HESI V2 health assessment
1. A 29 year old male client informs
the nurse that he came to the clinic
to see if, "Maybe I have lung can-
cer 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 si...
HESI V2 health assessment
1. A 29 year old male client informs Correct answer is B, as assess-
the nurse that he came to the clinic ment process includes chief com-
to see if, "Maybe I have lung can- plaint which is how the patient de-
cer or something," and wants to get scribe why he is here in the hospital
checked out since, "I can't seem to or clinic and can't include diagnosis.
get rid of this body-wracking dry
cough that has been hanging around
for the last six weeks." Which com-
puter documentation of this client's
concerns should the nurse enter?
A. Presents with a hacking non-pro-
ductive cough of 6 weeks duration.
B. Describe having a "body-wracking
dry cough" of 6 weeks duration.
C. Expresses concern of "lung can-
cer" symptoms for last 6 weeks.
D. Young adult male presents with
fears that he has "lung cancer"
2. A 75-year-old client with a recent his- Correct answer is D, brisk 4+ re-
tory of a cerebrovascular accident sponse is correlated with hyperactive
(CVA) presents with right hemipare- response.
sis. The nurse tests the deep tendon
reflexes on the right side and elicits
a brisk 4+ response. Which interpre-
tation of this finding is accurate?
A. A normal reflex response.
B. Absent or sluggish response con-
sistent with a lower motor neuron le-
sion.
C. Flaccid paralysis.
D. Hyperactive response consistent
with an upper motor neuron disorder.
3. The nurse examines a client's ab- Correct answer is D. McBurney's
domen. Which finding indicates an point is related to appendicitis and
abnormal response when palpating not spleen.
the spleen?
A. Pain notes when palpating McBur-
, HESI V2 health assessment
ney's point.
B. Tip of spleen palpable when client
is asked to forcefully exhale.
C. Rebound tenderness with com-
pression over right upper quadrant.
D. Firm mass palpated at bottom of
left rib cage.
4. In auscultating for the presence of a *under mandible towards lymph
carotid artery bruit, the nurse places nodes. transverse to trachea
the bell of the stethoscope at which
location?
5. A male client arrives at the clinic for Correct answer is C. The nurse
follow-up health assessment after re- should listen to all lungs fields during
cent antibiotic treatment for pneu- assessment and move from side to
monia without hospitalization. Which side during auscultation.
technique should the nurse imple-
ment 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 di-
aphragm firmly on the skin over each
lung field.
D. Shave all chest hair that may dis-
tort sounds heard through the di-
aphragm.
6. A client with streptococcus pharyn- Correct answer is C. Since infections
gitis reports high fever, difficulty are associated with abscesses and
swallowing and a muffled voice. pus.
Which complication should the nurse
suspect?
A. Foreign body obstruction.
B. Laryngeal polyps.
, HESI V2 health assessment
C. Peritonsillar abscess.
D. Nasal polyps
7. The nurse is obtaining a health his- Correct answer is C. When interview-
tory for a client prior to a scheduled ing the patient, questions should be
cholecystectomy. While interviewing clear and specific.
the client, which assessment tech-
nique should the nurse use when
asking about the client's use of ille-
gal drugs and alcohol?
A. Obtain a drug using screen to ver-
ify legitimacy of client's stated histo-
ry.
B. Allow the client to decline answer-
ing social questions.
C. Ask specifically about alcohol,
marijuana, cocaine, her
D. Use the term illegal or illicit to de-
scribe street drug.
8. The nurse applies pressure over an Correct answer is D. As this could be
area of the lower abdomen where the a sign of appendicitis.
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 pre-
scribed for PRN use.
B. Obtain a prescription to catheter-
ize the client's bladder.
C. Instruct the client in distraction
and relation techniques.
D. Notify the healthcare provider of
the rebound tenderness.
9. The nurse is assessing an ulcer on Correct answer is C. Location and
a client's lower extremity, which is appearance of the ulcer would give
likely the result of either venous or us the type (venous vs arterial)
arterial insufficiency. Which assess-
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