BSN 246 HESI HEALTH ASSESSMENT
V1 EXAM | CORRECTLY ANSWERED
AND GRADED A+ | NIGHTINGALE
A client is in the clinic for a routine health examination. The nurse notices
the client appears underweight. Which question is most important for the
nurse to ask when completing the health history of this client?
- Correct Answer - Have you experienced sudden weight loss?
A male executive is seen in the primary care clinic for a physical
examination. While obtaining the client's health history, the nurse
inquires about his drug and alcohol use. The executive denies drug use,
but reports that he has "two glasses of wine" per night. Which response
is best for the nurse to provide?
- Correct Answer - "What effect do you think your use of alcohol may
have on you?"
Which part of the body should the nurse examine when assessing for
peripheral edema in a client with heart failure?
- Correct Answer - Ankles.
,A client reports feeling increasingly fatigued for several months, and the
nurse observes that the client's lips are pale. Which additional data
should the nurse collect based on this presentation?
- Correct Answer - Use of vitamin and iron supplements.
What is the best place for the nurse to hear lower lobe lung sounds with
a stethoscope?
- Correct Answer - Posterior chest below the 3rd intercostalspace.
A registered nurse (RN) is performing a mini-mental state examination
(MMSE) for a client who is being admitted to an assisted living
community. Which communication techniques should the RN implement
to decrease anxiety in the client? (Select all that apply.)
- Correct Answer - Use simple sentences during the examination.
Reduce environmental detractors during the examination.
Ask questions one at a time to decrease confusion.
The nurse is interviewing a client who reports having a persistent,
productive cough during the winter caused by bronchitis. Which
additional finding should the nurse assess for bronchitis?
- Correct Answer - Phlegm production and wheezing.
The nurse is assessing the posterior pharynx during a physical
examination. Which technique should the nurse use?
, - Correct Answer - Press the tongue down one side at a time with a
tongue depressor.
The nurse is assessing a client who has a history of mitral stenosis. How
should the nurse assess this client with a stethoscope to listen for this
condition?
- Correct Answer - Place the bell on the 5th intercostal space, left
midclavicular line.
Which statement is accurate about assessing the spleen?
- Correct Answer - It must be enlarged at least three times normal size
for it to be palpable.
During an external examination of the eyes, the nurse gently palpates
the eyes while the client's eyelids are closed. The eyes are both very
firm and resist movement back into the orbit. How should the nurse
document this finding?
- Correct Answer - Abnormal finding.
Which tool should the nurse use when assessing the neurological status
of a client with traumatic brain injury?
- Correct Answer - Glasgow Coma Scale.
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