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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 of this client's
concerns should the nurse enter?
Describe having a "body-wracking dry cough" of 6 weeks duration.
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?
Hyperactive response consistent with an upper motor neuron disorder.
The nurse examines a client's abdomen. Which finding indicates an abnormal
response when palpating the spleen?
Firm mass palpated at bottom of left rib cage.
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In auscultating for the presence of a carotid artery bruit, the nurse places the bell
of the stethoscope at which location?
Place bell of stethoscope over carotid artery
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?
Press the stethoscope's diaphragm firmly on the skin over each lung field.
A client with streptococcus pharyngitis reports high fever, difficulty swallowing
and a muffled voice. Which complication should the nurse suspect?
Peritonsillar abscess.
The nurse is obtaining a health history for a client prior to a scheduled
cholecystectomy. While interviewing the client, which assessment technique
should the nurse use when asking about the client's use of illegal drugs and
alcohol?
Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts.
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, 1/15/26, 6:17 AM HESI Health Assessment Nightingale Colleg
The nurse applies pressure 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?
Notify the healthcare provider of the rebound tenderness.
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?
Observe the specific location and appearance of the ulceration.
A. What type of ulcer is this? Which pathophysiology? venous or arterial?
Venous leg ulcers usually develop on the inner lower leg, above the medial
malleolus.
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