HESI V2 health assessment

In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the stethoscope at which location?

*under mandible towards lymph nodes. transverse to trachea

When performing a neurologic assessment on an alert client, the nurse observes that the client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment? A. PERRL. B. GCS of 15. C. PERLA. D. Neuro status intact

Correct answer is A. "Pupils Equal, Round, and Reactive to Light".

Which assessment finding supports the client statement, "My feet swell all the time?" A. 2+ pitting edema of ankles bilaterally. B. Capillary refill both feet > 3 seconds. C. Pedal pulses weak and thread. D. Positive Homan's sign bilaterally.

Correct answer is A. 2+ pitting edema indicate swelling in the lower extremities. Homans's sign is often used in the diagnosis of deep venous thrombosis of the leg. A positive Homans's sign (calf pain at dorsiflexion of the foot) is thought to be associated with the presence of thrombosis.

The nurse has just completed palpitation maneuvers for lymph nodes on a 75-year-old female client. Which findings are considered normal for this elderly client? A. Nodes are non-palpable. B. Axillary nodes feel soft and fatty. C. Nodes feel ropey and rubbery. D. Inguinal nodes are enlarged and warm to the touch.

Correct answer is A. Normal lymph nodes are non-palpable.

A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I have lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this body-wracking dry cough that has been hanging around for the last six weeks." Which computer documentation of this client's concerns should the nurse enter? A. Presents with a hacking non-productive cough of 6 weeks duration. B. Describe having a "body-wracking dry cough" of 6 weeks duration. C. Expresses concern of "lung cancer" symptoms for last 6 weeks. D. Young adult male presents with fears that he has "lung cancer"

Correct answer is B, as assessment process includes chief complaint which is how the patient describe why he is here in the hospital or clinic and can't include diagnosis.

To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take? A. Ask the client to describe any other related symptoms. B. Use both hands to hold and palpate the client's hands. C. Lightly pinch a fold of skin over the client's sternum. D. Place the dorsum of the hand on the client's forehead.

Correct answer is B.

After checking a client's pupillary response to light, the practical nurse (PN) tells the nurse that the client's pupils are constricted with minimal response to light. Before verifying the PN's findings, which action should the nurse take? A. Brighten the light in the client's room. B. Assess the client's visual fields. C. Review the client's medication list. D. Administer PRN saline eye solution.

Correct answer is B. PERRLA: Accommodation is the following step which refers to your eyes' ability to see things that are both close up and far away.

In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. What should the nurse do next? A. Notify the healthcare provider. B. Observe for eye opening to a painful stimulus. C. Check the pupillary response to light. D. Ask the client to open his eyes

Correct answer is C.

A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response. Which interpretation of this finding is accurate? A. A normal reflex response. B. Absent or sluggish response consistent with a lower motor neuron lesion. C. Flaccid paralysis. D. Hyperactive response consistent with an upper motor neuron disorder.

Correct answer is D, brisk 4+ response is correlated with hyperactive response.

A client comes to the clinic due to shoulder discomfort and intermittent pain while swimming today. To assist normal range of motion (ROM) of the client's shoulder, which assessment techniques should the nurse ask the client to perform? A. Alternate both index fingers to tough the tip of nose accurately. B. Extend arms up to 180 degrees besides the ears. C. Extend arms straight out and hold without drifting. D. Hold arms up at 90 degree while arms are pushed downward

Correct answer is D.

A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis? A. Purulent secretions from eyes and nares. B. Eye tearing and thick yellow nasal drainage. C. Snoring and bilateral, pale gray nodules. D. Intranasal edema and swelling of turbinates.

Correct answer is D.

The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating the spleen? A. Pain notes when palpating McBurney's point. B. Tip of spleen palpable when client is asked to forcefully exhale. C. Rebound tenderness with compression over right upper quadrant. D. Firm mass palpated at bottom of left rib cage.

Correct answer is D. McBurney's point is related to appendicitis and not spleen.

The nurse completes inspection of the abdomen on an adult client. Which finding is considered normal for this client? A. Masses. B. Peristaltic waves. C. Heterogeneous color. D. Homogeneous color.

Correct answer is D. Symmetry is a great value of normal body imagine while performing inspection.

