HESI 1 - V1 and V2 REVIEW - Health Assessment 1

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?

Listen to the sound while observing the client's respirations.

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?

"My life is really out of balance."

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?

"Short-term memory is intact."

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?

24-hour dietary recall

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?

Abnormal finding.

When performing range of motion exercises on the joints of an older adult client, the nurse notes that joint range is greater with passive ranging than with active ranging. A goniometer indicates that this difference is as much as 15% in some joints. How should this finding be documented?

Abnormal.

Which part of the body should the nurse examine when assessing for peripheral edema in a client with heart failure?

Ankles.

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?

Deep palpation above and to the left of the umbilicus.

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

Diaphoresis. Scaling.

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.)

Diminished hair on legs. Skin cool to touch.

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?

Document a normal finding.

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?

Document an intact gag reflex.

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?

Document at least 3 generations of the client's family medical history.

A client reports lower abdominal pain and a feeling of pressure in the bladder. Which assessment finding indicates acute urinary retention?

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.

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?

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 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?

Family history of colon cancer on mother's side.

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?

Fibroadenoma.

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?

Friction rub

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

Fungal infection.

The nurse is completing a physical exam on an adult client. Which thyroid finding is considered normal?

Gland is not palpable.

Which tool should the nurse use when assessing the neurological status of a client with traumatic brain injury?

Glasgow Coma Scale.

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?

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.

A client is in the clinic for a routine health examination. The nurse notices the client appears underweight. Which question is most important for the nurse to ask when completing the health history of this client?

Have you experienced sudden weight loss?

The nurse is assessing a client who reports having shoulder pain. Which sign is the best indicator of a rotator cuff tear?

Inability to slowly lower the arm when abducted.

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?

Inspect the hair and skin.

A client presents with a rash along the occipital area of the hairline and reports intense itching. How should the nurse begin the objective part of the examination?

Inspect the scalp looking for nits.

Which statement is accurate about assessing the spleen?

It must be enlarged at least three times normal size for it to be palpable.

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?

Knee joint evaluation.

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?

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.

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?

Level of consciousness.

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?

Lying.

Which action should the registered nurse (RN) implement to complete an assessment for a client while using an interpreter?

Maintain eye contact with the client while listening to the translation.

How should the nurse assess for lower extremity edema in a client who has been diagnosed with heart failure?

Measure bilateral ankle circumference with a non-stretchable tape measure.

Which procedure should the nurse use to assessfor a pulse deficit?

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.

Which technique should the nurse use to assess a client for scoliosis?

Observe spine while the client is erect and bent forward

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

Pleural friction rub

What is the best place for the nurse to hear lower lobe lung sounds with a stethoscope?

Posterior chest below the 3rd intercostalspace.

The client reports to the nurse a recent exposure to the mumps. Which assessment finding suggests the client has contracted the mumps?

Swelling anterior to the ear lobe on one side of the face

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?

Swelling of the left arm and non-pitting edema.

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?

Use a bouncing motion to tap the middle finger placed within boundaries of the liver.

The nurse performs the Weber and Rinne tests to assess which cranial nerve?

VIII - vestibulocochlear

The nurse uses a tongue depressor to assess a client's mouth. Which structure should the nurse be able to visualize?

Pharynx

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?

Phlegm production and wheezing.

Which technique should the nurse implement when performing a Weber test?

Place a vibrating tuning fork midline on top of the head

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?

Place the bell on the 5th intercostal space, left midclavicular line.

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?

2nd intercostal space along the right sternal border.

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?

"What effect do you think your use of alcohol may have on you?"

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?

4th intercostal space, right midclavicular line.

The nurse is assessing the posterior pharynx during a physical examination. Which technique should the nurse use?

Press the tongue down one side at a time with a tongue depressor.

The nurse is testing the client's shoulders for range of motion. What should the nurse document to record normal internal rotation?

Range of 90 degrees when the hands are placed at the small of the back.

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?

Request a male nurse or healthcare provider to perform the exam.

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?

Request that the mother leave the exam room.

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?

Sit quietly to allow the client to respond comfortably.

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?

The client is treating the nurse with respect.

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?

The client works in a daycare setting that has had a scabies outbreak.

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?

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.

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?

The skin immediately returns to normal position.

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?

There is no sign of associated infection.

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?

Upper outer quadrant.

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?

Use of vitamin and iron supplements.

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.)

Use simple sentences during the examination. Reduce environmental detractors during the examination. Ask questions one at a time to decrease confusion.

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?

Verbal descriptor scale.

Which question should the nurse ask in order to test a client's remote memory?

What is your date of birth?

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?

With both arms at client's side, lift one arm and palpate the axilla.

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?

You have benign fibroid tumors, a common occurrence in women your age.

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?

A waist circumference is greater than 35 inches in women puts you at higher risk for type 2 diabetes and heart disease."

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?

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).

The nurse is assessing a client's range of motion as the client bends the right knee up to the chest while keeping the left leg straight, but is unable to keep the left thigh on the table. The assessment is repeated for the left knee, and the client is unable to keep the right thigh on the table. How should the nurse document this finding?

A flexion deformity referred to as a positive Thomas test.

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?

A round smooth mass that slides between the fingers.

What is the best nursing response to an older client who has not mentioned incontinence during a genitourinary assessment?

Ask the client specifically about any leakage of urine.

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?

Ask the client to urinate before beginning the examination.

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?

Audiometry.

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?

Barrel chest

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.)

Be open to people who are different. Have a curiosity about people. Become culturally competent.

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

Bradypnea.

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

Cataracts.

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?

Change in consistency.

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?

Dull, thud-like.

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?

Have you had sudden and severe pain in the toes or feet?

During a skin asssessment, the nurse notes, round and discrete lesions that are dark red in color and will not blanch. The lesions range from 1 to 3 mm in size. What is the first question the nurse should ask the client?

Have you notice any irregular bleeding

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

Health history

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

Height reduction of 1.5 inches.

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?

Percuss the splenic area as the client takes a deep breath.

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?

Note the character and frequency of bowel sounds

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?

Objective.

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?

Observe the direction of movement.

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?

Occlude one nostril and have the client identify various odors.

When assessing facial nerve function of a 96-year-old, the nurse asks the client to smile in an exaggerated manner. Which finding is most important for the nurse to further asses?

Only one side of the mouth moves when smiling.