NUR 245 - Hesi Practice Quiz Questions with Correct Answers and Rationales
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Course
NUR 245
Institution
NUR 245
A client is reporting chest pain. What statement made by the client, helps the nurse to understand this client has a naturalistic belief in the cause of illness?
A) "My life is really out of balance." B) "I knew I should have changed my diet." C) "I should have gone to church last week." D) "I for...
NUR 245 - Hesi Practice Quiz Questions
with Correct Answers and Rationales
A client is reporting chest pain. What statement made by the client, helps the nurse to
understand this client has a naturalistic belief in the cause of illness?
A) "My life is really out of balance."
B) "I knew I should have changed my diet."
C) "I should have gone to church last week."
D) "I forgot to take my medicines last night." ✅A.
Rationale
The cause of disease may be viewed in three ways: biomedical, naturalistic, and
magicoreligious. People who conform to the naturalistic perspective of disease
causation, believe that the forces of nature must be kept in a natural balance or
harmony.
A Muslim male client refuses to let the female nurse listen to his breath sounds during
the examination. How should the nurse respond?
A) Explain how the nursing skill will be performed before proceeding.
B) Examine client with an additional healthcare provider for support.
C) Request a male nurse or healthcare provider to perform the exam.
D) Avoid any skills that involve touching the client during the exam. ✅C.
Rationale
Modesty is an important value in the Muslim community, and Muslims are reluctant to
expose any part of their body to healthcare members. Muslim clients are accustomed to
examination by "same-sex" healthcare providers.
A client reports lower abdominal pain and a feeling of pressure in the bladder. Which
assessment finding indicates acute urinary retention?
Hyperactive bowel sounds.
Dull sound percussed over bladder.
Bruits auscultated in left lower quadrant.
Tenderness with palpation of lower back. ✅B.
Rationale
Clients with acute urinary retention may present with lower abdominal pain and bladder
distension. Percussion (tapping on the body wall) is performed to detect differences in
,pitch. A dull sound produced when percussing a distended urinary bladder is an
indication of urinary retention.
While performing a head-to-toe assessment, the nurse assesses the client's pupillary
accommodation. During the second portion of the test, the nurse notes that the client's
pupils constrict and there is a convergence of the axes of the eyes. What action should
the nurse implement next?
A) Document a normal finding.
B) Request a referral to an opthamologist.
C) Repeat the test after having the client rest for 5 minutes.
D)Ask the client, "Have you noticed that you cannot see things close up?" ✅A.
Document a normal finding
When testing for pupillary accommodation, the nurse asks the client to focus on a
distant object and then shift the gaze to a penlight tip near the nose. Focusing on a
distant object causes both pupils to dilate; shifting the gaze to a near object (a finger or
a penlight tip), which is held about 7 to 8 cm (3 inches) from the client's nose, should
result in bilateral pupillary constriction with both eyes focused on the object
simultaneously.
The nurse performs a physical assessment on an older female client. Which change
from the prior exam may be an indication of osteoporosis?
A) Thick and brittle fingernails.
B) Decreased range of motion.
C) Weight gain of 15 pounds.
D) Height reduction of 1.5 inches ✅D.
Rationale
Osteoporosis is a loss of bone density that causes brittle bones and an increased risk
for fractures. Reduced height in older female clients with osteoporosis is generally the
result of the shortening of the vertebral column due to loss of water and thinning of the
intervertebral discs.
The nurse is testing the client's shoulders for range of motion. What should the nurse
document to record normal internal rotation?
A) Ability to lift both arms over the head and swing each arm across the front of the
body.
B) Range of 90 degrees when the hands are placed at the small of the back.
C) A 90 degree range with both hands behind the head with elbows out.
D) Rolling of shoulders in a circular motion clockwise and counter clockwise. ✅B.
, Rationale
To document normal internal rotation of the shoulders, the client should be able to
demonstrate a range of 90 degrees when the hands are placed at the small of the back.
Which technique should the nurse use to assess a client for scoliosis?
A) Watch gait while the client ambulates down the hallway.
B) Observe spine while the client is erect and bent forward.
C) Palpate neck while the client rotates head from side to side.
D) Assess for presence of pain when the client twists the torso. ✅B.
Rationale
Scoliosis is a lateral curvature of the spine seen upon inspection of the spine while the
client stands erect and then bends forward.
The nurse is conducting an interview with a client who speaks limited English. Which
action should the nurse implement?
A) Seek the assistance of a healthcare team member who speaks the client's preferred
language.
B) Continue with the client's assessment interview using simple English words. C) Have
the client reschedule for a time when a family member can be there to interpret.
D) Ask the client to call a friend who speaks English and is able to interpret. ✅A.
Rationale
A healthcare team member who speaks the client's preferred language or a medical
interpreter must be provided whenever English is not the preferred language of the
client.
The nurse is requesting the client to perform a Romberg Test to assess neurological
status. During the test, the nurse notes that the client sways slightly. Which is the
nurse's next action?
A) Document the normal finding.
B) Have the client widen the base of the feet.
C) Ask the client to walk to the door and back.
D)Ask the client if there is any dizziness. ✅A.
Rationale
To perform a Romberg Test, the client is asked to stand up with feet together and arms
at the sides. Once in a stable position, the client is asked to close their eyes and hold
the position for about 20 seconds. Normally a person can maintain posture and balance
even with the visual orienting information blocked, although slight swaying may occur.
Which respiratory condition should the nurse document after measuring a respiratory
rate of 8 breaths/minute?
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