HEALTH ASSESSMENT HESI VERSION 2 EXAM COMPLETE GUIDE QUESTIONS WITH VERIFIED ANSWERS
A 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 co...
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HESI
V2
health
assessment
A
2 9
y e a r
o l d
m a l e
c l i e n t
i n f o r m s
t h e
n u r s e
t h a t
h e
c a m e
t o
t h e
c l i n i c
t o
s e e
i f ,
" M a y b e
I
h a v e
l u n g
c a n c e r
o r
s o m e t h i n g , "
a n d
w a n t s
t o
g e t
c h e c k e d
o u t
s i n c e ,
" I
c a n ' t
s e e m
t o
g e t
r i d
o f
t h i s
b o d y - w r a c k i n g
d r y
c o u g h
t h a t
h a s
b e e n
h a n g i n g
a r o u n d
f o r
t h e
l a s t
s i x
w e e k s . "
W h i c h
c o m p u t e r
d o c u m e n t a t i o n
o f
t h i s
c l i e n t ' s
c o n c e r n s
s h o u l d
t h e
n u r s e
e n t e r ?
A .
P r e s e n t s
w i t h
a
h a c k i n g
n o n - p r o d u c t i v e
c o u g h
o f
6
w e e k s
d u r a t i o n .
B .
D e s c r i b e
h a v i n g
a
" b o d y - w r a c k i n g
d r y
c o u g h "
o f
6
w e e k s
d u r a t i o n .
C .
E x p r e s s e s
c o n c e r n
o f
" l u n g
c a n c e r "
s y m p t o m s
f o r
t h e
l a s t
6
w e e k s .
D .
Y o u n g
a d u l t
m a l e
p r e s e n t s
w i t h
f e a r s
t h a t
h e
h a s
" l u n g
c a n c e r "
-
A N S
C o r r e c t
a n s w e r
i s
B ,
a s
a s s e s s m e n t
p r o c e s s
i n c l u d e s
c h i e f
c o m p l a i n t
w h i c h
i s
h o w
t h e
p a t i e n t
d e s c r i b e
w h y
h e
i s
h e r e
i n
t h e
h o s p i t a l
o r
c l i n i c
a n d
c a n ' t
i n c l u d e
d i a g n o s i s .
A
7 5 - y e a r - o l d
c l i e n t
w i t h
a
r e c e n t
h i s t o r y
o f
a
c e r e b r o v a s c u l a r
a c c i d e n t
( C V A )
p r e s e n t s
w i t h
r i g h t
h e m i p a r e s i s .
T h e
n u r s e
t e s t s
t h e
d e e p
t e n d o n
r e f l e x e s
o n
t h e
r i g h t
s i d e
a n d
e l i c i t s
a
b r i s k
4 +
r e s p o n s e .
W h i c h
i n t e r p r e t a t i o n
o f
t h i s
f i n d i n g
i s
a c c u r a t e ?
A .
A
n o r m a l
r e f l e x
r e s p o n s e .
B .
A b s e n t
o r
s l u g g i s h
r e s p o n s e
c o n s i s t e n t
w i t h
a
l o w e r
m o t o r
n e u r o n
l e s i o n .
C .
F l a c c i d
p a r a l y s i s .
D .
H y p e r a c t i v e
r e s p o n s e
c o n s i s t e n t
w i t h
a n
u p p e r
m o t o r
n e u r o n
d i s o r d e r .
-
A N S
C o r r e c t
a n s w e r
i s
D ,
b r i s k
4 +
r e s p o n s e
i s
c o r r e l a t e d
w i t h
h y p e r a c t i v e
r e s p o n s e .
T h e
n u r s e
e x a m i n e s
a
c l i e n t ' s
a b d o m e n .
W h i c h
f i n d i n g
i n d i c a t e s
a n
a b n o r m a l
r e s p o n s e
w h e n
p a l p a t i n g
t h e
s p l e e n ?
A .
P a i n
n o t e s
w h e n
p a l p a t i n g
M c B u r n e y ' s
p o i n t .
B .
T i p
o f
s p l e e n
p a l p a b l e
w h e n
c l i e n t
i s
a s k e d
t o
f o r c e f u l l y
e x h a l e .
C .
