Exam (elaborations)
HESI V2 HEALTH ASSESSMENT QUESTIONS
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HESI V2 HEALTH ASSESSMENT QUESTIONS
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HESI V2 HEALTH ASSESSMENT QUESTIONSA 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?
B. Describe having a "body-wracking dry cough" of 6 weeks duration.
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.
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?
D. Hyperactive response consistent with an upper 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?
D. Firm mass palpated at bottom of left rib cage.
Correct answer is D. McBurney'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?
C. Press the stethoscope's diaphragm firmly on the skin over each lung field.
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
muffled voice. Which complication should the nurse suspect?
.
C. Peritonsillar abscess.
, Correct answer is C. Since infections are associated with abscesses and pus.
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?
C. Ask specifically about alcohol, marijuana, cocaine, her
Correct answer is C. When interviewing the patient, questions 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?
D. Notify the healthcare provider of the rebound tenderness.
Correct answer is D. As this could be a sign of appendicitis.
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?
C. Observe the specific location and appearance of the ulceration.
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?
D. Condition of hair, nails, and skin.
Correct answer is D. Hair, nail, and skin are the most important reflection of nutritional
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. Document this normal bowel sound activity in the record.
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?
C. Oral mucosa is cyanotic.
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