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HESI 1 - V1 AND V2 REVIEW - HEALTH ASSESSMENT 1 WITH CORRECT ANSWERS
HESI 1 - V1 AND V2 REVIEW - HEALTH ASSESSMENT 1 WITH CORRECT ANSWERS
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HEALTH ASSESSMENT HESI PRACTICEWITH VERIFIED SOLUTIONS!!
A nurse conducting a physical assessment is observing the client's balance and performing tests to
determine the client's sense of equilibrium. Which cranial nerve is the nurse assessing?
1. Cranial nerve II
2. Cranial nerve IX
3. Cranial nerve VII
4. Cranial nerve VIII - Correct Answer - 4. Cranial nerve VIII
Cranial nerve VIII is the acoustic nerve. Hearing tests are performed to assess the cochlear portion of
this nerve. Tests to assess equilibrium, such as observation of the client's balance when the client is
walking or standing, involve the vestibular portion.
A nurse performing a neurological assessment of a client who has sustained a stroke (brain attack) is
preparing to check for stereognosis. Which action should the nurse take to perform this assessment?
1. Placing an object in the client's hand and asking the client to identify it
2. Tracing a number on the client's hand and asking the client to identify it
3. Moving the client's finger up and down and asking the client which way it is being moved
4. Making two simultaneous pinpricks on the skin and asking the client to distinguish them - Correct
Answer - 1. Placing an object in the client's hand and asking the client to identify it
Stereognosis is the client's ability to recognize objects placed in his or her hand.
A nurse performing an abdominal assessment of a client is preparing to auscultate for bowel sounds. In
which part of the abdomen should the nurse place the stethoscope first?
,1. Left upper quadrant
2. Left lower quadrant
3. Right upper quadrant
4. Right lower quadrant - Correct Answer - 4. Right lower quadrant
To auscultate for bowel sounds, the nurse places the diaphragm endpiece of the stethoscope lightly
against the skin, then begins to auscultate in the right lower abdominal quadrant, in the area of the
ileocecal valve, because bowel sounds are always present there normally.
A nurse performing a physical assessment of a client is checking the client's mouth and throat. As part of
the assessment, the nurse plans to assess the function of cranial nerve XII. What should the nurse ask
the client to do as a means of assessing this nerve?
1. Frown
2. Show the teeth
3. Stick out the tongue
4. Say "ah" as the tongue is depressed with a tongue blade - Correct Answer - 3. Stick out the tongue
To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse asks the client to stick out
the tongue. The nurse then notes the forward thrust in the midline as the client protrudes the tongue.
The nurse also asks the client to verbalize certain words and then listen for clear, distinct speech.
Discontinuous high-pitched crackling sounds heard during inspiration that do not clear with coughing -
Correct Answer - Fine Crackles
Loud, low-pitched bubbling and gurgling sounds heard on inspiration (may be present on expiration);
may decrease with coughing or suctioning but reappear - Correct Answer - Coarse Crackles
High-pitched, continuous musical sounds heard during inspiration or expiration - Correct Answer -
Wheezing
Loud, low-pitched, coarse rumbling sounds heard during inspiration or expiration; may be cleared by
coughing - Correct Answer - Rhonchi
,Dry, grating quality sounds heard best during inspiration; does not clear with coughing - Correct Answer
- Pleural Friction Rub
Moderately pitched; heard over the major bronchi - Correct Answer - Bronchovesicular sounds
Low-pitched rustling; heard over the peripheral lung fields - Correct Answer - Vesicular sounds
High-pitched, with a harsh, hollow, tubular quality heard over the trachea and larynx - Correct Answer -
Bronchial sounds
A nurse preparing to perform a respiratory assessment of an adult client is reading the client's medical
record. The nurse sees that the health care provider noted resonance on percussion of the client's
posterior chest. What interpretation does the nurse make of this finding?
1. The client has normal, healthy lungs.
2. The client may have a pneumothorax.
3. The client most likely has a lung tumor.
4. An excessive amount of air is present in the lungs. - Correct Answer - 1. The client has normal, healthy
lungs.
Resonance on percussion predominates in healthy adult lung tissue.
When too much air is present such as in the case of emphysema where it is trapped in the alveoli and
pneumothorax where it is trapped in the pleural space leading to lung collapse. - Correct Answer -
Hyperresonance
Indicates an abnormal density in the lungs, such as that noted in pneumonia, pleural effusion, or
atelectasis or in the presence of a tumor. - Correct Answer - Dull note on percussion of the lungs
A nurse performing a breast examination is preparing to palpate the client's breasts. Into which position
should the nurse assist the client to perform palpation?
1. A standing position, with the client holding both arms above her head
2. A standing position, with the client holding her hands firmly on her hips
3. A supine position, with the arm on the side being examined positioned across the chest
, 4. A supine position, with the arm on the side being examined positioned behind the head and a small
pillow placed under the shoulder on the same side - Correct Answer - 4. A supine position, with the arm
on the side being examined positioned behind the head and a small pillow placed under the shoulder on
the same side
To palpate the breasts, the nurse assists the client into a supine position and positions the client's arm
on the side being examined behind the head. A small pillow is placed under the shoulder on the same
side. The nurse uses the pads of the first three fingers to gently compress the breast tissue against the
chest wall and notes tissue consistency. Palpation is performed systematically, with care taken to ensure
that the entire breast and tail are palpated.
A nurse performing a neck assessment of a client is testing the status of cranial nerve XI. What does the
nurse ask the client to do to enable assessment of this nerve?
1. Smile
2. Lift the eyebrows
3. Stick out the tongue
4. Shrug the shoulders against resistance - Correct Answer - 4. Shrug the shoulders against resistance
Cranial nerve XI (spinal accessory nerve) is tested by asking the client to shrug the shoulders against the
resistance of the nurse's hand and to turn the head to each side as the nurse tries to resist the client's
movement.
Increased lumbar curvature - Correct Answer - Lordosis (Swayback)
Exaggeration of the posterior curvature of the thoracic spine - Correct Answer - Kyphosis (hunchback)
Lateral spinal curvature - Correct Answer - Scoliosis
A nurse performing a musculoskeletal assessment is inspecting the posterior aspect of the client's
posture as the client stands. After noting an exaggeration of the posterior curvature of the client's
thoracic spine, how does the nurse interpret this finding?
1. Lordosis
2. Scoliosis
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