R e b o u n d
t e n d e r n e s s
w i t h
c o m p r e s s i o n
o v e r
r i g h t
u p p e r
q u a d r a n t .
D .
F i r m
m a s s
p a l p a t e d
a t
b o t t o m
o f
l e f t
r i b
c a g e .
-
A N S
C o r r e c t
a n s w e r
i s
D .
M c B u r n e y ' s
p o i n t
i s
r e l a t e d
t o
a p p e n d i c i t i s
a n d
n o t
s p l e e n .
I n
a u s c u l t a t i n g
f o r
t h e
p r e s e n c e
o f
a
c a r o t i d
a r t e r y
b r u i t ,
t h e
n u r s e
p l a c e s
t h e
b e l l
o f
t h e
s t e t h o s c o p e
a t
w h i c h
l o c a t i o n ?
-
A N S
* u n d e r
m a n d i b l e
t o w a r d s
l y m p h
n o d e s .
t r a n s v e r s e
t o
t r a c h e a
A
m a l e
c l i e n t
a r r i v e s
a t
t h e
c l i n i c
f o r
f o l l o w - u p
h e a l t h
a s s e s s m e n t
a f t e r
r e c e n t
a n t i b i o t i c
t r e a t m e n t
f o r
p n e u m o n i a
w i t h o u t
h o s p i t a l i z a t i o n .
W h i c h
t e c h n i q u e
s h o u l d
t h e
n u r s e
i m p l e m e n t
t o
a s s e s s
f o r
a d v e n t i t i o u s
l u n g
s o u n d s ?
A .
U s e
t h e
b e l l
o f
t h e
s t e t h o s c o p e
t o
l i s t e n
t o
t h e
l u n g
f i e l d s
o v e r
l o w e r
l o b e s .
B .
H a v e
t h e
c l i e n t
l a y
f l a t
w h i l e
l i s t e n i n g
t o
t h e
a n t e r i o r
s u r f a c e
o f
t h e
c h e s t .
C .
P r e s s
t h e
s t e t h o s c o p e ' s
d i a p h r a g m
f i r m l y
o n
t h e
s k i n
o v e r
e a c h
l u n g
f i e l d . D .
S h a v e
a l l
c h e s t
h a i r
t h a t
m a y
d i s t o r t
s o u n d s
h e a r d
t h r o u g h
t h e
d i a p h r a g m .
-
A N S
C o r r e c t
a n s w e r
i s
C .
T h e
n u r s e
s h o u l d
l i s t e n
t o
a l l
l u n g s
f i e l d s
d u r i n g
a s s e s s m e n t
a n d
m o v e
f r o m
s i d e
t o
s i d e
d u r i n g
a u s c u l t a t i o n .
A
c l i e n t
w i t h
s t r e p t o c o c c u s
p h a r y n g i t i s
r e p o r t s
h i g h
f e v e r ,
d i f f i c u l t y
s w a l l o w i n g
a n d
a
m u f f l e d
v o i c e .
W h i c h
c o m p l i c a t i o n
s h o u l d
t h e
n u r s e
s u s p e c t ?
A .
F o r e i g n
b o d y
o b s t r u c t i o n .
B .
L a r y n g e a l
p o l y p s .
C .
P e r i t o n s i l l a r
a b s c e s s .
D .
N a s a l
p o l y p s
-
A N S
C o r r e c t
a n s w e r
i s
C .
S i n c e
i n f e c t i o n s
a r e
a s s o c i a t e d
w i t h
a b s c e s s e s
a n d
p u s .
T h e
n u r s e
i s
o b t a i n i n g
a
h e a l t h
h i s t o r y
f o r
a
c l i e n t
p r i o r
t o
a
s c h e d u l e d
c h o l e c y s t e c t o m y .
W h i l e
i n t e r v i e w i n g
t h e
c l i e n t ,
w h i c h
a s s e s s m e n t
t e c h n i q u e
s h o u l d
t h e
n u r s e
u s e
w h e n
a s k i n g
a b o u t
t h e
c l i e n t ' s
u s e
o f
i l l e g a l
d r u g s
a n d
a l c o h o l ?
A .
O b t a i n
a
d r u g
u s i n g
s c r e e n
t o
v e r i f y
l e g i t i m a c y
o f
c l i e n t ' s
s t a t e d
h i s t o r y .
