Health Assessment HESI Assignment
Which term should the nurse use to document the condition of a client who reports waking up frequently during the night to urinate? A. Nocturia. B. Polyuria. C. Oliguria. D. Dysuria.
A. Nocturia.
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? A. Document at least 3 generations of the client's family medical history. B. Ask about any genetic conditions that may be present in the family. C. Instruct the client to develop a genogram to bring to the next visit. D. Request medical records of all the client's immediate family members.
A. Document at least 3 generations of the client's family medical history.
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. "A waist circumference is greater than 35 inches in women puts you at higher risk for type 2 diabetes and heart disease." B. "Your hip circumference is larger than normal and it puts you at a higher risk of hip disease." C. "At least your BMI is normal, so you just need to exercise." D. "You will need to lose weight so you are not at risk for hypertension."
A. "A waist circumference is greater than 35 inches in women puts you at higher risk for type 2 diabetes and heart disease."
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? A. "Have you noticed any unusual bleeding?" B. "Have you fallen recently?" C. "How often do you drink alcohol?" D. "Have you been exposed to anyone with a rash lately?"
A. "Have you noticed any unusual bleeding?"
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? A. 4th intercostal space, right midclavicular line. B. 5th intercostal space, left midclavicular line. C. Left mid-posterior lung field. D. Right mid-posterior lung field.
A. 4th intercostal space, right midclavicular line.
The nurse is performing a head-to-toe assessment on a client. The nurse is assessing the client's pupillary light reflex by first darkening the room and asking the person to gaze into the distance. Then, the nurse advances a light toward one eye from the client's side. What would the nurse expect to see at this time? A. A consensual response in the opposite eye. B. No change in the eye on the opposite side of the face. C. Dilation of the eye on the opposite side of the face. D. Dilation of the eye on the same side of the face.
A. A consensual response in the opposite eye.
The nurse is testing the client's shoulders for range of motion. What should the nurse document to record normal internal rotation? A. Ability to lift both arms over head and swing each arm across front of the body. B. Range of 90 degrees when the hands are placed at the small of the back. C. A 90 degree range with both hands behind the head with elbows out. D. Rolling of shoulders in a circular motion clockwise and counter clockwise.
B. Range of 90 degrees when the hands are placed at the small of the back.
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? A. Keep the room cool so the client is not perspiring. B. Ask the client to urinate before beginning the examination. C. Examine painful or tender areas first. D. Position the client supine with arms over the head.
B. Ask the client to urinate before beginning the examination.
A client reports a recent onset of nausea and vomiting. What subjective information is important for the nurse to ascertain? A. Ask how much weight the client gained on vacation. B. Ask whether the client has been in a foreign country recently. C. Observe the symmetry of the abdomen. D. Count the bowel sounds in each abdominal quadrant.
B. Ask whether the client has been in a foreign country recently.
Which respiratory condition should the nurse document after measuring a respiratory rate of 8 breaths/minute? A. Tachypnea. B. Bradypnea. C. Hyperventilation. D. Hypoventilation.
B. Bradypnea.
During a health history interview, a male client reports that he smokes cigarettes and does not plan to quit. Which action is most important for the nurse to take? A. Document the client's statement verbatim. B. Calculate the client's pack year history. C. Express support for the client's right to choose. D. Ask about family history of lung cancer
B. Calculate the client's pack year history
An older client pushes the nurse's hand away when palpation is initiated during physical assessment. Which additional objective sign aids the nurse in assessing for abdominal tenderness? A. Takes deep breaths when palpation is performed. B. Changes vocal pitch when abdomen is palpated. C. Closes eyes during palpation of the abdomen. D. Smiles when asked if pain is illicited with palpation.
B. Changes vocal pitch when abdomen is palpated.
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? A. Dryness. B. Lentigines. C. Bruising. D. Tenting.
B. Lentigines.
The nurse performs a physical assessment on an older female client. Which change from the prior exam may be an indication of osteoporosis? A. Thick and brittle fingernails. B. Decreased range of motion. C. Weight gain of 15 pounds. D. Height reduction of 1.5 inches.
D. Height reduction of 1.5 inches.
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? A. Inch the stethoscope down the left side of the client's sternum. B. Ask the client to cough and then listen at the site again. C. Instruct client to hold his breath so the sound is clearer. D. Listen to the sound while observing the client's respirations.
