Hesi health assessment 2 Exam Questions and
Answers
1. In observing a client's face, which assessment finding requires
the most immediate intervention by the nurse?
A. Eyelids are matted and crusted.
B. Cornea are jaundiced.
C. Oral mucosa is cyanotic.
D. Face is flushed and diaphoretic. correct answer: C. Oral mucosa is cyanotic
2. While obtaining a health history, a male client tells the nurse
that he some- times experiences shortness of breath. The nurse
determines that the client's respirators are regular and deep, and his
respiratory rate is 14 breaths/minute. What is the best nursing
action?
A. Ask the client to perform light exercises and observe the respiratory
effect.
B. Document "dyspnea on exertion" in the client's medical record.
C. Ask the client to describe the episodes of dyspnea in more detail.
D.Explain to the client the possible causes of dyspnea or "shortness of
breath."-
correct answer: C. Ask the client to describe the episodes of dyspnea in more detail.
3. When assessing a male client's respiratory status, which
technique should the nurse use to assess his anterior- posterior (AP)
chest diameter?
A. Auscultation.
B. Percussion.
C. Palpation.
D. Observation. correct answer: D. Observation
4. Which assessment finding supports the client's statement, "My feet
swell all the time?"
A. 2+ pitting edema of ankles bilaterally.
,Hesi health assessment 2 Exam Questions and
Answers
B. Capillary refill both feet > 3 seconds.
C. Pedal pulses weak and thread.
D. Positive Homan's sign bilaterally. correct answer: A. 2+ pitting edema of the ankles
bilaterally
5. The nurse is performing a cranial nerve exam on an 87-year-old
client. The nurse notes that the client has a reduced upward gaze,
a decreased corneal
,Hesi health assessment 2 Exam Questions and
Answers
reflex, a high-frequency hearing loss, and a reduced gag reflex. What
action should the nurse take next?
A. Review past history for any episodes of a cerebral cortex lesion.
B. Implement neuro vital signs every 2 hours to detect Cushing's
Triad.
C. Continue the assessment to the next pairs of cranial nerves.
D. Assess the spinal reflexes for demyelination symptoms. correct answer:
C. Continue the assessment to the next pair of cranial nerves
6. When performing a neurologic assessment on an alert client,
the nurse observes that the client's pupils are both round, 3 mm
in size, and respond briskly to light. Which notation should the
nurse use when documenting the assessment?
A. PERRL.
B. GCS of 15.
C. PERLA.
D. Neuro status intact correct answer: A. PERRL
7. Which assessment technique provides the nurse with the best data
related to the client's level of peripheral perfusion? correct answer:
Capillary refill test
8. The nurse is assessing a female client who states that her
hemorrhoids are inflamed and hurt constantly. Which intervention
is best for the nurse to complete a focused assessment?
A. Ask the client how long she has experienced discomfort related
to hemor- rhoids.
B. Place the client in a standing position, leaning over the exam bed
for inspec- tion.
C. Determine if the client uses any over-the-counter preparation
for hemor- rhoids.
,Hesi health assessment 2 Exam Questions and
Answers
D. Position the client in the left lateral position to inspect the perianal
area for fissures or sacs. correct answer: D. Position the client in the left lateral position to
inspect the perianal area for fissures or sacs.
Answers
1. In observing a client's face, which assessment finding requires
the most immediate intervention by the nurse?
A. Eyelids are matted and crusted.
B. Cornea are jaundiced.
C. Oral mucosa is cyanotic.
D. Face is flushed and diaphoretic. correct answer: C. Oral mucosa is cyanotic
2. While obtaining a health history, a male client tells the nurse
that he some- times experiences shortness of breath. The nurse
determines that the client's respirators are regular and deep, and his
respiratory rate is 14 breaths/minute. What is the best nursing
action?
A. Ask the client to perform light exercises and observe the respiratory
effect.
B. Document "dyspnea on exertion" in the client's medical record.
C. Ask the client to describe the episodes of dyspnea in more detail.
D.Explain to the client the possible causes of dyspnea or "shortness of
breath."-
correct answer: C. Ask the client to describe the episodes of dyspnea in more detail.
3. When assessing a male client's respiratory status, which
technique should the nurse use to assess his anterior- posterior (AP)
chest diameter?
A. Auscultation.
B. Percussion.
C. Palpation.
D. Observation. correct answer: D. Observation
4. Which assessment finding supports the client's statement, "My feet
swell all the time?"
A. 2+ pitting edema of ankles bilaterally.
,Hesi health assessment 2 Exam Questions and
Answers
B. Capillary refill both feet > 3 seconds.
C. Pedal pulses weak and thread.
D. Positive Homan's sign bilaterally. correct answer: A. 2+ pitting edema of the ankles
bilaterally
5. The nurse is performing a cranial nerve exam on an 87-year-old
client. The nurse notes that the client has a reduced upward gaze,
a decreased corneal
,Hesi health assessment 2 Exam Questions and
Answers
reflex, a high-frequency hearing loss, and a reduced gag reflex. What
action should the nurse take next?
A. Review past history for any episodes of a cerebral cortex lesion.
B. Implement neuro vital signs every 2 hours to detect Cushing's
Triad.
C. Continue the assessment to the next pairs of cranial nerves.
D. Assess the spinal reflexes for demyelination symptoms. correct answer:
C. Continue the assessment to the next pair of cranial nerves
6. When performing a neurologic assessment on an alert client,
the nurse observes that the client's pupils are both round, 3 mm
in size, and respond briskly to light. Which notation should the
nurse use when documenting the assessment?
A. PERRL.
B. GCS of 15.
C. PERLA.
D. Neuro status intact correct answer: A. PERRL
7. Which assessment technique provides the nurse with the best data
related to the client's level of peripheral perfusion? correct answer:
Capillary refill test
8. The nurse is assessing a female client who states that her
hemorrhoids are inflamed and hurt constantly. Which intervention
is best for the nurse to complete a focused assessment?
A. Ask the client how long she has experienced discomfort related
to hemor- rhoids.
B. Place the client in a standing position, leaning over the exam bed
for inspec- tion.
C. Determine if the client uses any over-the-counter preparation
for hemor- rhoids.
,Hesi health assessment 2 Exam Questions and
Answers
D. Position the client in the left lateral position to inspect the perianal
area for fissures or sacs. correct answer: D. Position the client in the left lateral position to
inspect the perianal area for fissures or sacs.
