Health Assessment Practice HESI #2
BSN 246 Exam Questions & Answers
(Grade A+)
The registered nurse (RN) is developing the plan of care for a client
who is admitted for alcohol detoxification. Which goal should be
most important for the RN to primarily focus the client's care?
The client maintains optimal nutritional status.
The client will remain alert and oriented.
The client will remain free from injury.
The client will remain alcohol free during hospitalization. -
correct answer ✅The client will remain free from injury.
Rationale
The client is at highest risk for injury due to altered cognitive and
sensory disturbances as well as delirium tremors during
withdrawal. Remaining free from injury is the most important goal
for the acute phase of alcohol withdrawal.
A client with progressive hearing loss appears distressed when the
registered nurse (RN) asks open-ended questions about the client's
health history. Which forms of communication should the RN use?
Select all that apply
,Health Assessment Practice HESI #2
BSN 246 Exam Questions & Answers
(Grade A+)
Face the client so the client can see the RN's mouth.
Increase one's speech volume when interacting with the client.
Repeat information to the client if misunderstood.
Check if the client's hearing aides are working properly.
Reduce environmental noise surrounding the client. -
correct answer ✅Face the client so the client can see the RN's
mouth.
Check if the client's hearing aides are working properly.
Reduce environmental noise surrounding the client.
The nurse palpates a weak pedal pulse in the client's right foot.
Which assessment findings should the RN document that are
consistent with diminished peripheral circulation?
(Select all that apply.)
Diminished hair on legs
Bruising on extremities
Skin cool to touch
Capillary refill less than 3 seconds
, Health Assessment Practice HESI #2
BSN 246 Exam Questions & Answers
(Grade A+)
Darkened skin on extremities -
correct answer ✅Diminished hair on legs
Skin cool to touch
No on the Darkened skin on extremities - indicates hemosiderin
staining caused by the destruction of red blood cells and the
release of the pigment heme within hemoglobin. Occurs with
peripheral vascular disease.
Rationale
Diminished hair on the legs and skin that is cool to touch are
symptoms of decreased arterial blood flow. The other options are
not indicators for impaired peripheral circulation.
A female client calls the clinic and talks with the registered nurse
(RN) to inquire about a possible reaction after taking amoxicillin for
5 days. She reports having vaginal discomfort, itching, and a white
discharge. The RN should discuss which action with the client?
Discontinue the antibiotic because original symptoms have
subsided.
BSN 246 Exam Questions & Answers
(Grade A+)
The registered nurse (RN) is developing the plan of care for a client
who is admitted for alcohol detoxification. Which goal should be
most important for the RN to primarily focus the client's care?
The client maintains optimal nutritional status.
The client will remain alert and oriented.
The client will remain free from injury.
The client will remain alcohol free during hospitalization. -
correct answer ✅The client will remain free from injury.
Rationale
The client is at highest risk for injury due to altered cognitive and
sensory disturbances as well as delirium tremors during
withdrawal. Remaining free from injury is the most important goal
for the acute phase of alcohol withdrawal.
A client with progressive hearing loss appears distressed when the
registered nurse (RN) asks open-ended questions about the client's
health history. Which forms of communication should the RN use?
Select all that apply
,Health Assessment Practice HESI #2
BSN 246 Exam Questions & Answers
(Grade A+)
Face the client so the client can see the RN's mouth.
Increase one's speech volume when interacting with the client.
Repeat information to the client if misunderstood.
Check if the client's hearing aides are working properly.
Reduce environmental noise surrounding the client. -
correct answer ✅Face the client so the client can see the RN's
mouth.
Check if the client's hearing aides are working properly.
Reduce environmental noise surrounding the client.
The nurse palpates a weak pedal pulse in the client's right foot.
Which assessment findings should the RN document that are
consistent with diminished peripheral circulation?
(Select all that apply.)
Diminished hair on legs
Bruising on extremities
Skin cool to touch
Capillary refill less than 3 seconds
, Health Assessment Practice HESI #2
BSN 246 Exam Questions & Answers
(Grade A+)
Darkened skin on extremities -
correct answer ✅Diminished hair on legs
Skin cool to touch
No on the Darkened skin on extremities - indicates hemosiderin
staining caused by the destruction of red blood cells and the
release of the pigment heme within hemoglobin. Occurs with
peripheral vascular disease.
Rationale
Diminished hair on the legs and skin that is cool to touch are
symptoms of decreased arterial blood flow. The other options are
not indicators for impaired peripheral circulation.
A female client calls the clinic and talks with the registered nurse
(RN) to inquire about a possible reaction after taking amoxicillin for
5 days. She reports having vaginal discomfort, itching, and a white
discharge. The RN should discuss which action with the client?
Discontinue the antibiotic because original symptoms have
subsided.
