HESI RN EVOLVE Health Assessment Practice
Exam
-A client is reporting chest pain. What statement made by the client, helps the nurse to
understand this client has a naturalistic belief in the cause of illness?
a. "My life is really out of balance."
b. "I knew I should have changed my diet."
c. "I should have gone to church last week." Incorrect
d. "I forgot to take my medicines last night."
(answer)ANS; A
The cause of disease may be viewed from three ways: biomedical, naturalistic,
magicoreligious. People who conform to the naturalistic perspecive of disease
causation, believe that the forces of nature must be kept in a natural balance or
harmony.)
-A nurse is working in a healthcare facility that serves a diverse population. What
action(s) by the nurse will allow the nurse to empathize with and understand this
population? (Select all that apply.)
a. Be open to people who are different.
b. Have a curiosity about people.
c. Become culturally competent.
d. Interact with each person in the same way.
e. Request nurses take care of patients with the same ethnicity.
f. Always request an interpreter for people from other countries.
(answer)ANS: A,B,C
As a health professional, the nurse is expected to listen to, empathize with, and
understand people. To fulfill this role, nurses must first be open to people who are
different from them, have a curiosity about people, and begin a journey to being
culturally competent.)
-Which statement is accurate about assessing the spleen?
A. It must be enlarged at least three times normal size for it to be palpable.
,b. It is easily felt by reaching the left hand behind the 11th and 12thribs.
c. It is normally felt by rolling the client on the right side and palpating.
d. It is a firm mass palpated slightly left of midline in the upper abdomen.
(answer)ANS: A
Normally the spleen is not palpable at all and must be enlarged by three times its
normal size to be felt. To search for it, the nurse must reach the left hand over the
abdomen and behind the left side at the 11th and 12th ribs and lift up for support. The
nurse should place the right hand obliquely on the left upper quadrant (with the fingers
pointing toward the left axilla) and push the hand deeply down and under the left costal
margin while asking the client to take a deep breath. Under normal circumstances, the
nurse should feel nothing firm.)
-What is the best place for the nurse to hear lower lobe lung sounds with a
stethoscope?
a. Posterior chest below the 3rd intercostalspace.
b. Posterior-axillary line at the 4th intercostal space.
c. Anterior chest at the level of the 4th intercostal space.
d. Anterior-axillary line at the 5th intercostal space.
(answer)ANS: B
The posterior chest below the level of the 3rd intercostal spaces is occupied entirely by
the lower lobes. This makes the posterior chest the best place for the nurse to hear
lower lobe lung sounds with a stethoscope.)
-The nurse is assessing a client who has a history of mitral stenosis. How should the
nurse assess this client with a stethoscope to listen for this condition?
a. Place the bell on the 5th intercostal space, left midclavicular line.
b. Place the bell on the 2nd intercostal space, left midclavicular line.
c. Put the diaphragm on the 5th intercostal space, left sternal border.
d. Put the diaphragm on the 2nd intercostal space, left sternal border.
(answer)ANS: A
The best way to listen for low-pitch mitral heart sounds, such as a mitral stenosis
murmur, is to place the bell of stethoscope onto the 5th intercostal space at the left
midclavicular line.)
-The nurse is assessing a client who has a history of aortic regurgitation. Where should
the nurse place the stethoscope diaphragm to listen for this condition?
a. 2nd intercostal space along the right sternal border. Correct
b. 2nd intercostal space along the left sternal border.
c. 3rd intercostal space on the right midclavicular line.
d. 5th intercostal space on the left midclavicular line.
, (answer)ANS: A
The best way to listen for high-pitch aortic heart sounds, such as an aortic regurgitation
murmur, is to place the stethoscope diaphragm onto the 2nd intercostal space along the
right sternal border.)
-The client is experiencing severe pruritus and small papules and burrows on areas
over one hand and the inner thighs. Which assessment data best explains the condition
the client is experiencing?
a. The client works in a daycare setting that has had a scabies outbreak.
b. The client has been using a chemical stripping agent for home remodeling.
c. The client has a family history of psoriasis in both parents and a sibling.
d. The client routinely works with clay and paint as a hobby.
(answer)ANS: A
Scabies is a highly contagious condition that causes pruritus, small papules, vesicles
and burrows in the skin as the scabies mite burrows into the superficial layer of the skin
to lay her eggs. Scabies is often spread among children and others in close contact.)
-A client comes to the clinic with a report of fever and a recent exposure to someone
who was diagnosed with meningitis. Which nursing assessment should be completed
during the initial examination of this client?
a. Level of consciousness.
b. Gait characteristics.
c. Presence of trauma.
d. Bladder control ability.
(answer)ANS: A
Initial symptoms of meningitis include headache, fatigue, stiff neck, and changes in level
of consciousness. It is necessary to determine if the client is demonstrating signs of
meningitis before planning immediate care.)
-Aclient reports feeling increasingly fatigued for several months, and the nurse observes
that the client's lips are pale. Which additional data should the nurse collect based on
this presentation?
A. Current alcohol and tobacco use.
B. A 24-hour dietary recall.
C. Use of vitamin and iron supplements. Correct
D. Daily pattern of oral hygiene practices.
(answer)ANS: C
Increasing fatigue and pale lips could indicate anemia. The nurse should determine if
the client is taking vitamin or iron supplements to manage anemia.)