After a young adult woman describes feeling palpitations when she lies on her left side it is most important for the nurse to auscultate heart sounds at which anatomical location? A. Second intercostal space, left of the sternal border. B. Left third intercostal space, left lateral sternal border. C. Base of the heart at second intercostal space, right of the sternal border. D. Apex of the heart at the left fifth intercostal space at the midclavicular line

Correct answer is D. The apex beat or apical impulse is the palpable cardiac impulse farthest away from the sternum and farthest down on the chest wall, usually caused by the LV and located near the midclavicular line (MCL) in the fifth intercostal space

In observing a client's face, which assessment finding requires the most immediate intervention by the nurse? A. Eyelids are matted and crusted. B. Cornea are jaundiced. C. Oral mucosa is cyanotic. D. Face is flushed and diaphoretic.

Answer is C. Blue lips occur when the skin on the lips takes on a bluish tint or color. This generally is due to either a lock of oxygen in the blood or to extremely cold temperatures. When the skin becomes a bluish color, the symptom is called cyanosis. Most commonly, blue lips are caused by a lack of oxygen in the blood. Most causes of cyanosis are serious and symptom of your body not getting enough oxygen. Over time, this condition will become life-threatening. It can lead to respiratory failure, heart failure, and even death, if left untreated.

A male client returns to the clinic for a follow-up visit after being treated for a bladder infection. While examining the client, which finding indicated an expected response to the treatment? A. Orange sized prostate gland. B. Post-voided residual volume of 50 mL. C. Pain score of 1 out of 10 with urination. D. Decreasing sperm cell count.

C

A women comes to the clinic for her first prenatal visit. The nurse is conducting a health history and the women begins to cry when asked about previous pregnancies. Which response is best for the nurse to provide? A. "Why don't I come back in a few minutes after you are more composed." B. Offer a tissue and sit quietly until the crying subsides. C. Allow the client to compose herself then change the subject. D. "I'm so sorry that I made you cry. I didn't mean to upset you."

Correct answer C. Try always to listen to the patient when she is in a bad mood or wants to express her feeling.

A male client reports the onset of a burning sensation in his hands and legs. How should the nurse document this finding in the electronic medical record? A. Circulation impaired. B. Inflammation present. C. Reports feeling "on fire." D. Paresthesia reported.

Correct answer D.

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perineal area and anus. Which findings indicates a normal appearance of the anus? A. Increased pigmentation and coarse skin. B. Flap of tissue at sphincter. C. Hypotonic tone of the anal sphincter. D. Dimpled area above anus.

Correct answer is A

A male client who is admitted for an acute brain attack reports the onset of a burning sensation in his hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client's paresthesia? A. Evaluate client's muscle strength and hand grips. B. Observe skin for erythema, edema, and warmth. C. Review the client's serum electrolytes. D. Check distal phalanges capillary refill

Correct answer is A.

The nurse prepares to begin a systematic assessment of a client's heart sounds. Upon positioning the stethoscope as seen in the picture what should the nurse do first? A. Identify S1 and S2 heart sounds. B. Change to the bell of the stethoscope. C. Move the stethoscope to the apical site. D. Listen for abnormal sounds

Correct answer is A. 1st assessment of hearts sounds is to identify S1 and S2 heart sounds. S1 is normally a single sound because mitral and tricupsid valve closure occurs almost simultaneously. Clinically S1 corresponds to the pulse. The second sound S2 represents closure of the smilunar (aortic and pulmonary) valves.

While assessing the legs of a female client, the nurse observes leathery-looking skin. The client reports aching tired legs that swell if she stands for long periods of time. To screen for venous insufficiency, the nurse should ask the client if she has experienced which subject finding? A. Decreased pain when legs are elevated. B. Deep, continuous pain in the calf muscles. C. Cool, pale skin below the knees. D. Painful symptoms alleviated by warmth.

Correct answer is A. Elevation of the legs decreases welling and helps with blood flow.

The nurse is assessing a healthy adult male during an annual physical examination. The nurse auscultates the client's abdomen and hears gurgling sound every ten seconds. What action should the nurse take in response to this finding? A. Document this normal bowel sound activity in the record. B. Encourage increased consumption of fiber in the diet. C. Observe the next bowel movement for signs of bleeding. D. Report the hyperactivity to the healthcare provider.

Correct answer is A. Normal Bowel sound consist of clicks and gurgles and 5-30 per minute. An occasional borborygmus (Loud prolonged gurgle) may be hear.

A homeless male client with a history of alcohol abuse had a cerebrovascular accident (CVA) 10 years ago that resulted in left hemiparesis. Today he is complaining of pain in his left leg, is afebrile, has 4+ pitting edema in the lower left leg, and minimal swelling of the right leg. Which action should the nurse implement first? A. Inspect legs for infection of trauma. B. Obtain a blood alcohol level. C. Complete a mental status exam. D. Inquire about dietary salt intake.

