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HESI- HEALTH ASSESSMENT 2024 WITH CORRECT ANSWERS.
HESI- HEALTH ASSESSMENT 2024 WITH CORRECT ANSWERS.
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HESI- HEALTH ASSESSMENT 2024 WITHCORRECT ANSWERS
The nurse is setting up the physical environment for an interview with a client and plans
to obtain subjective data regarding the client's health. Which interventions are
appropriate? Select all that apply.
A.Set the room temperature at a comfortable level.
B.Remove distracting objects from the interviewing area.
C.Place a chair for the client across from the nurse's desk.
D.Ensure comfortable seating at eye level for the client and nurse.
E.Provide seating for the so that the faces a strong light.
F.Ensure that the distance between the client and the nurse is at least 7 feet. - Correct
Answer - Correct Answers: A, B, and D
Rationale:When preparing the physical environment for an interview, the nurse would
set the room temperature at a comfortable level. The nurse would provide sufficient
lighting for the client and nurse to see each other. The nurse would avoid having the
client face a strong light because the client would have to squint into the full light.
Distracting objects and equipment need to be removed from the interview area. The
nurse would arrange seating so that the nurse and client are seated comfortably at eye
level, and the nurse avoids facing the client across a desk or table, because this creates
a barrier. The distance between the nurse and the client would be set by the nurse at 4
to 5 feet (1.2 to 1.5 meters). If the nurse places the client any closer, the nurse will be
invading the client's private space and may create anxiety in the client. If the nurse
places the client farther away, the nurse may be seen as distant and aloof by the client.
After performing an initial abdominal assessment on a client with nausea and vomiting,
the nurse would expect to note which finding?
A. Waves of loud gurgles auscultated in all four quadrants.
B. Low-pitched swishing auscultated in one or two quadrants.
C. Relatively high-pitched clicks or gurgles auscultated in one or two quadrants.
D. Very high pitched, loud rushes auscultated in especially in one or two quadrants. -
Correct Answer - Correct Answer: A
Rationale:Although frequency and intensity of bowel sounds vary, depending on the
phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles.
Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly associated with
nausea and vomiting. A swishing or buzzing sound represents turbulent blood flow
,associated with a bruit. Bruits are not normal sounds. Bowel sounds are very high-
pitched and loud (hyperresonance) when the intestines are under tension, such as in
intestinal obstruction. Therefore, options 2, 3, and 4 are incorrect.
The nurse is performing a neurological assessment on a client and elicits a positive
Romberg's sign. The nurse makes this determination based on which observation?
A. An involuntary rhythmic, rapid twitching of the eyeballs.
B. A dorsiflexion of the ankle and great toe with fanning of the other toes.
C. A significant sway when the client stands erect with feet together, arms at the side
and the eyes closed.
D. A lack of sense of position when the client is unable to return extended fingers to a
point of reference. - Correct Answer - Correct Answer: C
Rationale: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 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 ankle and 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.
A client with pneumonia is admitted to the hospital with difficulty breathing. Which is the
best approach for the nurse to use in obtaining the client's health history?
A.Focus only on the physical assessment.
B.Obtain all history information from the family members.
C.Plan short sessions with the client to obtain data.
D.Use the primary healthcare provider's medical history. - Correct Answer - Correct
Answer: C
Rationale:The best source of information is the client. Option 1 is incorrect; the physical
examination is not part of the health history. Option 2 is incorrect because it refers to all
information. Option 4 is incorrect because the primary health care provider's medical
history provides data that are different from the nurse's assessment. All efforts need to
be made to obtain as much information as possible from the client, using short sessions
and closed-ended questions.
The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's
sign. Which finding did the nurse observe?
A.The client rigidly extends the arms with pronated forearms and plantar flexion of the
feet.
B.The client flexes a leg at the hip and knee and reports pain in the vertebral column
when the leg is extended.
,C.The client passively flexes his hip and knee in response to neck flexion and reports
pain in the vertebral column.
