Exam (elaborations)
BSN 246 HESI Health Assessment V 2024
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- Nightingale College
BSN 246 HESI Health Assessment V 2024
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BSN 246 HESI HEALTH ASSESSMENT V11. The nurse is performing a thoracic assessment on a client with chronic
asthma and hyperinflation of the lungs. Which finding should be expected
for this client?: Barrel chest
2. The nurse is assessing bowel sounds for a hospitalized client. The
nurse has heard bowel sounds in the right upper quadrant. What action
should the nurse take next?: Note the character and frequency of bowel sounds
3. During inspection of a client's mouth and pharynx, the nurse places a
tongue blade on the back of the tongue which causes the client to gag. After
removing the tongue blade, what action should the nurse take?: Document
an intact gag reflex.
4. When teaching a client how to perform a monthly breast self-
assessment, the nurse should tell the client that it is most important to
assess which part of the breast more closely for changes?: Upper outer
quadrant.
5. The nurse is assessing a postmenopausal client who has a BMI of 32.
The client has a chest measurement of 42 inches, waist measurement of 45
inches, and hip measurement of 50 inches. What important message should
the nurse explain to the client to promote health promotion?: A waist
circumference is greater than 35 inches in women puts you at higher risk for type
2 diabetes and heart disease."
6. The nurse performs a physical assessment on an older female client.
Which change from the prior exam may be an indication of osteoporosis?:
Height reduction of 1.5 inches.
7. 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?: Sit quietly to allow the client
to respond comfortably.
8. A client is in the clinical for a yearly physical examination. Which action
should the nurse take when preparing to examine the client's abdomen?:
Ask the client to urinate before beginning the examination.
9. Which respiratory condition should the nurse document after
measuring a respiratory rate of 8 breaths/minute?: Bradypnea.
10. Which procedure should the nurse use to assessfor a pulse deficit?:
Measure the apical pulse and compare it to the peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point of
maximal impulse and the radial pulse palpated at the wrist.
, .
11. A client has been diagnosed with bilateral lower lobe atelectasis. What
percussion sound should the nurse expect to hear when percussing over
the client's lower lobes?: Dull, thud-like.
12 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.
13. The nurse is assessing a healthy young adult during an annual physical
examination. Which assessment technique should the nurse implement when
palpating the abdominal aorta?: Deep palpation above and to the left of the
umbilicus.
14. The nurse is conducting a family history as part of the assessment
interview. Which action should the nurse take to ensure that sufficient
information about the client's blood relatives is obtained?: Document at least
3 generations of the client's family medical history.
15. The nurse is testing the client's shoulders for range of motion. What
should the nurse document to record normal internal rotation?: Range of 90
degrees when the hands are placed at the small of the back.
16. A client presents with a rash along the occipital area of the hairline and
reports intense itching. How should the nurse begin the objective part of the
examination?: Inspect the scalp looking for nits.
17. The nurse is assessing a client's range of motion as the client bends the
right knee up to the chest while keeping the left leg straight, but is unable to
keep the left thigh on the table. The assessment is repeated for the left knee,
and the client is unable to keep the right thigh on the table. How should the
nurse document this finding?: A flexion deformity referred to as a positive
Thomas test.
18. During a skin asssessment, the nurse notes, round and discrete lesions
that are dark red in color and will not blanch. The lesions range from 1 to 3
mm in size. What is the first question the nurse should ask the client?: Have
you notice any irregular bleeding
19. A client with progressive hearing loss appears distressed when the
registered nurse (RN) asks open-ended questions about the client's health
history. Which forms of communication should the RN use?: Face the client
so the client can see the RN's mouth.
Check if the client's hearing aides are working properly.
Reduce environmental noise surrounding the client.
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