HESI RN EVOLVE Health Assessment Assignment Exam
During the interview portio of the health assessment, a nurse notes the person's posture, physical
appearance, and ability to converse. How should the nurse document these findings?
Objective.
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
When teaching a client how to perform a monthly breast self-assessment, the nurse should tell the
client that it is most important to assess which part of the breast more closely for changes?
Upper outer quadrant.
The nurse is completing a physical exam on an adult client. Which thyroid finding is considered normal?
Gland is not palpable
The nurse is assessing a client's middle lung lobe. What is the best location for the nurse to place a
stethoscope diaphragm to hear normal lung sounds in this lobe?
4th intercostal space, right midclavicular line. Correct
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 is performing a head-to-toe assessment on a client. The nurse is assessing the client's
pupillary light reflex by first darkening the room and asking the person to gaze into the distance. Then,
the nurse advances a light toward one eye from the client's side. What would the nurse expect to see at
this time?
A consensual response in the opposite eye.
, A client presents with a rash along the occipital area of the hairline and reports intense itching. How
should the nurse begin the objective part of the examination?
Inspect the scalp looking for nits
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?
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.
The nurse is conducting an interview with a client who speaks limited English. What action should the
nurse implement?
Seek the assistance of a healthcare team member who speaks the client's preferred language.
A client reports a recent onset of nausea and vomiting. What subjective information is important for the
nurse to ascertain?
Ask whether the client has been in a foreign country recently.
The nurse is conducting a family history as part of the assessment interview. Which action should the
nurse take to ensure that sufficient information about the client's blood relatives is obtained?
Document at least 3 generations of the client's family medical history. Correct
An older client has just returned to the room following a surgical procedure. Which pain scale should the
nurse use when assessing the client's pain level?
Verbal descriptor scale.
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.
During the interview portio of the health assessment, a nurse notes the person's posture, physical
appearance, and ability to converse. How should the nurse document these findings?
Objective.
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
When teaching a client how to perform a monthly breast self-assessment, the nurse should tell the
client that it is most important to assess which part of the breast more closely for changes?
Upper outer quadrant.
The nurse is completing a physical exam on an adult client. Which thyroid finding is considered normal?
Gland is not palpable
The nurse is assessing a client's middle lung lobe. What is the best location for the nurse to place a
stethoscope diaphragm to hear normal lung sounds in this lobe?
4th intercostal space, right midclavicular line. Correct
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 is performing a head-to-toe assessment on a client. The nurse is assessing the client's
pupillary light reflex by first darkening the room and asking the person to gaze into the distance. Then,
the nurse advances a light toward one eye from the client's side. What would the nurse expect to see at
this time?
A consensual response in the opposite eye.
, A client presents with a rash along the occipital area of the hairline and reports intense itching. How
should the nurse begin the objective part of the examination?
Inspect the scalp looking for nits
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?
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.
The nurse is conducting an interview with a client who speaks limited English. What action should the
nurse implement?
Seek the assistance of a healthcare team member who speaks the client's preferred language.
A client reports a recent onset of nausea and vomiting. What subjective information is important for the
nurse to ascertain?
Ask whether the client has been in a foreign country recently.
The nurse is conducting a family history as part of the assessment interview. Which action should the
nurse take to ensure that sufficient information about the client's blood relatives is obtained?
Document at least 3 generations of the client's family medical history. Correct
An older client has just returned to the room following a surgical procedure. Which pain scale should the
nurse use when assessing the client's pain level?
Verbal descriptor scale.
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.
