HESI Health Assessment Exam 2
Objective. - ANSDuring the interview portio of the health assessment, a nurse notes the
person's posture, physical appearance, and ability to converse. How should the nurse
document these findings?
A round smooth mass that slides between the fingers - ANSAs a part of a routine health
assessment, the nurse assesses the kidneys as part of the abdominal assessment. Which
assessment finding should the nurse conclude is normal when palpating the client's right
kidney?
Upper outer quadrant. - ANSWhen teaching a client how to perform a monthly breast
self-assessment, the nurse should tell the client that it is most important to assess which part
of the breast more closely for changes?
Gland is not palpable - ANSThe nurse is completing a physical exam on an adult client.
Which thyroid finding is considered normal?
4th intercostal space, right midclavicular line. Correct - ANSThe nurse is assessing a client's
middle lung lobe. What is the best location for the nurse to place a stethoscope diaphragm to
hear normal lung sounds in this lobe?
Document a normal finding. - ANSWhile 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 convergence of the axes of the
eyes. What action should the nurse implement next?
A consensual response in the opposite eye. - ANSThe nurse is performing a head-to-toe
assessment on a client. The nurse is assessing the client's pupillary light reflex by first
darkening the room and asking the person to gaze into the distance. Then, the nurse
advances a light toward one eye from the client's side. What would the nurse expect to see
at this time?
Inspect the scalp looking for nits - ANSA client presents with a rash along the occipital area
of the hairline and reports intense itching. How should the nurse begin the objective part of
the examination?
Have you had sudden and severe pain in the toes or feet? - ANSA client has come to the
clinic for a routine health assessment. What is the best assessment question for the nurse to
ask a client after observing tophi on the client's ear cartilage?
Measure bilateral ankle circumference with a non-stretchable tape measure. - ANSHow
should the nurse assess for lower extremity edema in a client who has been diagnosed with
heart failure?
, Seek the assistance of a healthcare team member who speaks the client's preferred
language. - ANSThe nurse is conducting an interview with a client who speaks limited
English. What action should the nurse implement?
Ask whether the client has been in a foreign country recently. - ANSA client reports a recent
onset of nausea and vomiting. What subjective information is important for the nurse to
ascertain?
Document at least 3 generations of the client's family medical history. Correct - ANSThe
nurse is conducting a family history as part of the assessment interview. Which action should
the nurse take to ensure that sufficient information about the client's blood relatives is
obtained?
Verbal descriptor scale. - ANSAn older client has just returned to the room following a
surgical procedure. Which pain scale should the nurse use when assessing the client's pain
level?
Dull sound percussed over bladder. - ANSA client reports lower abdominal pain and a feeling
of pressure in the bladder. Which assessment finding indicates acute urinary retention?
Nocturia. - ANSWhich term should the nurse use to document the condition of a client who
reports waking up frequently during the night to urinate?
Measure the apical pulse and compare it to the peripheral pulse. - ANSWhich procedure
should the nurse use to assess for a pulse deficit?
Ask the client to urinate before beginning the examination. - ANSA client is in the clinical for
a yearly physical examination. Which action should the nurse take when preparing to
examine the client's abdomen?
Friction rub. - ANSWhich term should the nurse use to document in the client's medical
record for a high-pitched scratchy sound during auscultation of the heart?
Use abdominal muscles to sit up. - ANSThe nurse is assessing for the presence of a hernia.
Which action should the nurse ask the client to perform while lying supine?
Note the character and frequency of bowel sounds. - ANSThe nurse is assessing bowel
sounds for a hospitalized client. The nurse has heard bowel sounds in the right upper
quadrant. What action should the nurse take next?
Inspect the hair and skin. - ANSA client is being assessed upon admission to the
medical-surgical unit. The nurse is preparing to complete a head-to-toe assessment and will
begin at the head of the client. Which technique should the nurse use to begin the
assessment?
Height reduction of 1.5 inches. - ANSThe nurse performs a physical assessment on an older
female client. Which change from the prior exam may be an indication of osteoporosis?
