BSN 246 HESI Health Assessment Exam V2 | FREQUENTLY
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HESI 266 Nightingale BSN 266 Hesi updated HESI V2 health assessment BS
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Terms in this set (93)
In observing a client's face, which assessment finding A. Oral mucosa is cyanotic.
requires the most immediate intervention by the nurse?
A. Oral mucosa is cyanotic.
B. Nasolabial folds present bilaterally
C. Smooth and even skin tone
D. Absence of facial drooping
While obtaining a health history, a male client tells the B. Ask the client to describe the episodes of dyspnea in more detail.
nurse that he sometimes experiences shortness of
breath. The nurse determines that the client's respirators
are regular and deep, and his respiratory rate is 14
breaths/minutes. What is the best nursing action?
A. Administer oxygen immediately.
B. Ask the client to describe the episodes of dyspnea in
more detail.
C. Notify the healthcare provider about the client's
condition.
D. Place the client in a prone position to ease
breathing.
When assessing a male client's respiratory status, which D. Observation.
technique should the nurse use to assess his anterior-
posterior (AP) chest diameter?
A. Intervention.
B. Assessment.
C. Documentation.
D. Observation.
,Which assessment finding supports the client's B. 2+ pitting edema of ankles bilaterally.
statement, "My feet swell all the time?"
A. No edema present.
B. 2+ pitting edema of ankles bilaterally.
C. Non-pitting edema of the lower extremities.
D. Redness and warmth in the ankles.
The nurse is performing a cranial nerve exam on an 87- D. Continue the assessment to the next pairs of cranial nerves.
year-
old client. The nurse notes that the client has a reduced
upward gaze, a decreased corneal reflex, a high-
frequency hearing loss, and a reduced gag reflex. What
action should the nurse take next?
A. Repeat the cranial nerve test to confirm the findings.
B. Document the findings and notify the healthcare
provider.
C. Ask the client if they are experiencing any unusual
symptoms.
D. Continue the assessment to the next pairs of cranial
nerves.
When performing a neurologic assessment on an alert A. PERRL
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. Dilated pupils
C. Unequal pupil size
D. Sluggish pupillary reaction?
Which assessment technique provides the nurse with .
the best data related to the client's level of peripheral
perfusion?
The nurse is assessing a female client who states that A. Position the client in the left lateral position to inspect the perianal area for
her hemorrhoids are inflamed and hurt constantly. fissures or sacs.
Which intervention is best for the nurse to complete a
focused assessment?
A. Position the client in the left lateral position to
inspect the perianal area for fissures or sacs.
B. Palpate the perianal area with both hands to assess
skin elasticity.
C. Ask the client to stand and bend forward to assess
the sacrum.
D. Apply deep palpation to the lower abdomen to
detect tenderness.
, The nurse is performing an initial assessment of a client A. "Have you been sleeping well?"
who has an expressionless facial affect, slurred speech,
and red conjunctivae. What question should the nurse
ask first?
A. "Have you been sleeping well?"
B. "What did you eat for breakfast today?"
C. "Do you experience any changes in your vision?"
D. "How often do you exercise during the week?"
After checking a client's pupillary response to light, the A. Assess the client's visual fields.
practical nurse (PN) tells the nurse that the client's
pupils are constricted with minimal response to light.
Before verifying the PN's findings, which action should
the nurse take?
A. Assess the client's visual fields
B. Check the client's blood pressure
C. Ask the client about recent headaches
D. Observe the client's facial symmetry
The nurse completes inspection of the abdomen on an A. Homogeneous color.
adult client. Which finding is considered normal for this
client?
A. Homogeneous color.
B. Redness with patches.
C. Uneven pigmentation.
D. Presence of lesions.
Which skill should the nurse have an older client B. Sorting a collection of socks.
demonstrate to evaluate performance of daily living
activities?
A. Reading a book aloud.
B. Sorting a collection of socks.
C. Writing a letter to a friend.
D. Watching a movie.
A client sustained a subconjunctival hemorrhage. The B. Diminished ability to focus on close work and excessive illumination required.
presence of which set of symptoms indicate that the
client needs to be seen for further evaluation by an
ophthalmologist?
A. Difficulty seeing objects at a distance.
B. Diminished ability to focus on close work and
excessive illumination required.
C. Increased sensitivity to bright lights.
D. Frequent headaches when reading or using a
computer.
TESTED QUESTIONS WITH CORRECT ANSWERS | BRAND
NEW!