D. Listen to the sound while observing the client's respirations.
Which procedure should the nurse use to assessfor a pulse deficit? A. Compare the brachial pulse and femoral pulse. B. Document the observed pulse rate and quality. C. Obtain the systolic blood pressure and subtract the apical pulse. D. Measure the apical pulse and compare it to the peripheral pulse.
D. Measure the apical pulse and compare it to the peripheral pulse
Which technique should the nurse implement when performing a Weber test? A. Tap the patellar tendon using a reflex hammer. B. Shine the light of an ophthalmoscope into the pupil. C. Visualize the tympanic membrane using an otoscope. D. Place a vibrating tuning fork midline on top of the head.
D. Place a vibrating tuning fork midline on top of the head.
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? A. Reassure the client that there are no wrong answers. B. Tell the client to return later for another interview. C. Continue to ask questions until the client responds. D. Sit quietly to allow the client to respond comfortably.
D. Sit quietly to allow the client to respond comfortably.
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 concludeis normalwhen palpating the client's right kidney? A. A round smooth mass that slides between the fingers. B. The right kidney is palpated higher than the left kidney. C. The kidney slides forward and has movable nodules throughout. D. A vibration is felt slightly left of the abdominal midline.
A. A round smooth mass that slides between the fingers.
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? A. Deep palpation above and to the left of the umbilicus. B. Palpation of abdomen as client completes a deep breath. C. With client standing, compress the abdomen as the nurse stands behind the client. D. With palm of one hand, compress the abdomen 2 fingerbreaths below xiphoid process.
A. Deep palpation above and to the left of the umbilicus.
The registered nurse (RN) 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.) A. Diminished hair on legs. B. Bruising on extremities. C. Skin cool to touch. D. Capillary refill less than 3 seconds. E. Darkened skin on extremities.
A. Diminished hair on legs C. 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? A. Document a normal finding. B. Request a referral to an opthamologist. C. Repeat the test after having the client rest for 5 minutes. D. Ask the client, "Have you noticed that you cannot see things close up?"
A. Document a normal finding.
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? A. Document a normal finding. B. Request a referral to an opthamologist. C. Repeat the test after having the client rest for 5 minutes. D. Ask the client, "Have you noticed that you cannot see things close up?"
A. Document a normal finding.
The nurse is requesting the client to perform a Romberg Test to assess neurological status. During the test, the nurse notes that the client sways slightly. What is the nurses next action? A. Document the normal finding. B. Have the client widen the base of the feet. C. Ask the client to walk to the door and back. D. Ask the client if there is any dizziness.
A. Document the normal finding
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? A. Dull, thud-like. B. Hyperresonant,booming. C. Tympanic,drum like. D. Flat,extremely dull.
A. Dull, thud-like.
The nurse is completing a physical exam on an adult client. Which thyroid finding is considered normal? A. Gland is not palpable. B. Gland is solid bilaterally. C. Bruits are detected bilaterally. D. Nodals are palpated.
A. Gland is not palpable.
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? A. Have you had sudden and severe pain in the toes or feet? B. Do you have a family history of osteoporosis? C. Have you ever had pain along the side of your leg? D. Do you have a history of rheumatoid arthritis or bursitis?
A. Have you had sudden and severe pain in the toes or feet?
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? A. Inspect the hair and skin. B. Palpate the temperature of the skin. C. Percuss for tenderness. D. Auscultate the temporal arteries.
A. 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? A. Inspect the scalp looking for nits. B. Palpate the area to determine if there are lesions. C. Ask the client whether the client has been in a foreign country. D. Take the client's temperature.
A. Inspect the scalp looking for nits.
How should the nurse assess for lower extremity edema in a client who has been diagnosed with heart failure? A. Measure bilateral ankle circumference with a non-stretchable tape measure. B. Press skin over the tibia and report edema according to the grading scale. C. Ask if the client feels the bilateral edema has changed and to what extent. D. Inspect the lower extremities together to compare the amount of swelling.
A. Measure bilateral ankle circumference with a non-stretchable tape measure.
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? A. Objective. B. Subjective. C. Expected. D. Reportable.
A. 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? A. Observe the direction of movement. B. Auscultate the area of movement. C. Lightly palpate the area of movement. D. Percuss the area of movement.
