D. Received an implanted intrauterine device (IUD) last month. - ANSWER Correct answer is D. When using IUD, the hormones act locally on the uterus—versus hanging out in your bloodstream, like with the pill—they also thin the uterine lining. In some women, the uterine lining is so thinned by the IUD that nothing comes out, aka no period.

A male client reports the onset of a burning sensation in his hands and legs. How should the nurse document this finding in the electronic medical record? A. Circulation impaired. B. Inflammation present.

C. Reports feeling "on fire." D. Paresthesia reported. - ANSWER Correct answer D.

The nurse prepares to begin a systematic assessment of a client's heart sounds. Upon positioning the stethoscope as seen in the picture what should the nurse do first? A. Identify S1 and S2 heart sounds. B. Change to the bell of the stethoscope. C. Move the stethoscope to the apical site. D. Listen for abnormal sounds - ANSWER Correct answer is A. 1st assessment of hearts sounds is to identify S1 and S2 heart sounds. S1 is normally a single sound because mitral and tricupsid valve closure occurs almost simultaneously. Clinically S corresponds to the pulse. The second sound S2 represents closure of the smilunar (aortic and pulmonary) valves.

During assessment of a client's neck, the nurse prepares to assess for jugular vein distention (JVD) as seen in the picture. What should the nurse do next? A. Listen to swishing sound during systole. B. Use the bell of the stethoscope to auscultate. C. Remove the stethoscope to observe the site. D. Palpate the site of erythema and tenderness. - ANSWER Correct answer is C.

During a health assessment, the client reports being treated for osteoarthritis. The nurse examines a client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record? A. Proximal intertarsal join swelling of big toe. B. Non-painful enlarged interphalangeal joints. C. Distal interphalangeal joint nodules that deviate. D. Frozen, non-movable phalangeal joints. - ANSWER correct answer is C. Heberden nodes (hard or bony swelilngs in the distal interphalangeal joints) along with a deviated distal finger are a classic finding in osteoarthritis.

The nurse asks a 50-year-old female client what her natural hair color is. The client replies, "I've been dying my hair for so long, I'm not even sure,,,, I just know that this month it's ravishing red." Based on this information, the nurse expects to obtain which finding when palpating this client's scalp hair? A. Excess vellus hair. B. Receding front hairline. C. Fine, thin, limp texture. D. Coarse, dry, brittle texture. - ANSWER Correct answer is D. Excessive dying of the hair will lead the hair to be coarse and dry.