B .
A l l o w
t h e
c l i e n t
t o
d e c l i n e
a n s w e r i n g
s o c i a l
q u e s t i o n s .
C .
A s k
s p e c i f i c a l l y
a b o u t
a l c o h o l ,
m a r i j u a n a ,
c o c a i n e ,
h e r
D .
U s e
t h e
t e r m
i l l e g a l
o r
i l l i c i t
t o
d e s c r i b e
s t r e e t
d r u g .
-
A N S
C o r r e c t
a n s w e r
i s
C .
W h e n
i n t e r v i e w i n g
t h e
p a t i e n t ,
q u e s t i o n s
s h o u l d
b e
c l e a r
a n d
s p e c i f i c .
T h e
n u r s e
a p p l i e s
p r e s s u r e
o v e r
a n
a r e a
o f
t h e
l o w e r
a b d o m e n
w h e r e
t h e
c l i e n t
r e p o r t s
p a i n .
T h e
c l i e n t
d e n i e s
p a i n
u p o n
p a l p a t i o n ,
b u t
r e p o r t s
p a i n
w h e n
t h e
p r e s s u r e
i s
r e l e a s e d .
W h a t
a c t i o n
s h o u l d
t h e
n u r s e
i m p l e m e n t ?
A .
O f f e r
t o
a d m i n i s t e r
a
l a x a t i v e
p r e s c r i b e d
f o r
P R N
u s e .
B .
O b t a i n
a
p r e s c r i p t i o n
t o
c a t h e t e r i z e
t h e
c l i e n t ' s
b l a d d e r .
C .
I n s t r u c t
t h e
c l i e n t
i n
d i s t r a c t i o n
a n d
r e l a t i o n
t e c h n i q u e s .
D .
N o t i f y
t h e
h e a l t h c a r e
p r o v i d e r
o f
t h e
r e b o u n d
t e n d e r n e s s .
-
A N S
C o r r e c t
a n s w e r
i s
D .
A s
t h i s
c o u l d
b e
a
s i g n
o f
a p p e n d i c i t i s .
T h e
n u r s e
i s
a s s e s s i n g
a n
u l c e r
o n
a
c l i e n t ' s
l o w e r
e x t r e m i t y ,
w h i c h
i s
l i k e l y
t h e
r e s u l t
o f
e i t h e r
v e n o u s
o r
a r t e r i a l
i n s u f f i c i e n c y .
W h i c h
a s s e s s m e n t
t e c h n i q u e
s h o u l d
t h e
n u r s e
u s e
t o
d i f f e r e n t i a t e
t h e
p a t h o p h y s i o l o g y
c a u s i n g
t h e
u l c e r ?
A .
M e a s u r e
t h e
d e g r e e
o f
j o i n
r a n g e
o f
m o t i o n
i n
t h e
e x t r e m i t y .
B .
C o m p a r e
t h e
s k i n
t u r g o r
o f
t h e
c l i e n t ' s
u p p e r
a n d
l o w e r
l e g .
C .
O b s e r v e
t h e
s p e c i f i c
l o c a t i o n
a n d
a p p e a r a n c e
o f
t h e
u l c e r a t i o n .
D .
N o t e
a n y
c h a n g e
i n
t h e
c o l o r
o f
t h e
u l c e r
w h e n
t h e
l e g
i s
m o v e d
-
A N S
C o r r e c t
a n s w e r
i s
C .
L o c a t i o n
a n d
a p p e a r a n c e
o f
t h e
u l c e r
w o u l d
g i v e
u s
t h e
t y p e
( v e n o u s
v s
a r t e r i a l )
T h e
n u r s e
i s
c o n d u c t i n g
a
p h y s i c a l
a s s e s s m e n t
o f
a
y o u n g
a d u l t .
W h i c h
i n f o r m a t i o n
p r o v i d e s
t h e
b e s t
i n d i c a t i o n
o f
t h e
i n d i v i d u a l ' s
n u t r i t i o n a l
s t a t u s ?
A .
S t a t u s
o f
c u r r e n t
a p p e t i t e .
B .
A
2 4 - h o u r
d i e t
h i s t o r y .
C .
H i s t o r y
o f
a
r e c e n t
w e i g h t
l o s s .
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