BSN 246 HESI HEALTH ASSESSMENT
FINAL EXAM QUESTIONS AND
CORRECT ANSWERS WITH
RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
The nurse is caring for a client with several broken ribs.
The client is most likely to experience what type of acid-
base imbalance?
1. Respiratory acidosis from inadequate ventilation
2. Respiratory alkalosis from anxiety and hyperventilation
3. Metabolic acidosis from calcium loss due to broken
bones
4. Metabolic alkalosis from taking analgesics containing
base Correct Answer 1. Respiratory acidosis from
inadequate ventilation
Respiratory acidosis is most often caused by
hypoventilation. The client with broken ribs will have
difficulty with breathing adequately and is at risk for
hypoventilation and resultant respiratory acidosis.
The remaining options are incorrect. Respiratory
alkalosis is associated with hyperventilation. There
are no data in the question that indicate calcium loss
or that the client is taking analgesics containing base
products.
A Spanish-speaking client arrives at the triage desk in the
emergency department and states to the nurse that an
,interpreter is needed. Which is the best action for the
nurse to take?
1. Have one of the client's family members interpret.
2. Have the Spanish-speaking triage receptionist interpret.
3. Page an interpreter from the hospital's interpreter
services.
4. Obtain a Spanish-English dictionary and attempt to
triage the client. Correct Answer 3. Page an interpreter
from the hospital's interpreter services.
The best action is to have a professional hospital-
based interpreter translate for the client. English-
speaking family members may not appropriately
understand what is asked of them and may
paraphrase what the client is actually saying. Also,
client confidentiality as well as accurate information
may be compromised when a family member or a non-
health care provider acts as interpreter.
The nurse is performing a neurological assessment on a
client and notes a positive Romberg's test. The nurse
makes this determination based on which observation?
1. An involuntary rhythmic, rapid, twitching of the eyeballs
2. A dorsiflexion of the great toe with fanning of the other
toes
3. A significant sway when the client stands erect with feet
together, arms at the side, and the eyes closed
4. A lack of normal sense of position when the client is
unable to return extended fingers to a point of reference
Correct Answer 3. A significant sway when the client
,stands erect with feet together, arms at the side, and the
eyes closed
In Romberg's test, the client is asked to stand with the
feet together and the arms at the sides, and to close
the eyes and hold the position; normally the client can
maintain posture and balance. A positive Romberg's
sign is a vestibular 409 neurological sign that is found
when a client exhibits a loss of balance when closing
the eyes. This may occur with cerebellar ataxia, loss
of proprioception, and loss of vestibular function. A
lack of normal sense of position coupled with an
inability to return extended fingers to a point of
reference is a finding that indicates a problem with
coordination. A positive gaze nystagmus evaluation
results in an involuntary rhythmic, rapid twitching of
the eyeballs. A positive Babinski's test results in
dorsiflexion of the great toe with fanning of the other
toes; if this occurs in anyone older than 2 years it
indicates the presence of central nervous system
disease.
The nurse notes documentation that a client is exhibiting
Cheyne-Stokes respirations. On assessment of the client,
the nurse should expect to note which finding?
1. Rhythmic respirations with periods of apnea
2. Regular rapid and deep, sustained respirations
3. Totally irregular respiration in rhythm and depth
4. Irregular respirations with pauses at the end of
inspiration and expiration Correct Answer 1. Rhythmic
respirations with periods of apnea
, Cheyne-Stokes respirations are rhythmic respirations
with periods of apnea and can indicate a metabolic
dysfunction in the cerebral hemisphere or basal
ganglia. Neurogenic hyperventilation is a regular,
rapid and deep, sustained respiration that can indicate
a dysfunction in the low midbrain and middle pons.
Ataxic respirations are totally irregular in rhythm and
depth and indicate a dysfunction in the medulla.
Apneustic respirations are irregular respirations with
pauses at the end of inspiration and expiration and
can indicate a dysfunction in the middle or caudal
pons.
A client diagnosed with conductive hearing loss asks the
nurse to explain the cause of the hearing problem. The
nurse plans to explain to the client that this condition is
caused by which problem?
1. A defect in the cochlea
2. A defect in cranial nerve VIII
3. A physical obstruction to the transmission of sound
waves
4. A defect in the sensory fibers that lead to the cerebral
cortex Correct Answer 3. A physical obstruction to the
transmission of sound waves
A conductive hearing loss occurs as a result of a
physical obstruction to the transmission of sound
waves. A sensorineural hearing loss occurs as a
result of a pathological process in the inner ear, a
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