Download HESI 1 V1 and V2 REVIEW Health Assessment 1 Questions and Answers 2025.pdf and more Exams Nursing in PDF only on Docsity!
HESI 1 V1 and V2 REVIEW Health Assessment 1 Questions and Answers 202 5 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS Bradypnea. Which procedure should the nurse use to assessfor a pulse deficit? - ANS Measure the apical pulse and compare it to the peripheral pulse. *A pulse deficit is a palpable difference between the apical pulse at the point of maximal impulse and the radial pulse palpated at the wrist. A client has been diagnosed with bilateral lower lobe atelectasis. What percussion sound should the nurse expect to hear when percussing over the client's lower lobes? - ANS Dull, thud-like. A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing to complete a head-to-toe assessment and will begin at the head of the client. Which technique should the nurse use to begin the assessment? - ANS Inspect the hair and skin. The nurse is assessing a healthy young adult during an annual physical examination. Which assessment technique should the nurse implement when palpating the abdominal aorta? - ANS Deep palpation above and to the left of the umbilicus. The nurse is conducting a family history as part of the assessment interview. Which action should the nurse take to ensure that sufficient information about the client's blood relatives is obtained? - ANS Document at least 3 generations of the client's family medical history.
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? - ANS 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? - ANS "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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? -
ANS 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.) - ANS 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.) - ANS Diaphoresis. Scaling. Which question should the nurse ask in order to test a client's remote memory? - ANS 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? - ANS 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? - ANS 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? - ANS The skin immediately returns to normal position.
A male executive is seen in the primary care clinic for a physical examination. While obtaining the client's health history, the nurse inquires about his drug and alcohol use. The executive denies drug use, but reports that he has "two glasses of wine" per night. Which response is best for the nurse to provide? - ANS "What effect do you think your use of alcohol may have on you?" Which part of the body should the nurse examine when assessing for peripheral edema in a client with heart failure? - ANS Ankles. A client reports feeling increasingly fatigued for several months, and the nurse observes that the client's lips are pale. Which additional data should the nurse collect based on this presentation?
- ANS Use of vitamin and iron supplements. What is the best place for the nurse to hear lower lobe lung sounds with a stethoscope? - ANS Posterior chest below the 3rd intercostalspace. A registered nurse (RN) is performing a mini-mental state examination (MMSE) for a client who is being admitted to an assisted living community. Which communication techniques should the RN implement to decrease anxiety in the client? (Select all that apply.) - ANS Use simple sentences during the examination. Reduce environmental detractors during the examination. 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? - ANS Phlegm production and wheezing. The nurse is assessing the posterior pharynx during a physical examination. Which technique should the nurse use? - ANS 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? - ANS Place the bell on the 5th intercostal space, left midclavicular line. Which statement is accurate about assessing the spleen? - ANS It must be enlarged at least three times normal size for it to be palpable. 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? - ANS Abnormal finding. Which tool should the nurse use when assessing the neurological status of a client with traumatic brain injury? - ANS 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? - ANS 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? - ANS 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? - ANS The client is treating the nurse with respect. 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? - ANS The left leg remains on the table
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? - ANS 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.) - ANS 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 assessment technique should the nurse implement when evaluating the client's spleen? - ANS Percuss the splenic area as the client takes a deep breath. The nurse enters an examination room to conduct a routine health assessment on an adolescent female client, who is accompanied by her mother. Which action by the nurse is likely to facilitate accurate responses to personal and social history questions? - ANS Request that the mother leave the exam room. While performing a mental status exam (MSE), the nurse asks a client to remember three unrelated words and repeat them later. The client was able to repeat the words as directed. Which computer documentation is accurate? - ANS "Short-term memory is intact." Which technique should the nurse implement when performing a Weber test? - ANS Place a vibrating tuning fork midline on top of the head Which technique should the nurse use to assess a client for scoliosis? - ANS Observe spine while the client is erect and bent forward Which term should the nurse use to document in the client's medical record for a high-pitched scratchy sound during auscultation of the heart? -
ANS Friction rub While performing a head-to-toe assessment, the nurse assesses the client's pupillary accommodation. During the second portion of the test, the nurse notes that the client's pupils constrict and there is convergence of the axes of the eyes. What action should the nurse implement next? - ANS Document a normal finding. The nurse performs the Weber and Rinne tests to assess which cranial nerve? - ANS VIII - vestibulocochlear The nurse uses a tongue depressor to assess a client's mouth. Which structure should the nurse be able to visualize? - ANS Pharynx As a part of a routine health assessment, the nurse assesses the kidneys as part of the abdominal assessment. Which assessment finding should the nurse conclude is normal when palpating the client's right kidney? - ANS A round smooth mass that slides between the fingers. A client reports lower abdominal pain and a feeling of pressure in the bladder. Which assessment finding indicates acute urinary retention? - ANS 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. 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? - ANS Lentigines.
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? - ANS 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? - ANS 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? - ANS 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? - ANS Request a male nurse or healthcare provider to perform the exam.