Objective. - ANSDuring the interview portio of the health assessment, a nurse notes the
person's posture, physical appearance, and ability to converse. How should the nurse
document these findings?
A round smooth mass that slides between the fingers - ANSAs a part of a routine health
assessment, the nurse assesses the kidneys as part of the abdominal assessment. Which
assessment finding should the nurse conclude is normal when palpating the client's right
kidney?
Upper outer quadrant. - ANSWhen teaching a client how to perform a monthly breast
self-assessment, the nurse should tell the client that it is most important to assess which part
of the breast more closely for changes?
Gland is not palpable - ANSThe nurse is completing a physical exam on an adult client.
Which thyroid finding is considered normal?
4th intercostal space, right midclavicular line. Correct - ANSThe nurse is assessing a client's
middle lung lobe. What is the best location for the nurse to place a stethoscope diaphragm to
hear normal lung sounds in this lobe?
Document a normal finding. - ANSWhile 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 convergence of the axes of the
eyes. What action should the nurse implement next?
A consensual response in the opposite eye. - ANSThe nurse is performing a head-to-toe
assessment on a client. The nurse is assessing the client's pupillary light reflex by first
darkening the room and asking the person to gaze into the distance. Then, the nurse
advances a light toward one eye from the client's side. What would the nurse expect to see
at this time?
Inspect the scalp looking for nits - ANSA client presents with a rash along the occipital area
of the hairline and reports intense itching. How should the nurse begin the objective part of
the examination?
Have you had sudden and severe pain in the toes or feet? - ANSA client has come to the
clinic for a routine health assessment. What is the best assessment question for the nurse to
ask a client after observing tophi on the client's ear cartilage?
Measure bilateral ankle circumference with a non-stretchable tape measure. - ANSHow
should the nurse assess for lower extremity edema in a client who has been diagnosed with
heart failure?
, Seek the assistance of a healthcare team member who speaks the client's preferred
language. - ANSThe nurse is conducting an interview with a client who speaks limited
English. What action should the nurse implement?
Ask whether the client has been in a foreign country recently. - ANSA client reports a recent
onset of nausea and vomiting. What subjective information is important for the nurse to
ascertain?
Document at least 3 generations of the client's family medical history. Correct - ANSThe
nurse is conducting a family history as part of the assessment interview. Which action should
the nurse take to ensure that sufficient information about the client's blood relatives is
obtained?
Verbal descriptor scale. - ANSAn older client has just returned to the room following a
surgical procedure. Which pain scale should the nurse use when assessing the client's pain
level?
Dull sound percussed over bladder. - ANSA client reports lower abdominal pain and a feeling
of pressure in the bladder. Which assessment finding indicates acute urinary retention?
Nocturia. - ANSWhich term should the nurse use to document the condition of a client who
reports waking up frequently during the night to urinate?
Measure the apical pulse and compare it to the peripheral pulse. - ANSWhich procedure
should the nurse use to assess for a pulse deficit?
Ask the client to urinate before beginning the examination. - ANSA client is in the clinical for
a yearly physical examination. Which action should the nurse take when preparing to
examine the client's abdomen?
Friction rub. - ANSWhich term should the nurse use to document in the client's medical
record for a high-pitched scratchy sound during auscultation of the heart?
Use abdominal muscles to sit up. - ANSThe nurse is assessing for the presence of a hernia.
Which action should the nurse ask the client to perform while lying supine?
Note the character and frequency of bowel sounds. - ANSThe nurse is assessing bowel
sounds for a hospitalized client. The nurse has heard bowel sounds in the right upper
quadrant. What action should the nurse take next?
Inspect the hair and skin. - ANSA client is being assessed upon admission to the
medical-surgical unit. The nurse is preparing to complete a head-to-toe assessment and will
begin at the head of the client. Which technique should the nurse use to begin the
assessment?
Height reduction of 1.5 inches. - ANSThe nurse performs a physical assessment on an older
female client. Which change from the prior exam may be an indication of osteoporosis?
