Health Assessment Remediation – HESI Already Rated A

Health Assessment Remediation – HESI Already Rated A In assessing the flexion of a client's neck, which action should the nurse instruct the client to perform? Tilt the chin toward the ceiling. Move the chin toward each shoulder. Press the chin against the chest. Direct one ear toward the shoulder. Rationale Move the chin toward each shoulder. Flexion, or bending, of the neck is best assessed by asking the client to press the chin against the chest. During a physical exam, the nurse observes the external genitalia of an older adult female. The nurse notes that the client's pubic hair is thin and sparse. What follow-up action should the nurse take in response to this finding? Review the client's metabolic profile. Conduct a nutritional assessment. Document the finding in the medical record. Determine if the client uses estrogen cream. Rationale Conduct a nutritional assessment. Changes in estrogen production following menopause result in many physical changes, including a reduction and thinning of pubic hair in the older adult woman. The nurse should document this normal finding in the client's medical record. During a routine assessment, the nurse plans to assess a client for vertigo. Which assessment technique should the nurse use? Listen for changes in speech patterns. Measure blood pressure while standing. Assess orientation to person, place, and time. Ask about sensations of spinning around. Rationale Ask about sensations of spinning around. Vertigo is a subjective feeling of rotational spinning, which is assessed by asking the client about any sensations of spinning. The nurse listens for a client's heart sounds by firmly pressing the diaphragm of the stethoscope against the client's chest. After hearing normal heart sounds, the nurse wants to listen for extra heart sounds. What action should the nurse take first? Rotate the endpiece of the stethoscope. Release the amount of pressure used to hold the stethoscope. Re-adjust the earpieces of the stethoscope. Continue to hold the stethoscope firmly in place with one hand. stethoscope. Rotate the endpiece of the Rationale The diaphragm of the stethoscope is best for hearing high pitched sounds, including normal heart and lung sounds. To best listen for extra heart sounds, the nurse should first turn the endpiece of the stethoscope so that the bell of the stethoscope can be used to hear these low-pitched sounds.