Correct answer is A. Since it is a single leg, the nurse has to rule out any trauma of infection especially the left side for the patient is awakened.

To confirm the presence of a barrel chest documented in the client's medical record, which action should the nurse take? A. Observe the appearance of the thorax. B. Auscultate the client's breath sounds. C. Percuss diaphragmatic excursion. D. Palpate tactile fremitus on the posterior chest

Correct answer is A. The chest takes on a barrel-like appearance called a "barrel chest." A barrel chest forms because your lungs are chronically overfilled with air and can't deflate normally. This causes your rib cage to be partially expanded at all times. This is common in COPD patients.

Which question by the nurse is likely to elicit the most information regarding a client's use of medications to treat a chronic cough? A. What medications are you currently taking? B. Have you tried any generic brands of cough syrup? C. Have you been prescribed any medications for your cough? D. What medications have you used for your cough?

Correct answer is A. The nurse should always ask general questions about medication which include OTC and herbal products. Also, there might be other medications that cause cough like ACE inhibitors so the nurse should assist the who image.

In assessing a client's sensory nerve function, the nurse prepares to assess the client's response to temperature. What action should the nurse include during this assessment? A. Darken the client's room environment. B. Cover the client with a warmed blanket. C. Measure the client's body temperature. D. Instruct the client to close both eyes.

Correct answer is B

Which skill should the nurse have an older client demonstrate to evaluate performance of daily living activities? A. Opening a bar soap package. B. Sorting a collection of socks. C. Reading a short paragraph. D. Telephoning a family member.

Correct answer is B. ADL is used as an indicator of a person's functional status. The inability to perform ADLs results in the dependence of other individuals and/or mechanical devices. The inability to accomplish essential activities of daily living may lead to unsafe conditions and poor quality of life.

When auscultating a client's lung sounds, the nurse hears rhonchi in the upper lung fields anteriorly. Which action should the nurse take first? A. Measure capillary refill. B. Ask the client to cough. C. Monitor oxygen saturation. D. Document the finding.

Correct answer is B. Many abnormal breath sounds are best heard asking the patient to cough.

Which focused assessment technique should the nurse use for a client admitted with possible dehydration? A. Press skin over a bony prominence. B. Grasp skin fold of the posterior forearm. C. Check hands for parchment-like appearance. D. Measure the circumference of the calf.

Correct answer is B. Skin turgor is assessed by firsts grasping a fold of skin on the back of a patient's hand

During assessment of a client's neck, the nurse prepares to assess for jugular vein distention (JVD) as seen in the picture. What should the nurse do next? A. Listen to swishing sound during systole. B. Use the bell of the stethoscope to auscultate. C. Remove the stethoscope to observe the site. D. Palpate the site of erythema and tenderness.

Correct answer is C.

While obtaining a health history, a male client tells the nurse that he sometimes experiences shortness of breath. The nurse determines that the client's respirators are regular and deep, and his respiratory rate is 14 breaths/minutes. What is the best nursing action? A. Ask the client to perform light exercise and observe the respiratory effect. B. Document "dyspnea on exertion" in the client's medical record. C. Ask the client to describe the episodes of dyspnea in more detail. D. Explain to the client the possible causes of dyspnea or "shortness of breath."

Correct answer is C. Both respiratory rate and breath sounds are normal. Further assessment is needed by asking the client to describe his SOB

The nurse is performing a cranial nerve exam on an 87-year-old client. The nurse notes that the client has a reduced upward gaze, a decreased corneal reflex, a high frequency hearing loss, and a reduced gag reflex. What action should the nurse take next? A. Review past history for any episodes of a cerebral cortex lesion. B. Implement neuro vital signs every 2 hours to detect Cushing's Triad. C. Continue the assessment to the next pairs of cranial nerves. D. Assess the spinal reflexes for demyelination symptoms.

Correct answer is C. Full cranial nurses assessment should be completed before considering the other options.

An older adult client is admitted to the medical unit because of loss of appetite and generalized malaise. To analyze the client medical condition, which laboratory value is most important for the nurse to review? A. Hematocrit. B. Serum Calcium. C. Hemoglobin. D. Serum pre-albumin

Correct answer is C. Hemoglobin is the main lab value to check for anemia. Anemia is a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues. Having anemia can make you feel tired and weak. There are many forms of anemia, each with its own cause. Anemia can be temporary or long term, and it can range from mild to severe.

To assess a female client for hirsutism, which action should the nurse take? A. Lightly palpate over the client's entire scalp. B. Apply and release light pressure to the skin. C. Assess the appearance of the client's face. D. Observe the hair shafts on the client's scalp

Correct answer is C. Hirsutism is a condition in women that results in excessive growth of dark or coarse hair in a male-like pattern like face, chest and back.

