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HESI HEALTH ASSESMENT V2 HEALTH ASSESSMENT ACTUAL EXAM 2 DIFFERENT VERSIONS 2023/2024 CORRECT AND ACCURATE VERIFIED FOR GUARANTEED PASS| ALREADY GRADED A$11.49
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HESI HEALTH ASSESMENT V2 HEALTH ASSESSMENT ACTUAL EXAM 2 DIFFERENT VERSIONS 2023/2024 CORRECT AND ACCURATE VERIFIED FOR GUARANTEED PASS| ALREADY GRADED A
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Course
HESI HEALTH
Institution
HESI HEALTH
HESI HEALTH ASSESMENT V2 HEALTH ASSESSMENT
ACTUAL EXAM 2 DIFFERENT VERSIONS 2023/2024
CORRECT AND ACCURATE VERIFIED FOR GUARANTEED
PASS| ALREADY GRADED A
HESI HEALTH ASSESMENT V2 HEALTH ASSESSMENT ACTUAL EXAM 2 DIFFERENT VERSION S 2023/2024 CORRECT AND ACCURATE VERIFIED FOR GUARANTEED PASS| ALREADY GRADED A 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 p athophysiology 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 c olor 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 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 nutriti onal status. 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. Documen t 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. 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 lo ck 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. 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 respirat ory 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 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 p atient describe why he is here in the hospital or clinic and can't include diagnosis. 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 up per motor neuron disorder. Correct answer is D, brisk 4+ response is correlated with hyperactive response. 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. McB urney's point is related to appendicitis and not spleen. 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 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 stethosco pe 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 sound s 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. A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a muffle d 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. The nurse is obtaining a health h istory 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, q uestions should be clear and specific. 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 an swer is D. As this could be a sign of appendicitis. 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. 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 disc harge 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. 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. An older adult client is admitted to the medical unit because of loss of appetite and generaliz ed 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 a nemia. 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. 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
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