D.The client's upper arms are flexed and held tightly to the sides of the body and the
legs are extended and internally rotated. - Correct Answer - Correct Answer:C
Rationale:Brudzinski's sign is tested with the client in the supine position. The nurse
flexes the client's head (gently moves the head to the chest), and there would be no
reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed
if the client passively flexes the hip and knee in response to neck flexion and reports
pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is
positive when the client flexes the legs at the hip and knee and complains of pain along
the vertebral column when the leg is extended. Decorticate posturing is abnormal
flexion and is noted when the client's upper arms are flexed and held tightly to the sides
of the body and the legs are extended and internally rotated. Decerebrate posturing is
abnormal extension and occurs when the arms are fully extended, forearms pronated,
wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed.
The nurse is testing a client for astereognosis. The nurse would ask the client to close
the eyes and perform which action?
A.Identify three numbers or letters traced in the client's palm.
B.Identify an object in the client's hand.
C.State whether one or two pinpricks are felt when the skin is pricked bilaterally in the
same place.
D.Identify the smallest distance between two detectable pinpricks, made with two pins
held at various lengths. - Correct Answer - Correct Answer: B
Rationale:Astereognosis is the inability to discern the form or configuration of common
objects using the sense of touch. Graphesthesia is the inability to recognize the form of
written symbols. The remaining options test for extinction phenomena and two-point
stimulation, respectively.
The nurse performing a neurological examination is assessing eye movement to
evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which
action to obtain the assessment data?
A. Turn the flashlight on directly in front of the eye and watch for a response.
B. Check pupil size, and then ask the client to alternate looking at the flashlight and the
examiners finger.
C. Instruct the client to look straight ahead, and then shine the flashlight from the
temporal area to the eye.
D. Ask the client to follow the flashlight through the six cardinal positions of gaze -
Correct Answer - Correct Answer: D
Rationale:The nurse asks the client to follow the flashlight through the six cardinal
positions of gaze to assess for eye movement related to cranial nerves III, IV, and VI.
Options 1 and 3 relate to pupillary response to light. Also, shining the light directly into
, the client's eye without asking the client to focus on a distant object is not an
appropriate technique. Option 4 assesses accommodation of the eye.
The nurse is monitoring a client for signs of hypocalcemia after thyroidectomy. Which
sign or symptom, if noted in the client, would most likely indicate the presence of
hypocalcemia?
A. Bradycardia
B. Flaccid paralysis
C. Tingling around the mouth
D. Absence of Chvostek's sign - Correct Answer - Correct Answer: C
Rationale:After thyroidectomy the nurse assesses the client for signs of hypocalcemia
and tetany. Early signs inclfingertips, muscle twitching or spasms, palpitations or aude
tingling around the mouth and in the rrhythmias, and Chvostek's and Trousseau's signs.
Bradycardia, flaccid paralysis, and absence of Chvostek's sign are not signs of
hypocalcemia.
The nurse is caring for a client with a new diagnosis of hypothyroidism. Which clinical
manifestations might the nurse expect to note on examination of this client? Select all
that apply.
A.Irritability
B.Periorbital edema
C.Coarse, brittle hair
D.Slow or slurred speech
E.Abdominal distention
F.Soft, silky, thinning hair - Correct Answer - Correct Answer: B, C, D,E
Rationale:The manifestations of hypothyroidism are the result of decreased metabolism
from low levels of thyroid hormones. The client may exhibit skin manifestations, such as
coarse, brittle hair; thick, brittle nails; coarse, scaly skin; delayed wound healing;
periorbital edema; and face puffiness. Neuromuscular manifestations include lethargy,
slow or slurred speech, and impaired memory. Gastrointestinal manifestations include
complaints of constipation, weight gain, and abdominal distention. Irritability and soft,
silky, thinning hair on the scalp are manifestations of hyperthyroidism.
A nursing student is performing a respiratory assessment on an adult client and is
assessing for tactile fremitus. Which action by the nursing student indicates a need for
further teaching?
A.Palpating over the lung apices in the supraclavicular area
B.Asking the client to repeat the word ninety-nine during palpation
C.Palpating over the breast tissue to assess and compare vibrations from one side to
the other
D.Comparing vibrations from one side to the other as the client repeats the word ninety-
nine - Correct Answer - Correct Answer: C
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