Exam
-A client is reporting chest pain. What statement made by the client, helps the nurse to
understand this client has a naturalistic belief in the cause of illness?
a. "My life is really out of balance."
b. "I knew I should have changed my diet."
c. "I should have gone to church last week." Incorrect
d. "I forgot to take my medicines last night."
(answer)ANS; A
The cause of disease may be viewed from three ways: biomedical, naturalistic,
magicoreligious. People who conform to the naturalistic perspecive of disease
causation, believe that the forces of nature must be kept in a natural balance or
harmony.)
-A nurse is working in a healthcare facility that serves a diverse population. What
action(s) by the nurse will allow the nurse to empathize with and understand this
population? (Select all that apply.)
a. Be open to people who are different.
b. Have a curiosity about people.
c. Become culturally competent.
d. Interact with each person in the same way.
e. Request nurses take care of patients with the same ethnicity.
f. Always request an interpreter for people from other countries.
(answer)ANS: A,B,C
As a health professional, the nurse is expected to listen to, empathize with, and
understand people. To fulfill this role, nurses must first be open to people who are
different from them, have a curiosity about people, and begin a journey to being
culturally competent.)
-Which statement is accurate about assessing the spleen?
A. It must be enlarged at least three times normal size for it to be palpable.
,b. It is easily felt by reaching the left hand behind the 11th and 12thribs.
c. It is normally felt by rolling the client on the right side and palpating.
d. It is a firm mass palpated slightly left of midline in the upper abdomen.
(answer)ANS: A
Normally the spleen is not palpable at all and must be enlarged by three times its
normal size to be felt. To search for it, the nurse must reach the left hand over the
abdomen and behind the left side at the 11th and 12th ribs and lift up for support. The
nurse should place the right hand obliquely on the left upper quadrant (with the fingers
pointing toward the left axilla) and push the hand deeply down and under the left costal
margin while asking the client to take a deep breath. Under normal circumstances, the
nurse should feel nothing firm.)
-What is the best place for the nurse to hear lower lobe lung sounds with a
stethoscope?
a. Posterior chest below the 3rd intercostalspace.
b. Posterior-axillary line at the 4th intercostal space.
c. Anterior chest at the level of the 4th intercostal space.
d. Anterior-axillary line at the 5th intercostal space.
(answer)ANS: B
The posterior chest below the level of the 3rd intercostal spaces is occupied entirely by
the lower lobes. This makes the posterior chest the best place for the nurse to hear
lower lobe lung sounds with a stethoscope.)
-The nurse is assessing a client who has a history of mitral stenosis. How should the
nurse assess this client with a stethoscope to listen for this condition?
a. Place the bell on the 5th intercostal space, left midclavicular line.
b. Place the bell on the 2nd intercostal space, left midclavicular line.
c. Put the diaphragm on the 5th intercostal space, left sternal border.
d. Put the diaphragm on the 2nd intercostal space, left sternal border.
(answer)ANS: A
The best way to listen for low-pitch mitral heart sounds, such as a mitral stenosis
murmur, is to place the bell of stethoscope onto the 5th intercostal space at the left
midclavicular line.)
-The nurse is assessing a client who has a history of aortic regurgitation. Where should
the nurse place the stethoscope diaphragm to listen for this condition?
a. 2nd intercostal space along the right sternal border. Correct
b. 2nd intercostal space along the left sternal border.
c. 3rd intercostal space on the right midclavicular line.
d. 5th intercostal space on the left midclavicular line.
, (answer)ANS: A
The best way to listen for high-pitch aortic heart sounds, such as an aortic regurgitation
murmur, is to place the stethoscope diaphragm onto the 2nd intercostal space along the
right sternal border.)
-The client is experiencing severe pruritus and small papules and burrows on areas
over one hand and the inner thighs. Which assessment data best explains the condition
the client is experiencing?
a. The client works in a daycare setting that has had a scabies outbreak.
b. The client has been using a chemical stripping agent for home remodeling.
c. The client has a family history of psoriasis in both parents and a sibling.
d. The client routinely works with clay and paint as a hobby.
(answer)ANS: A
Scabies is a highly contagious condition that causes pruritus, small papules, vesicles
and burrows in the skin as the scabies mite burrows into the superficial layer of the skin
to lay her eggs. Scabies is often spread among children and others in close contact.)
-A client comes to the clinic with a report of fever and a recent exposure to someone
who was diagnosed with meningitis. Which nursing assessment should be completed
during the initial examination of this client?
a. Level of consciousness.
b. Gait characteristics.
c. Presence of trauma.
d. Bladder control ability.
(answer)ANS: A
Initial symptoms of meningitis include headache, fatigue, stiff neck, and changes in level
of consciousness. It is necessary to determine if the client is demonstrating signs of
meningitis before planning immediate care.)
-Aclient reports feeling increasingly fatigued for several months, and the nurse observes
that the client's lips are pale. Which additional data should the nurse collect based on
this presentation?
A. Current alcohol and tobacco use.
B. A 24-hour dietary recall.
C. Use of vitamin and iron supplements. Correct
D. Daily pattern of oral hygiene practices.
(answer)ANS: C
Increasing fatigue and pale lips could indicate anemia. The nurse should determine if
the client is taking vitamin or iron supplements to manage anemia.)
