HESI Practice Exam

The nurse is assessing a client who is suspected of having memory loss. Which question asked by the nurse will be appropriate to test recent recall memory of the client

"How did you reach the clinic?"

Which assessment finding will the nurse expect when caring for a client with peripheral arterial disease?

Absent of hair on toe nails report of pain associated with exercise

Which client would a nurse expect to be diagnosed with primary amenorrhea?

An 18-year-old with normally developed secondary sexual characteristics who has not yet reached menarche

Which client finding would the nurse document as a pulse deficit?

Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8

During an assessment, the nurse shines a light into the client's eyes and observes that the pupil remains dilated. Which cranial nerve (CN) would the nurse suspect to be affected?

CN III

The nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. Which term would the nurse use to document these sounds?

Crackles

Which skin color change would the nurse expect to see if a client with dark skin develop cyanosis

Gray

When palpating the chest during a respiratory assessment, which finding would the nurse expect in a client with pneumonia?

Increased fremitus over the affected area

When the nurse auscultates a client's lungs and hears fine, high-pitched, popping sounds in the left lower lung as the client inhales, which term would the nurse use when documenting the findings?

Inspiratory crackles

Which metabolic manifestations are likely to be observed in a client with hypothyroidism?

Intolerance to cold Decreased body temperature

Upon noticing a client with heart disease has digital cyanosis, which site would the nurse assess to confirm cyanosis?

Lips

When monitoring a client 24 to 48 hours after abdominal surgery, the nurse would assess for which problem associated with anesthetic agents?

Paralytic ileus

Which term would the nurse use to document observing the characteristic gait associated with Parkinson Disease?

Shuffling

Which developmental changes require the nurse's assessment in a 12 year old female?

Skeletal growth

Which type of test would the nurse perform to assess for myopia?

Snellen eye chart

Which description of pain would the nurse expect a client with a ureteral calculus to report?

Spasmodic and radiating from the side to the suprapubic area

In which area would the nurse place the stethoscope when taking an apical pulse?

The mitral area

Which pulse site would the nurse use to perform an Allen test?

Ulnar

During auscultation of the heart, where would the nurse expect the first heart sound (S1) to be the loudest?

apex of the heart

Which assessment would the nurse perform first for a client with severe trauma?

Airway

Which action would the nurse take first when caring for a client with abdominal aortic aneurysm who is suddenly pale and reports feeling light-headed and having abdominal pain?

Check the blood pressure for hypotension.

The nurse is inspecting the abdomen of an 18-month child. Which method would the nurse adopt to inspect for an inguinal hernia? Select that apply

Have the child blow a bubble. Get the child to laugh so as to raise the intraabdominal pressure

Which clinical manifestation would indicate the cancer is in an early stage in a male client with a preliminary diagnosis of cancer of the urinary bladder?

Hematuria

Which clinical finding would the nurse expect to identify when assessing a female client with Cushing syndrome? Select all that apply

Hirsutism Buffalo hump

Which assessment finding would the nurse consider abnormal?

Joint crepitation Muscular atrophy Tenderness of the spine

Which finding in a client seen at the outpatient clinic supports a diagnosis of an arterial ulcer?

Lack of hair Thicken toenails Diminished pedal pulse

Which finding would the nurse expect when assessing a client with peripheral arterial disease?

Pallor of feet Ulcers on the toes Delayed capillary refills

Which assessment technique will the nurse avoid in a client with a suspected hematological disease?

Palpating the abdominal left upper quadrant

Which action would the nurse take to assess for ascites?

Percuss the client's abdomen and listen for dull sounds.

Which action would the nurse take first when caring for a postoperative client who reports pain?

Perform a focused assessment of the client.

What reliable site would the nurse utilize to assess a client for jaundice?

Sclera

Which intervention would the nurse classify as the highest priority for an older client with lower-extremity ulcerations due to chronic venous insufficiency?

Teaching how to transfer from a bed to chair in the least painful manner

Which information would the nurse expect the client who has multiple sclerosis with hand tremors to report?

The tremors increase when I perform an activity

During an assessment, the client complains of tenderness when the nurse palpates the calf muscle. Which technique would be the nurse's next assessment?

To assess for swelling, warmth, and muscle firmness.

