Hesi RN practice test Research Study Latest Answers.

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? A) Level of consciousness. B) Gait characteristics. C) Presence of trauma. D) Bladder control ability. - correct answer A) Level of consciousness Initial symptoms of meningitis include headache, fatigue, stiff neck, and changes in level of consciousness. It is necessary to determine if the client is demonstrating signs of meningitis before planning immediate care. The nurse is assessing the posterior pharynx during a physical examination. Which technique should the nurse use? A) Press the tongue down one side at a time with a tongue depressor. B) Ask the client to open the mouth and say "ah." C) Listen for hoarseness after asking the client to speak. D) Palpate the neck and ask the client to swallow. - correct answer A) Press the tongue down one side at a time with a tongue depressor. When assessing the posterior pharynx, a tongue depressor should be used to press down one side of the tongue at a time to avoid stimulating the gag reflex. Which findings can the nurse determine by palpating a client's skin? (Select all that apply.) A) Pruritus. B) Diaphoresis. C) Pallor. D) Jaundice. E) Scaling. - correct answer B) Diaphoresis. E) Scaling. Palpation, or touch, can provide information about skin texture, including the presence of scaling and skin moisture, including diaphoresis, or perspiration. Pruritus, or itching, is a subjective finding reported by the client, and pallor and jaundice describe skin color, assessed through observation. 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? A) Elevate head of bed 30 degrees to percuss the spleen. B) Palpate the splenic borders before percussing. C) Percuss the splenic area as the client takes a deep breath. D) Place client in a Trendelenburg position to isolate the spleen. - correct answer C) Percuss the splenic area as the client takes a deep breath If the spleen is enlarged due to an infection or trauma, tympany changes are noted with dullness upon inspiration. Which information should the nurse obtain to identify the client's self-perception of health status? A) Vital signs. B) Health history. C) Informed consent. D) Genetic predisposition. - correct answer B) Health history. A health history is a collection of subjective data. Obtaining a detailed health history is a good way for the nurse to assess the client's perception of current health status. Which action should the registered nurse (RN) implement to complete an assessment for a client while using an interpreter? A) Ask closed-ended questions with the assistance of the interpreter. B) Maintain eye contact with the client while listening to the translation. C) Instruct interpreter to answer questions from interpreter's point of view. D) Protect the client's privacy by asking a limited number of questions. - correct answer B) Maintain eye contact with the client while listening to the translation. When completing an assessment, the RN should maintain eye contact with the client to gather additional information from the client's nonverbal cues. 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? A) Normal. B) Expected in older adults. C) Minor deviation. D) Abnormal. - correct answer D) Abnormal. This finding is abnormal and may be indicative of generalized muscle weakness or a joint disorder. 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? A) 24-hour dietary recall B) Food diary. C) Intake and output record. D) Lab information (albumin, pre-albumin). - correct answer A) 24-hour dietary recall Nutritional history, which includes the client's recall of food and fluid intake during a 24-hour period, is an important factor in determining a client's nutritional status. The nurse should include the client's dietary recall when performing a nutritional screening. 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? A) Administration of rubeola vaccine at age 7. B) Removal of gallbladder 5 years ago. C) Family history of colon cancer on mother's side. D) Family history of hypertension on father's side. - correct answer C) Family history of colon cancer on mother's side Abdominal pain and constipation can be signs of colon cancer, and some forms of colon cancer can be hereditary. A family history of colon cancer is of significant concern, and the nurse should report this information to the healthcare provider. 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? A) The left leg internally rotates. B) The left leg rises off of the table. C) The left leg remains on the table. D) The left leg externally rotates. - correct answer C) 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.