HESI V2 health assessment with correct 100% answers.
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Course
HESI V2
Institution
HESI V2
Book
Admission Assessment Exam Review
A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I have lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this body-wracking dry cough that has been hanging around for the last six weeks." Which computer documentation ...
HESI V2 health assess ment with correct 100% answers. A 29 year old male client informs the nurse that he came to the clinic to see if, "Mayb e I have lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this body -wracking dry cough that has been hanging around for the last six weeks." Which computer documentation of this client's concerns should the nurse e nter? A. Presents with a hacking non -productive cough of 6 weeks duration. B. Describe having a "body -wracking dry cough" of 6 weeks duration. C. Expresses concern of "lung cancer" symptoms for last 6 weeks. D. Young adult male presents with fears that he has "lung cancer" - correct answerCorrect answer is B, as assessment process includes chief complaint which is how the patient describe why he is here in the hospital or clinic and can't include diagnosis. A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response. Which interpretation of this finding is accurate? A. A normal reflex response. B. Absent or slu ggish response consistent with a lower motor neuron lesion. C. Flaccid paralysis. D. Hyperactive response consistent with an upper motor neuron disorder. - correct answerCorrect answer is D, brisk 4+ response is correlated with hyperactive response. The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating the spleen? A. Pain notes when palpating McBurney's point. B. Tip of spleen palpable when client is asked to forcefully exhale. C. Rebound tenderness with compression over right upper quadrant. D. Firm mass palpated at bottom of left rib cage. - correct answerCorrect answer is D. McBurney's point is related to appendicitis and not spleen. In auscultating for the presence of a carotid artery bruit, the nurs e places the bell of the stethoscope at which location? - correct answer*under mandible towards lymph nodes. transverse to trachea A male client arrives at the clinic for follow -up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds? A. Use the bell of the stethoscope to listen to the lung fields over lower lobes. B. Have the client lay flat while listening to the anterior surface of th e chest. C. Press the stethoscope's diaphragm firmly on the skin over each lung field. D. Shave all chest hair that may distort sounds heard through the diaphragm. - correct answerCorrect answer is C. The nurse should listen to all lungs fields during assessment and move from side to side during auscultation. A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a muffled voice. Which complication should the nurse suspect? A. Foreign body obstruction. B. Laryngeal polyps . C. Peritonsillar abscess. D. Nasal polyps - correct answerCorrect answer is C. Since infections are associated with abscesses and pus. The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the cl ient, which assessment technique should the nurse use when asking about the client's use of illegal drugs and alcohol? A. Obtain a drug using screen to verify legitimacy of client's stated history. B. Allow the client to decline answering social question s. C. Ask specifically about alcohol, marijuana, cocaine, her D. Use the term illegal or illicit to describe street drug. - correct answerCorrect answer is C. When interviewing the patient, questions should be clear and specific. The nurse applies pressu re over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. What action should the nurse implement? A. Offer to administer a laxative prescribed for PRN use. B. Obtain a prescription to catheterize the client's bladder. C. Instruct the client in distraction and relation techniques. D. Notify the healthcare provider of the rebound tenderness. - correct answerCorrect answer is D. As this could be a sign of appe ndicitis. The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or arterial insufficiency. Which assessment technique should the nurse use to differentiate the pathophysiology causing the ulcer? A. Meas ure the degree of join range of motion in the extremity. B. Compare the skin turgor of the client's upper and lower leg. C. Observe the specific location and appearance of the ulceration. D. Note any change in the color of the ulcer when the leg is move d - correct answerCorrect answer is C. Location and appearance of the ulcer would give us the type (venous vs arterial)
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