Which component is important in a neurovascular assessment performed by the nurse?

movement and sensation capillary refill pulse and skin temperature

When obtaining a health history from the newly admitted client who has chronic pain in the right knee, which pain assessment data would the nurse include?

pain history, including location, intensity, and quality of pain pain pattern, including precipitating and alleviating factors

which client receiving a blood transfusion who develops an adverse reaction would require immediate nursing intervention?

wheezing

Which is an abnormal finding of the urinary system?

when striking the area, pain in the flank region is felt by the client.

The nurse determines that a newborn is suffering from respiratory distress. Which visible signs confirm this assessment?

Cyanosis Tachypnea Retraction

Which test helps a primary health care provider distinguish between conductive and sensorineural hearing loss?

Weber test

Which question would the nurse ask the client when obtaining their health history? Select all that apply

"Tell me about your food habits." "Do you use alcohol or tobacco?" "Have you ever experienced any allergic reactions?"

Which clinical manifestations would the nurse associate with successful fluid replacement therapy?

a trended urinary output of at least 30 mL/h

Which nursing assessment supports a diagnosis of atelectasis in a postoperative client?

Diminished breath sounds on auscultation

Which finding would the nurse expect when caring for a client with right-sided heart failure?

Distended neck veins

Which clinical finding would the nurse anticipate for a client who has an exacerbation of multiple sclerosis?

Double vision Scanning speech

Which manifestations of surgically induced hypothyroidism might the client exhibit after a thyroidectomy?

Dry skin Fatigue

Which information noted in a child's history by the home-care nurse would indicate a potential mental health issue?

History of being abused as a child Currently living in a foster home Parents has substance abused issues.

Which skin growth would require health care provider follow-up to evaluate for possible skin cancer?

Mole that is 12 mm wide

An adolescent arrives at the clinic reporting buzzing in the ears. Which assessment data are essential for the nurse to obtain?

Music preferences

Which disorder would the nurse suspect when assessing a client who reports excessive daytime sleepiness, sudden muscle weakness during intense emotions, and an inability to walk just after waking or before going to sleep?

Narcolepsy

Which is the first action of the nurse when a parent expresses concern about a child's diet?

Perform a nutritional assessment

Which clinical finding is commonly associated with hyperglycemia? Select all that apply

Polyuria Polydipsia Polyphagia

A primary health care provider diagnoses the client's condition as otitis media. Which assessment finding supports that diagnosis?

Redness of the eardrum.

Which parameter would the nurse access first when evaluating memory impairment in a client with Alzheimer Disease?

Remembrance of recent events

Which findings supports the conclusion that a 12 month old infant has normal development?

The childs toes hyperextend when the nurse strokes from the heel upward across the foot.

The nurse performs a respiratory assessment and auscultates high-pitched, creaking, and accentuated breath sounds on expiration. Which term describes the findings?

Wheezes

An older client who has been undergoing months of treatment for osteomyelitis reports perianal itching and diarrhea. WHich assessment finding would the nurse expect to identify?

Whitish-yellow lesions in the oral cavity

Where would the nurse place the stethoscope to listen for mitral valve insufficiency (regurgitation)?

the mitral area (5th intercostal space)

Which physical assessment technique involves listening to the sounds of the body?

Auscultation

Which heart sound, normally heard in a toddler, is considered abnormal in an adult over 30?

S3

The nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin; decreased hair growth; and thickened toenails. Which condition might this indicate?

Arterial insufficiency

Which action will the nurse take FIRST, when a client with peripheral arterial disease returns to the nursing unit after having a femoral angiogram?

Assess the clients affected leg

Which action would the nurse plan to take to prevent respiratory complications after abdominal surgery?

Assist client to use the incentive spirometer

Which reflex is the nurse testing when using a dull object to stroke from the lateral sole of a client's foot upward to the great toe?

Babinski reflex

Which action would the nurse take when a client develops a maculopapular rash on the upper extremities and audible wheezing during the admistinration of intravenous vancomycin?

Stop the infusion

Which clinical manifestation indicates a client may have an actively bleeding stress ulcer?

Sudden hematemesis and and rectal blood

Which clinical finding is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block?

Syncope

Which client's joint fluid examination report indicates a normal finding?

Transparent straw-colored fluid

Hemoptysis is a clinical manifestation of which disease process?

Tuberculosis