HESI V2 health assessment
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?
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 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 sluggish response consistent with a lower motor neuron
lesion.
C. Flaccid paralysis.
D. Hyperactive response consistent with an upper motor neuron
disorder.
Correct 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 answer is D. McBurney's point is related to appendicitis and not
spleen.
In auscultating for the presence of a carotid artery bruit, the nurse
places the bell of the stethoscope at which location?
,*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 the 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 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 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 client, 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 questions.
C. Ask specifically about alcohol, marijuana, cocaine, her
D. Use the term illegal or illicit to describe street drug.
Correct answer is C. When interviewing the patient, questions should be
clear and specific.
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?
, 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 answer is D. As this could be a sign of appendicitis.
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. Measure 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 moved
Correct answer is C. Location and appearance of the ulcer would give us the
type (venous vs arterial)
The nurse is conducting a physical assessment of a young adult.
Which information provides the best indication of the individual's
nutritional status?
A. Status of current appetite.
B. A 24-hour diet history.
C. History of a recent weight loss.
D. Condition of hair, nails, and skin.
Correct answer is D. Hair, nail, and skin are the most important reflection of
nutritional status.
The nurse is assessing a healthy adult male during an annual
physical examination. The nurse auscultates the client's abdomen
and hears gurgling sound every ten seconds. What action should the
nurse take in response to this finding?
A. Document this normal bowel sound activity in the record.
B. Encourage increased consumption of fiber in the diet.
C. Observe the next bowel movement for signs of bleeding.
D. Report the hyperactivity to the healthcare provider.
Correct answer is A. Normal Bowel sound consist of clicks and gurgles and 5-
30 per minute. An occasional borborygmus (Loud prolonged gurgle) may be
hear.
In observing a client's face, which assessment finding requires the
most immediate intervention by the nurse?
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?
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 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 sluggish response consistent with a lower motor neuron
lesion.
C. Flaccid paralysis.
D. Hyperactive response consistent with an upper motor neuron
disorder.
Correct 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 answer is D. McBurney's point is related to appendicitis and not
spleen.
In auscultating for the presence of a carotid artery bruit, the nurse
places the bell of the stethoscope at which location?
,*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 the 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 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 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 client, 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 questions.
C. Ask specifically about alcohol, marijuana, cocaine, her
D. Use the term illegal or illicit to describe street drug.
Correct answer is C. When interviewing the patient, questions should be
clear and specific.
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?
, 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 answer is D. As this could be a sign of appendicitis.
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. Measure 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 moved
Correct answer is C. Location and appearance of the ulcer would give us the
type (venous vs arterial)
The nurse is conducting a physical assessment of a young adult.
Which information provides the best indication of the individual's
nutritional status?
A. Status of current appetite.
B. A 24-hour diet history.
C. History of a recent weight loss.
D. Condition of hair, nails, and skin.
Correct answer is D. Hair, nail, and skin are the most important reflection of
nutritional status.
The nurse is assessing a healthy adult male during an annual
physical examination. The nurse auscultates the client's abdomen
and hears gurgling sound every ten seconds. What action should the
nurse take in response to this finding?
A. Document this normal bowel sound activity in the record.
B. Encourage increased consumption of fiber in the diet.
C. Observe the next bowel movement for signs of bleeding.
D. Report the hyperactivity to the healthcare provider.
Correct answer is A. Normal Bowel sound consist of clicks and gurgles and 5-
30 per minute. An occasional borborygmus (Loud prolonged gurgle) may be
hear.
In observing a client's face, which assessment finding requires the
most immediate intervention by the nurse?
