HESI Health Assessment Exam

HESI Health Assessment Exam "My life is really out of balance." Ans- 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? Be open to people who are different Have a curiosity about people. Become culturally competent. Ans- 2. 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.) It must be enlarged at least three times normal size for it to be palpable. Ans- Which statement is accurate about assessing the spleen? Posterior chest below the 3rd intercostalspace. Ans- What is the best place for the nurse to hear lower lobe lung sounds with a stethoscope? Place the bell on the 5th intercostal space, left midclavicular line. Ans- 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? 2nd intercostal space along the right sternal border. Ans- 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? The client works in a daycare setting that has had a scabies outbreak. Ans- 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? Level of consciousness. Ans- 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? Use of vitamin and iron supplements. Ans- A client 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? There is no sign of associated infection. Ans- The nurse is assessing a client who has experienced a sudden onset of hearing loss in the right ear. Which finding should alert the nurse to a potentially serious medical condition that requires further evaluation? Swelling anterior to the ear lobe on one side of the face. Ans- The client reports to the nurse a recent exposure to the mumps. Which assessment finding suggests the client has contracted the mumps? Swelling of the left arm and non-pitting edema. Ans- A client states that she had a mastectomy of her left breast last year and now experiences lymphedema. What should the nurse expect to find when examining the client? Ask the client specifically about any leakage of urine. Ans- What is the best nursing response to an older client who has not mentioned incontinence during a genitourinary assessment? Have you experienced sudden weight loss? Ans- A client is in the clinic for a routine health examination. The nurse notices the client appears underweight. Which question is most important for the nurse to ask when completing the health history of this client? Family history of colon cancer on mother's side. Correct Ans- A client is in the clinic and is reporting lower abdominal pain and constipation. Which information is of greatest concern to the nurse when obtaining the health history from this client? Health history. Ans- Which information should the nurse obtain to identify the client's self-perception of health status? Cataracts Ans- During the initial assessment, the nurse notes that a client has blurred vision with cloudy lenses. Which condition should the nurse document? Fibroadenoma. Ans- While palpating a client's breasts, the nurse detects a nontender, solitary, round lobular mass that is solid and firm and slides easily through the breast tissue . The findings of this breast exam are consistent with which condition? Ankles. Ans- Which part of the body should the nurse examine when assessing for peripheral edema in a client with heart failure? Fungal infection Ans- Which condition is indicated by a fluorescent, yellow-green color when the nurse uses a Wood's lamp toexamine a client's skin lesions? Have you ever felt guilty about your drinking? Ans- The nurse is performing a routine physical examination on an adult client. When gathering a health history, which question is included in the CAGE questionnaire? Lying Ans- A client has just returned from the recovery room and asks to get out of bed to go to the bathroom. The nurse decides to obtain orthostatic vital signs first. How will the nurse position the client to begin this procedure? The left leg remains on the table. Ans- The nurse is assessing a client for a hip flexion contracture. Which finding indicates a negative Thomas test when the client's right knee is brought toward the chest? The skin immediately returns to normal position. Ans- An adult client is in the clinic for a regular physical examination. The nurse is assessing the client's hydration status by pinching then releasing the client's skin. Which finding is indicative of good hydration status? barrel chest Ans- The nurse is performing a thoracic assessment on a client with chronic asthma and hyperinflation of the lungs. Which finding should be expected for this client? Occlude one nostril and have the client identify various odors. Ans- The nurse performs a series of cranial nerve tests on a client with a head injury. Which test should the nurse use to assess damage to the first cranial nerve? Glasgow Coma Scale Ans- Which tool should the nurse use when assessing the neurological status of a client with traumatic brain injury? Change in consistency Ans- A client with dark skin is reporting a painful and itching area on the lower left leg. What should the nurse look for when assessing this client's skin for inflammation? 12 Ans- While assessing level of consciousness, the nurse finds that a client localizes to pain, is confused during conversation, and opens the eyes to sound. How should the nurse document the Glasgow score of this client? What is your date of birth? Ans- Which question should the nurse ask in order to test a client's remote memory? Pleural friction rub. Ans- A client reports pain when taking a deep breath. Which lung auscultation sound should the nurse anticipate hearing? Knee joint evaluation Ans- The nurse is examining the hip joint of a client who reports hip pain. Which other assessment is most helpful in determining the cause of the client's pain? You have benign fibroid tumors, a common occurrence in women your age. Ans- A postmenopausal female client is undergoing a routine physical examination. She has reported nothing out of the ordinary. When performing the examination of the genitourinary system, the nurse finds an irregularly enlarged uterus with firm, mobile, painless nodules in the uterine wall. How should the nurse explain this finding to the client? Press the tongue down one side at a time with a tongue depressor. Ans- The nurse is assessing the posterior pharynx during a physical examination. Which technique should the nurse use? 24-hour dietary recall Ans- A nurse is completing a nutritional assessment with a client. What is the easiest method for the nurse to use to get information about the client's nutritional intake? audiometry Ans- The nurse is preparing to assess the hearing of a client with a history of prolonged exposure to occupational noise. Which hearing test provides the most reliable assessment of hearing status? Diminished hair on legs Skin cool to touch Ans- The nurse palpates a weak pedal pulse in the client's right foot. Wh