The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or arterial insufficiency. Which assessment technique should the nurse use to differentiate the pathophysiology causing the ulcer? A. Measure the degree of join range of motion in the extremity. B. Compare the skin turgor of the client's upper and lower leg. C. Observe the specific location and appearance of the ulceration. D. Note any change in the color of the ulcer when the leg is moved

Correct answer is C. Location and appearance of the ulcer would give us the type (venous vs arterial)

The school nurse is interviewing a 13-year-old girl who wants to go home from school because of "back pain". Which question should the nurse ask the adolescent first? A. "Have you taken any medications to relieve the pain?" B. "What were you doing when you first noticed the problem?" C. "Do you remember ever having this type of pain in the past?" D. "Does changing your position make the pain worse?"

Correct answer is C. Scoliosis (a severe curvature of the spine) is a possible cause of back pain, especially in adolescent girls. Your pediatrician evaluates your child's posture during regular well-child visits to make sure her back is straight and she's growing normally.

A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a muffled voice. Which complication should the nurse suspect? A. Foreign body obstruction. B. Laryngeal polyps. C. Peritonsillar abscess. D. Nasal polyps

Correct answer is C. Since infections are associated with abscesses and pus.

A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds? A. Use the bell of the stethoscope to listen to the lung fields over lower lobes. B. Have the client lay flat while listening to the anterior surface of the chest. C. Press the stethoscope's diaphragm firmly on the skin over each lung field. D. Shave all chest hair that may distort sounds heard through the diaphragm.

Correct answer is C. The nurse should listen to all lungs fields during assessment and move from side to side during auscultation.

The nurse is assessing a client for goiter and is unable to observe the thyroid gland. Which action should the nurse take? A. Defer the thyroid exam and observe the client for signs of myxedema. B. Document that thyroid gland size is normal with no visible goiter. C. Ask the client to swallow while palpating along the sides of the trachea. D. Palpate deeply and firmly over the location of the thyroid gland.

Correct answer is C. To palpate a client thyroid gland: Use one hand to slightly retract the sternocleidomastoid muscle while using the other to palpate the thyroid. Have the patient swallow a sip of water as you palpate, feeling for the upward movement of the thyroid gland.

The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client's use of illegal drugs and alcohol? A. Obtain a drug using screen to verify legitimacy of client's stated history. B. Allow the client to decline answering social questions. C. Ask specifically about alcohol, marijuana, cocaine, her D. Use the term illegal or illicit to describe street drug.

Correct answer is C. When interviewing the patient, questions should be clear and specific.

A client reports to the healthcare provider's office for a routine post-surgical evaluation six weeks after a hysterectomy. Which history-taking approach should the nurse use to gather the needed information? A. Conduct a comprehensive review of systems. B. Perform a head-to-toe physical assessment. C. Prepare to collect a vaginal specimen for Papanicolaou smear. D. Collect information about the client's activities since surgery.

Correct answer is D.

During an abdominal assessment, a client with a temperature of 103 F (39.4 C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement? A. Electrocardiogram. B. Complete bed rest. C. Monitor urinary output. D. Nothing by mouth.

Correct answer is D.

The nurse is assessing a female client who states that her hemorrhoids are inflamed and hurt constantly. Which intervention is best for the nurse to complete a focused assessment? A. Ask the client how long she has experienced discomfort related to hemorrhoids. B. Place the client in a standing position, leaning over the exam bed for inspection. C. Determine if the client uses any over-the-counter preparation for hemorrhoids. D. Position client in left lateral position to inspect perianal area for fissures or sacs.

Correct answer is D. A focused assessment collects relevant information pertaining to the current condition of the patient after a change or new symptom develops.

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. What action should the nurse implement? A. Offer to administer a laxative prescribed for PRN use. B. Obtain a prescription to catheterize the client's bladder. C. Instruct the client in distraction and relation techniques. D. Notify the healthcare provider of the rebound tenderness.

Correct answer is D. As this could be a sign of appendicitis.

A client sustained a subconjunctival hemorrhage. The presence of which set of symptoms indicate that the client needs to be seen for further evaluation by an ophthalmologist? A. Acute pain, change in visual acuity, and foreign body sensation. B. Frequent burning, irritation and tearing of the eyes. C. Bilateral itchy, red eyes with watery discharge D. Diminished ability to focus on close work and excessive illumination required.