A. Observe the direction of movement.
The nurse is conducting an interview wiht a client who speaks limited English. What action should the nurse implement? A. Seek the assistance of a healthcare team member who speaks the client's preferred language. B. Continue with the client's assessment interview using simple English words. C. Have the client reschedule for a time when a family member can be there to interpret. D. Ask the client to call a friend who speaks English and is able to interpret.
A. Seek the assistance of a healthcare team member who speaks the client's preferred language.
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? A. Upper outer quadrant. B. Lower inner quadrant. C. Upper inner quadrant. D. Lower outerquadrant.
A. Upper outer quadrant
The nurse performs the Weber and Rinne tests to assess which cranial nerve? A. VIII. B. VI. C. I. D. V.
A. VIII.
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? A. Verbal descriptor scale. B. Wong-Baker scale. C. Numeric rating scale. D. Faces pain scale-revised.
A. Verbal descriptor scale.
A client reports lower abdominal pain and a feeling of pressure in the bladder. Which assessment finding indicates acute urinary retention? A. Hyperactive bowel sounds. B. Dull sound percussed over bladder. C. Bruits auscultated in left lower quadrant. D. Tenderness with palpation of lower back.
B. Dull sound percussed over bladder.
The nurse is assessing a client who reports having shoulder pain. Which sign is the best indicator of a rotator cuff tear? A. Inability to adduct the arm from the body. B. Inability to slowly lower the arm when abducted. C. Inability to externally rotate the arm. D. Inability to internally rotate the arm.
B. Inability to slowly lower the arm when abducted.
Which technique should the nurse use to assess a client for scoliosis? A. Watch gait while the client ambulates down the hallway. B. Observe spine while the client is erect and bent forward. C. Palpate neck while the client rotates head from side to side. D. Assess for presence of pain when the client twists the torso.
B. Observe spine while the client is erect and bent forward.
After completing the initial general assessment, the nurse is now completing a focused abdominal assessment of a client who was admitted for abdominal pain. Which assessment is most important for the nurse to implement? A. Inspect for abdominal distension then percuss for tympany. B. Palpate the abdomen after auscultating for bowel sounds. C. Measure the client's oxygen saturation. D. Ask if pain medication was taken
B. Palpate the abdomen after auscultating for bowel sounds.
Following abdominal auscultation of a client who is admitted for signs of splenomegaly, which additional assessment should the nurse use to verify splenomegaly? A. Rebound tenderness. B. Percussion. C. Deep palpation. D. Inspection.
B. Percussion.
The nurse uses a tongue depressor to assess a client's mouth. Which structure should the nurse be able to visualize? A. Esophagus. B. Pharynx. C. Trachea. D. Maxillary sinus.
B. Pharynx.
The registered nurse (RN) uses the mini-mental state examination (MMSE) when assessing a client for admission to an assisted living facility. Which finding is the RN assessing when requesting the client to count by 7s? A. Recall of information. B. Orientation to surroundings. C. Attention to details. D. Ability to follow complex commands.
C. Attention to details.
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? A. Initiate aspiration precautions. B. Notify the healthcare provider. C. Document an intact gag reflex. D. Provide a warm salt water gargle.
C. Document an intact gag reflex.
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? A. Murmur. B. Ejection click. C. Friction rub. D. Normal heart sound.
C. Friction rub.
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? A. Auscultate over the other 3 abdominal quadrants. B. Count the number of bowel sounds per minute. C. Note the character and frequency of bowel sounds. D. Count to determine how many bowel sounds occur in one minute.
C. Note the character and frequency of bowel sounds.
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? A. Explain how the nursing skill will be performed before proceeding. B. Examine client with an additional healthcare provider for support. C. Request a male nurse or healthcare provider to perform the exam. D. Avoid any skills that involve touching the client during the exam.
C. Request a male nurse or healthcare provider to perform the exam.
The nurse is assessing for the presence of a hernia. Which action should the nurse ask the client to perform while lying supine? A. Bring the knees toward the chest. B. Place the chin onto the chest. C. Roll from one side to the other. D. Use abdominal muscles to sit up.
D. Use abdominal muscles to sit up.
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? A. Palpate each breast simultaneously noting any differences. B. Inspect the areolar area's color, shape, and the nipples for galactorrhea. C. Check for breast symmetry while the client's hands are above the head. D. With both arms at client's side, lift one arm and palpate the axilla.
D. With both arms at client's side, lift one arm and palpate the axilla.
