Exam (elaborations)
HESI Health Assessment
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HESI Health Assessment
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HESI Health AssessmentThe nurse is conducting an interview with a client who speaks limited English. Which action
should the nurse implement?
Seek the assistance of a healthcare team member who speaks the client's preferred language.
Continue with the client's assessment interview using simple English words.
Have the client reschedule for a time when a family member can be there to interpret.
Ask the client to call a friend who speaks English and is able to interpret.
Seek the assistance of a healthcare team member who speaks the client's preferred language.
Rationale:
A healthcare team member who speaks the client's preferred language or a medical interpreter
must be provided whenever English is not the preferred language of the client.
While conducting an interview to obtain a health history, the nurse notices that the client
pauses frequently and looks at the nurse expectantly. Which response is best for the nurse to
provide?
Reassure the client that there are no wrong ANSWERs.
Tell the client to return later for another interview.
Continue to ask questions until the client responds.
Sit quietly to allow the client to respond comfortably.
Sit quietly to allow the client to respond comfortably.
Rationale
,A silent attentiveness or intelligent repose communicates that the nurse has time and is willing
to listen to the client's responses.
A client has been diagnosed with bilateral lower lobe atelectasis. Which percussion sound
should the nurse expect to hear when percussing over the client's lower lobes?
Dull, thud-like.
Hyperresonant, booming.
Tympanic, drum like.
Flat, extremely dull.
Dull, thud-like.
Rationale
An atelectatic or consolidated lung will produce a dullness or thud-like sound when percussed
during an assessment.
A client reports a recent onset of nausea and vomiting. What subjective information is
important for the nurse to ascertain?
Ask how much weight the client gained on vacation.
Ask whether the client has been in a foreign country recently.
Observe the symmetry of the abdomen.
Count the bowel sounds in each abdominal quadrant.
Ask whether the client has been in a foreign country recently.
Rationale
GI upset and diarrhea occur when exposed to new local pathogens in developing countries. The
water supply may be contaminated.
A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing to
complete a head-to-toe assessment and will begin at the head of the client. Which technique
should the nurse use to begin the assessment?
, Inspect the hair and skin.
Palpate the temperature of the skin.
Percuss for tenderness.
Auscultate the temporal arteries.
Inspect the hair and skin.
Rationale
The usual order for a physical assessment is inspection, palpation, percussion, and auscultation.
When beginning a physical assessment, the nurse should perform an inspection, which is a
general survey of the individual as a whole and of each body system.
While performing a head-to-toe assessment, the nurse assesses the client's pupillary
accommodation. During the second portion of the test, the nurse notes that the client's pupils
constrict and there is a convergence of the axes of the eyes. What action should the nurse
implement next?
Document a normal finding.
Request a referral to an opthamologist.
Repeat the test after having the client rest for 5 minutes.
Ask the client, "Have you noticed that you cannot see things close up?"
Document a normal finding.
Rationale
When testing for pupillary accommodation, the nurse asks the client to focus on a distant object
and then shift the gaze to a penlight tip near the nose. Focusing on a distant object causes both
pupils to dilate shifting the gaze to a near object (a finger or a penlight tip), which is held about
7 to 8 cm (3 inches) from the client's nose, should result in bilateral pupillary constriction with
both eyes focused on the object simultaneously.
Which term should the nurse use to document in the client's medical record for a high-pitched
scratchy sound during auscultation of the heart?
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