Correct answer is D. Diminished ability to focus on close work could be a sign of cranial nerve damage and could lead to reduced visual acuity, due to a reduced ability of the lens in the eye to focus light on the retina, results in images that appear blurry.

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take? A. Apply warm blankets to both feet. B. Palpate pulse points with legs dependent. C. Notify the healthcare provider. D. Use a doppler ultrasonic stethoscope.

Correct answer is D. Doppler ultrasonic stethoscope is used when the nurse couldn't palpate a pedal pulse of a client.

The nurse asks a 50-year-old female client what her natural hair color is. The client replies, "I've been dying my hair for so long, I'm not even sure,,,, I just know that this month it's ravishing red." Based on this information, the nurse expects to obtain which finding when palpating this client's scalp hair? A. Excess vellus hair. B. Receding front hairline. C. Fine, thin, limp texture. D. Coarse, dry, brittle texture.

Correct answer is D. Excessive dying of the hair will lead the hair to be coarse and dry.

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high pitched almost continuous gurgling in two quadrants. What action should the nurse implement? A. Use the bell of the stethoscope to auscultate again. B. Elevate the head of the client's bed immediately. C. Document the presence of borborygmi. D. Auscultate the remaining two quadrants.

Correct answer is D. Full assessment of all parts of the lungs, side by side, should be performed before taking any other action or document the findings.

The nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual's nutritional status? A. Status of current appetite. B. A 24-hour diet history. C. History of a recent weight loss. D. Condition of hair, nails, and skin.

Correct answer is D. Hair, nail, and skin are the most important reflection of nutritional status.

When assessing a male client's respiratory status, which technique should the nurse use to assess his anterior- posterior (AP) chest diameter? A. Auscultation. B. Percussion. C. Palpation. D. Observation.

Correct answer is D. Observation is the way to detect barrel chest which is associated with COPD

The nurse completes palpitation of the abdomen on an older adult client. Which finding is considered normal for the client? A. Non-tender. B. Gallop. C. Thrill. D. Peristaltic waves.

Correct answer is D. The small intestine undergoes segmental contractions and peristaltic waves Segmental contractions occur for short distances only along the small intestine Peristaltic waves occur for variable distances to cause the chyme to move along the small intestine.

The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. What question should the nurse ask first? "Have you A. Been depressed lately?" B. Had everything to eat in the last 24 hours?" C. Ever had problems with you blood sugar?" D. Been sleeping well?"

Correct answer is D. To rule out symptoms for lack of sleep, asking the client if he slept well would help determining why he has the presented symptoms.

During a health assessment for a young adult female client's gynecological annual screening, the client reports amenorrhea. The nurse calculates the client body mass index (BMI) as 16. Which finding should the nurse document in the electronic medical record that indicates an expected rationale for this condition? A. Increased calcium intake with 3 glasses if non-fat milk daily. B. Reports a history of chronic urinary tract infections. C. Trains for competition and runs 12 miles every day. D. Received an implanted intrauterine device (IUD) last month.

Correct answer is D. When using IUD, the hormones act locally on the uterus—versus hanging out in your bloodstream, like with the pill—they also thin the uterine lining. In some women, the uterine lining is so thinned by the IUD that nothing comes out, aka no period.

The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? (Select all that apply) A. Osteopenia. B. Kyphosis. C. Atrophy. D. Contracture. E. Crepitus

Correct answers are B, C, and D.

A client states that he is legally blind. Which assessment techniques should the nurse use to obtain data to support the client's statement? A. Observe the client's optic disc through an ophthalmoscope. B. Assess the client's ability to read a Snellen chart from a distance of 20 feet. C. Observe the client's pupillary response to a penlight. D. Observe the client's eye movements through the cardinal fields of vision.

correct answer B.

Which assessment technique provides the nurse with the best data related to the client's level of peripheral perfusion?

correct answer C. Capillary refill test

The nurse is obtaining a health history for a client during an annual physical examination. When evaluating the client for menopausal symptoms, which finding indicates the client is perimenopausal? A. Drenching night sweats. B. Excessive vaginal moisture. C. Increase in sexual desire. D. Cessation of menstruation.

correct answer is A

During a health assessment, the client reports being treated for osteoarthritis. The nurse examines a client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record? A. Proximal intertarsal join swelling of big toe. B. Non-painful enlarged interphalangeal joints. C. Distal interphalangeal joint nodules that deviate. D. Frozen, non-movable phalangeal joints.

correct answer is C. Heberden nodes (hard or bony swelilngs in the distal interphalangeal joints) along with a deviated distal finger are a classic finding in osteoarthritis.