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HESI Practice Health Assessment Physical Assessment.pdf
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HESI Practice Health Assessment/Physical Assessment The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation? An involuntary rhythmic, rapid, twitching of the eyeballs A dorsiflexion of the great toe with fanning of the other toes A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed A lack of normal sense of position when the client is unable to return extended fingers to a point of reference - ✔ A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? Rhythmic respirations with periods of apnea Regular rapid and deep, sustained respirations Totally irregular respiration in rhythm and depth Irregular respirations with pauses at the end of inspiration and expiration - ✔ Rhythmic respirations with periods of apnea A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? A defect in the cochlea A defect in cranial nerve VIII A physical obstruction to the transmission of sound waves
A defect in the sensory fibers that lead to the cerebral cortex - ✔ A physical obstruction to the transmission of sound waves While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? Lub-dub sounds Scratchy, leathery heart noise A blowing or swooshing noise Abrupt, high-pitched snapping noise - ✔ A blowing or swooshing noise The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? Test the corneal reflexes. Test the 6 cardinal positions of gaze. Test visual acuity, using a Snellen eye chart. Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin. - ✔ Test the 6 cardinal positions of gaze. The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? After a shower or bath While standing to void After having a bowel movement While lying in bed before arising - ✔ After a shower or bath
Assessing the strength of peripheral pulses Obtaining information about the client's respirations Performing a musculoskeletal and neurological examination Asking the client about a family history of any illness or disease - ✔ Auscultating lung sounds Obtaining the client's temperature Obtaining information about the client's respirations The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure? To examine the testicles while lying down That the best time for the examination is after a shower To gently feel the testicle with one finger to feel for a growth That TSEs should be done at least every 6 months - ✔ That the best time for the examination is after a shower The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time? At the onset of menstruation Every month during ovulation Weekly at the same time of day One week after menstruation begins - ✔ One week after menstruation begins The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test?
The right eye is tested, followed by the left eye, and then both eyes are tested. Both eyes are assessed together, followed by an assessment of the right eye and then the left eye. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the largest line on the chart. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read 200 feet (60 meters) away by an individual with unimpaired vision. - ✔ The right eye is tested, followed by the left eye, and then both eyes are tested. A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? Provide the client with materials on legal blindness. Instruct the client that he or she may need glasses when driving. Inform the client of where he or she can purchase a white cane with a red tip. Inform the client that it is best to sit near the back of the room when attending lectures. - ✔ Instruct the client that he or she may need glasses when driving. The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply. Set the room temperature at a comfortable level. Remove distracting objects from the interviewing area. Place a chair for the client across from the nurse's desk. Ensure comfortable seating at eye level for the client and nurse. Provide seating for the client so that the client faces a strong light.
Obtain all information from family members. Plan short sessions with the client to obtain data. Use the primary health care provider's medical history. - ✔ Plan short sessions with the client to obtain data. A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take? Have 1 of the client's family members interpret. Have the Spanish-speaking triage receptionist interpret. Page an interpreter from the hospital's interpreter services. Obtain a Spanish-English dictionary and attempt to triage the client. - ✔ Page an interpreter from the hospital's interpreter services. The nurse is instructing a client in breast self-examination (BSE). The nurse tells the client to lie down and examine the left breast. The nurse should instruct the client that while examining the left breast she should place a pillow under which area? Left shoulder Right scapula Right shoulder Small of the back - ✔ Left shoulder The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. The appropriate instruction regarding when the BSE should be performed is at which time? At ovulation time 7 to 10 days after menses
Just before menses begins At a specific day of the month and on that same day every month thereafter - ✔ At a specific day of the month and on that same day every month thereafter The registered nurse (RN) is educating a new RN on conducting a problem-based or focused assessment on a client. Which statement by the new RN indicates that the teaching has been effective? "This is mostly used in a walk-in clinic or emergency department." "This is focused on disease detection and conducted in a health care provider's office." "This is conducted on admission in a primary care or long-term care setting." "This is conducted as a follow-up examination by a health care provider." - ✔ "This is mostly used in a walk-in clinic or emergency department." The emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion? Poor hygiene Difficulty walking Fear of the parents Bald spots on the scalp - ✔ Difficulty walking The community health nurse is conducting a breast cancer screening clinic in a local neighborhood and is providing sessions on breast self-examination (BSE). A postmenopausal woman arrives at the clinic for information on BSE. Which information should the nurse give to the client? "You need to perform BSE on the same day every month."
the past 10 years. The nurse determines that the client has a smoking history of how many pack-years? Fill in the blank. - ✔ 10 pack years The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds? Wheezes Rhonchi Crackles Pleural friction rub - ✔ Pleural friction rub The nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets this to mean that the client has which condition? Ataxia Nystagmus Pronator drift Hyperreflexia - ✔ Pronator drift The nurse is testing a client for astereognosis. The nurse should ask the client to close the eyes and perform which action? Identify an object placed in the client's hand. Identify 3 numbers or letters traced in the client's palm. State whether 1 or 2 pinpricks are felt when the skin is pricked bilaterally in the same place.
Identify the smallest distance between 2 detectable pinpricks, made with 2 pins held at various distances. - ✔ Identify an object placed in the client's hand. The nurse is conducting a neurological assessment, including a health history, on a client with a neurological disorder. The nurse observes that the client is having difficulty answering the questions and should perform which action? Ask a second nurse to be present during the interview. Defer both the health history and the neurological examination. Defer the health history and proceed with the neurological examination. Ask the client to give permission for a family member to stay during the interview. - ✔ Ask the client to give permission for a family member to stay during the interview. The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems? Select all that apply. Allergy to pollen History of headaches Previous back injury History of hypertension History of diabetes mellitus - ✔ History of headaches Previous back injury History of hypertension History of diabetes mellitus The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data?
