BSN246 HESI HEALTH
ASSESSMENT V1 WITH ALL
CORRECT ANSWERS FOR A
GUARANTEED PASS
While performing a mental status exam (MSE), the nurse asks a client to
remember three unrelated words and repeat them later. The client was able
to repeat the words as directed. Which computer documentation is accurate?
"Short-term memory is intact."
Which technique should the nurse implement when performing a Weber test?
Place a vibrating tuning fork midline on top of the head
Which technique should the nurse use to assess a client for scoliosis?
Observe spine while the client is erect and bent forward
Which term should the nurse use to document in the client's medical record
for a high-pitched scratchy sound during auscultation of the heart?
Friction rub
While 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?
Document a normal finding.
The nurse performs the Weber and Rinne tests to assess which cranial
nerve?
VIII - vestibulocochlear
The nurse uses a tongue depressor to assess a client's mouth. Which
structure should the nurse be able to visualize?
Pharynx
As 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?
A round smooth mass that slides between the fingers.
A client reports lower abdominal pain and a feeling of pressure in the
bladder. Which assessment finding indicates acute urinary retention?
Dull sound percussed over bladder.
*Clients with acute urinary retention may present with lower abdominal pain
and bladder distension. Percussion (tapping on the body wall) is performed to
detect differences in pitch. A dull sound produced when percussing a
distended urinary bladder is an indication of urinary retention.
, The nurse examines the skin of an older adult client. Which skin variation is
considered a normal finding for a client in this age group?
Lentigines.
*Lentigines or commonly referred to as liver spots are irregularly shaped
dark spots on the skin caused by aging and extensive sun exposure. This
skin variation is a normal finding in an older adult client.
During a client's routine well-woman physical exam, the nurse examines the
breasts. Which assessment technique should the nurse implement to
evaluate for any abnormal lumps?
With both arms at client's side, lift one arm and palpate the axilla.
The nurse is completing a physical exam on an adult client. Which thyroid
finding is considered normal?
Gland is not palpable.
How should the nurse assess for lower extremity edema in a client who has
been diagnosed with heart failure?
Measure bilateral ankle circumference with a non-stretchable tape measure.
A 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?
Have you had sudden and severe pain in the toes or feet?
ASSESSMENT V1 WITH ALL
CORRECT ANSWERS FOR A
GUARANTEED PASS
While performing a mental status exam (MSE), the nurse asks a client to
remember three unrelated words and repeat them later. The client was able
to repeat the words as directed. Which computer documentation is accurate?
"Short-term memory is intact."
Which technique should the nurse implement when performing a Weber test?
Place a vibrating tuning fork midline on top of the head
Which technique should the nurse use to assess a client for scoliosis?
Observe spine while the client is erect and bent forward
Which term should the nurse use to document in the client's medical record
for a high-pitched scratchy sound during auscultation of the heart?
Friction rub
While 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?
Document a normal finding.
The nurse performs the Weber and Rinne tests to assess which cranial
nerve?
VIII - vestibulocochlear
The nurse uses a tongue depressor to assess a client's mouth. Which
structure should the nurse be able to visualize?
Pharynx
As 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?
A round smooth mass that slides between the fingers.
A client reports lower abdominal pain and a feeling of pressure in the
bladder. Which assessment finding indicates acute urinary retention?
Dull sound percussed over bladder.
*Clients with acute urinary retention may present with lower abdominal pain
and bladder distension. Percussion (tapping on the body wall) is performed to
detect differences in pitch. A dull sound produced when percussing a
distended urinary bladder is an indication of urinary retention.
, The nurse examines the skin of an older adult client. Which skin variation is
considered a normal finding for a client in this age group?
Lentigines.
*Lentigines or commonly referred to as liver spots are irregularly shaped
dark spots on the skin caused by aging and extensive sun exposure. This
skin variation is a normal finding in an older adult client.
During a client's routine well-woman physical exam, the nurse examines the
breasts. Which assessment technique should the nurse implement to
evaluate for any abnormal lumps?
With both arms at client's side, lift one arm and palpate the axilla.
The nurse is completing a physical exam on an adult client. Which thyroid
finding is considered normal?
Gland is not palpable.
How should the nurse assess for lower extremity edema in a client who has
been diagnosed with heart failure?
Measure bilateral ankle circumference with a non-stretchable tape measure.
A 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?
Have you had sudden and severe pain in the toes or feet?
