HESI RN HEALTH ASSESSMENT FALL 2024 REAL
EXAM QUESTIONS WITH COMPLETE SOLUTIONS
NIGHTINGALE COLLEGE (Download To Get An A)
The nurse inspects the client's fingernails. Which
differentiating characteristics are observed in this
assessment finding?
A. Longitudinal pigmented bands and red brown linear streaks
of recent onset. 9% B. Thinned depressed nails with lateral
edges tilting up to form a concave profile and proximal
subungual fungal infection. 20% C. Transverse furrows and nail
plate white spots that move forward with nail growth. 2% D. A
nail base angle greater than 180 degrees and nail plate loosened
at the distal-lateral edge, progressing proximally. 67% Most
selected
Answer and Explanation
Choice A:
Longitudinal pigmented bands and red-brown linear streaks of
recent onset. This description is more indicative of longitudinal
melanonychia, which presents as pigmented bands along the
length of the nail plate. It's not typically associated with finger
clubbing.
Choice B:
Thinned, depressed nails with lateral edges tilting up to form a
concave profile and proximal subungual fungal infection. This
description suggests koilonychia, also known as spoon nails,
which are characterized by thin, depressed nails with lateral
edges tilting up. The mention of a fungal infection points to a
different condition. It doesn't align with finger clubbing.
Choice C:
,Transverse furrows and nail plate white spots that move forward
with nail growth. This description corresponds to Beau's lines
and leukonychia, which are not associated with finger clubbing.
Beau's lines are transverse furrows or depressions in the nail
plate, while leukonychia manifests as white spots or lines.
Choice D:
A nail base angle greater than 180 degrees and nail plate
loosened at the distal-lateral edge, progressing proximally. This
description fits the characteristics of finger clubbing, where
there's an increased nail base angle (greater than 180 degrees)
and the nail plate is loosened at the distal-lateral edge,
progressing proximally. This choice aligns with the assessment
finding.
The nurse is calculating the one-minute Apgar score for a
newborn infant and determines that the heart rate is 150
beats/minute, a vigorous cry is present, muscle tone is good
with total flexion, quick reflex irritability noted, and skin
color is dusky and cyanotic.
Which Apgar score should the nurse assign to this infant?
(Enter numeric value only.)
Answer and Explanation
Correct Answer: "9"
Explanation
To determine the Apgar score for the newborn infant, we assess
five parameters: heart rate, respiratory effort, muscle tone, reflex
irritability, and color. Each parameter is scored from 0 to 2, with
2 being the highest score. Let's evaluate each parameter:
1. Heart rate: 150 beats/minute --> Score of 2.
2. Respiratory effort: Vigorous cry present --> Score of 2.
, 3. Muscle tone: Good muscle tone with total flexion -->
Score of 2.
4. Reflex irritability: Quick reflex irritability noted --> Score
of 2.
5. Color: Dusky and cyanotic skin color --> Score of 1.
Now, we sum up the scores: 2+2+2+2+1=92+2+2+2+1=9
Therefore, the Apgar score for this infant is 9.
The nurse notes an enlarged, visible lymph node on the
client's neck. Which action should the nurse take next?
A. Auscultate the lymph node for the presence of a
bruit. 8% B. Ask the client about any localized tenderness at the
site. 88% Most selected C. Cover the inflamed area and notify
the healthcare provider. 0% D. Record this normal finding in the
assessment record. 2%
Answer and Explanation
Choice A:
Auscultate the lymph node for the presence of a
bruit.Auscultating for a bruit over a lymph node may not be the
most immediate or relevant action in this situation. While it
could provide additional information about blood flow, it may
not necessarily explain the cause of the enlarged lymph node.
Choice B:
Ask the client about any localized tenderness at the site.This is
an appropriate action. Localized tenderness at the site of an
enlarged lymph node could indicate inflammation or infection.
Gathering information about tenderness can help in
understanding the possible cause of the lymphadenopathy.
Choice C:
Cover the inflamed area and notify the healthcare provider.This
is a reasonable action. Covering the inflamed area can help
, protect it from further irritation or infection. Notifying the
healthcare provider is important because they can assess the
lymph node, gather additional history, and determine if further
evaluation or treatment is necessary.
Choice D:
Record this normal finding in the assessment record.This option
is incorrect. An enlarged, visible lymph node is not considered a
normal finding. It could indicate underlying infection,
inflammation, or another health issue. Recording it as a normal
finding could lead to overlooking potential health concerns.
A woman comes to the clinic for her first prenatal visit. The
nurse is conducting a health history and the woman begins
to cry when asked about previous pregnancies. Which
response is best for the nurse to provide?
A. Allow the client to compose herself then change the
subject. 5% B. "Why don't I come back in a few minutes after
you are more composed." 5% C. "I'm so sorry that I made you
cry. I didn't mean to upset you." 13% D. Offer a tissue and sit
quietly until the crying subsides. 75% Most selected
Answer and Explanation
Choice A:
Allow the client to compose herself then change the subject.This
response allows the client some time to regain composure,
which can be helpful. However, abruptly changing the subject
may make the client feel dismissed or unheard. It's essential to
address the emotional response with sensitivity.
Choice B:
"Why don't I come back in a few minutes after you are more
composed."While this response acknowledges the client's
emotional state, it may unintentionally communicate a lack of
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