The nurse conducting a health screening is performing hearing assessments on clients. Senior nursing students are assisting the nurse with the assessments. The nurse instructs the students to perform a voice test by taking which action? Whisper a statement while the client blocks both ears. Quietly whisper a statement and test both ears at the same time. Whisper a statement with the examiner's back to the client. Stand 1 to 2 ft (30 to 60 cm) away from the client and ask the client to block 1 external ear canal. - ✔ Stand 1 to 2 ft (30 to 60 cm) away from the client and ask the client to block 1 external ear canal. The nurse is preparing to perform a Weber test on a client. The nurse should obtain which item needed to perform this test? A tuning fork A stethoscope A tongue blade A reflex hammer - ✔ A tuning fork The nurse is performing a neurological assessment on a client with a head injury. The nurse should use which technique to assess the plantar reflex? Stroking the foot from the heel to the toe Gently inserting a gloved finger in the rectum Directing a flashlight onto the pupils of the eyes Using a tongue depressor and stimulating the back of the throat - ✔ Stroking the foot from the heel to the toe
The nurse reviews the findings from a physical exam done on a client for ear or hearing disorders and notes documentation that the client has hyperacusis. Which would the nurse expect to note on assessment of the client? Complaints of ringing in the ear An excessive amount of cerumen in the ear canal Intolerance for sound levels that do not bother other people Complaints of dizziness and sensations of being "off balance" - ✔ Intolerance for sound levels that do not bother other people A nursing student is performing a respiratory assessment on a female adult client and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching? Palpating over the lung apices in the supraclavicular area Asking the client to repeat the word ninety-nine during palpation Palpating over the breast tissue to assess and compare vibrations from 1 side to the other Comparing vibrations from 1 side to the other as the client repeats the word ninety- nine - ✔ Palpating over the breast tissue to assess and compare vibrations from 1 side to the other The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve? Ask the client to puff out the cheeks. Separate the client's jaw by pushing down on the chin. Place a small amount of sugar on the client's tongue and ask him or her to identify the taste.
Raise 1 finger when the sound is heard - ✔ Focus on a distant object The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all that apply. Sclera Tongue Nail beds Elbows and knees Mucous membranes - ✔ Tongue Nail beds Mucous membranes The school nurse has conducted a class on testicular self-examination (TSE) at the local high school. The nurse determines that the information was correctly interpreted if 1 of the students states that which action should be performed? Perform the exam after a cold shower. Expect the exam to be slightly painful. Perform the self-examination every other month. Roll the testicle between the thumb and forefinger. - ✔ Roll the testicle between the thumb and forefinger. The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II? Flashlight Snellen chart Reflex hammer
Ophthalmoscope - ✔ Snellen chart The nurse is assessing for the presence of pallor in a dark-skinned client. What finding should the nurse look for? A yellow tinge to the skin Bluish discoloration of the skin Loss of normal red tones in the skin An ashen-gray appearance to the skin - ✔ Loss of normal red tones in the skin The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will best observe these lesions in which body area? Sclerae Oral mucosa Sole of the foot Palm of the hand - ✔ Oral mucosa The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How should the nurse best determine the presence of erythema? Assess for drainage from the wound. Assess for redness around the wound edges. Palpate for swelling around the wound edges. Palpate for increased skin temperature around the wound edges - ✔ Palpate for increased skin temperature around the wound edges The nurse is conducting a health screening clinic and is preparing to test the visual acuity of a client using a Snellen chart. The nurse educates the client about the
"I will tell you when the blocks and shapes are in my visual field." - ✔ "I will tell you when the small object is in my visual field." A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client monitors the status of breath sounds in that area by placing the stethoscope at which location? Near the lateral 12th rib Just under the left clavicle In the fifth intercostal space Posteriorly under the left scapula - ✔ Just under the left clavicle The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest? Over the second intercostal space at the left sternal border Over the fourth intercostal space at the right sternal border Over the second intercostal space at the right sternal border Over the fifth intercostal space in the left midclavicular line - ✔ Over the fifth intercostal space in the left midclavicular line The nurse is making an initial home visit to a client who was recently discharged from the hospital after treatment for a myocardial infarction. The nurse should use which type of database initially to obtain information from the client? An episodic database A follow-up database An emergency database A complete health database - ✔ A complete health database
A client experiencing "skipped heartbeats" is diagnosed with benign premature ventricular contractions and is placed on metoprolol tartrate. The client returns to the primary health care provider's (PHCP's) office 1 month later for a checkup. The nurse should implement which type of database when performing an assessment? A problem-centered database A follow-up database An emergency database A complete health database - ✔ A follow-up database The nurse is reviewing a client's record and notes that the result of a vision test using a Snellen chart is 20/30. How should the nurse explain these results to the client? "You have normal vision." "You have some degree of blindness." "You can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 30 ft (9 meters)." "You can read at a distance of 30 ft (9 meters) what a person with normal vision can read at 20 ft (6 meters)." - ✔ "You can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 30 ft (9 meters)." The nurse is preparing to test the sensory function of cranial nerve V in a client. The nurse should obtain which item to test the sensory function of this nerve? Coffee beans A tuning fork A wisp of cotton An ophthalmoscope - ✔ A wisp of cotton