Leave the first rating
Save
Students also studied
Flashcard sets Study guides
HESI 266 Nightingale BSN 266 Hesi updated HESI V2 health assessment BS
54 terms 55 terms 59 terms 77
Ajramos17 Preview quizlette5114663 Preview Classy_Princess Preview
Terms in this set (93)
In observing a client's face, which assessment finding A. Oral mucosa is cyanotic.
requires the most immediate intervention by the nurse?
A. Oral mucosa is cyanotic.
B. Nasolabial folds present bilaterally
C. Smooth and even skin tone
D. Absence of facial drooping
While obtaining a health history, a male client tells the B. Ask the client to describe the episodes of dyspnea in more detail.
nurse that he sometimes experiences shortness of
breath. The nurse determines that the client's respirators
are regular and deep, and his respiratory rate is 14
breaths/minutes. What is the best nursing action?
A. Administer oxygen immediately.
B. Ask the client to describe the episodes of dyspnea in
more detail.
C. Notify the healthcare provider about the client's
condition.
D. Place the client in a prone position to ease
breathing.
When assessing a male client's respiratory status, which D. Observation.
technique should the nurse use to assess his anterior-
posterior (AP) chest diameter?
A. Intervention.
B. Assessment.
C. Documentation.
D. Observation.
,Which assessment finding supports the client's B. 2+ pitting edema of ankles bilaterally.
statement, "My feet swell all the time?"
A. No edema present.
B. 2+ pitting edema of ankles bilaterally.
C. Non-pitting edema of the lower extremities.
D. Redness and warmth in the ankles.
The nurse is performing a cranial nerve exam on an 87- D. Continue the assessment to the next pairs of cranial nerves.
year-
old client. The nurse notes that the client has a reduced
upward gaze, a decreased corneal reflex, a high-
frequency hearing loss, and a reduced gag reflex. What
action should the nurse take next?
A. Repeat the cranial nerve test to confirm the findings.
B. Document the findings and notify the healthcare
provider.
C. Ask the client if they are experiencing any unusual
symptoms.
D. Continue the assessment to the next pairs of cranial
nerves.
When performing a neurologic assessment on an alert A. PERRL
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. Dilated pupils
C. Unequal pupil size
D. Sluggish pupillary reaction?
Which assessment technique provides the nurse with .
the best data related to the client's level of peripheral
perfusion?
The nurse is assessing a female client who states that A. Position the client in the left lateral position to inspect the perianal area for
her hemorrhoids are inflamed and hurt constantly. fissures or sacs.
Which intervention is best for the nurse to complete a
focused assessment?
A. Position the client in the left lateral position to
inspect the perianal area for fissures or sacs.
B. Palpate the perianal area with both hands to assess
skin elasticity.
C. Ask the client to stand and bend forward to assess
the sacrum.
D. Apply deep palpation to the lower abdomen to
detect tenderness.
, The nurse is performing an initial assessment of a client A. "Have you been sleeping well?"
who has an expressionless facial affect, slurred speech,
and red conjunctivae. What question should the nurse
ask first?
A. "Have you been sleeping well?"
B. "What did you eat for breakfast today?"
C. "Do you experience any changes in your vision?"
D. "How often do you exercise during the week?"
After checking a client's pupillary response to light, the A. Assess the client's visual fields.
practical nurse (PN) tells the nurse that the client's
pupils are constricted with minimal response to light.
Before verifying the PN's findings, which action should
the nurse take?
A. Assess the client's visual fields
B. Check the client's blood pressure
C. Ask the client about recent headaches
D. Observe the client's facial symmetry
The nurse completes inspection of the abdomen on an A. Homogeneous color.
adult client. Which finding is considered normal for this
client?
A. Homogeneous color.
B. Redness with patches.
C. Uneven pigmentation.
D. Presence of lesions.
Which skill should the nurse have an older client B. Sorting a collection of socks.
demonstrate to evaluate performance of daily living
activities?
A. Reading a book aloud.
B. Sorting a collection of socks.
C. Writing a letter to a friend.
D. Watching a movie.
A client sustained a subconjunctival hemorrhage. The B. Diminished ability to focus on close work and excessive illumination required.
presence of which set of symptoms indicate that the
client needs to be seen for further evaluation by an
ophthalmologist?
A. Difficulty seeing objects at a distance.
B. Diminished ability to focus on close work and
excessive illumination required.
C. Increased sensitivity to bright lights.
D. Frequent headaches when reading or using a
computer.
