HESI Health Assessment Exam 2

HESI Health Assessment Exam 2 Objective. Ans- 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? A round smooth mass that slides between the fingers Ans- 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? Upper outer quadrant. Ans- 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? Gland is not palpable Ans- The nurse is completing a physical exam on an adult client. Which thyroid finding is considered normal? 4th intercostal space, right midclavicular line. Correct Ans- 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? Document a normal finding. Ans- 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? A consensual response in the opposite eye. Ans- 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? Inspect the scalp looking for nits Ans- 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? Have you had sudden and severe pain in the toes or feet? Ans- 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? Measure bilateral ankle circumference with a non-stretchable tape measure. Ans- How should the nurse assess for lower extremity edema in a client who has been diagnosed with heart failure? Seek the assistance of a healthcare team member who speaks the client's preferred language. Ans- The nurse is conducting an interview with a client who speaks limited English. What action should the nurse implement? Ask whether the client has been in a foreign country recently. Ans- A client reports a recent onset of nausea and vomiting. What subjective information is important for the nurse to ascertain? Document at least 3 generations of the client's family medical history. Correct Ans- 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? Verbal descriptor scale. Ans- 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? Dull sound percussed over bladder. Ans- A client reports lower abdominal pain and a feeling of pressure in the bladder. Which assessment finding indicates acute urinary retention? Nocturia. Ans- Which term should the nurse use to document the condition of a client who reports waking up frequently during the night to urinate? Measure the apical pulse and compare it to the peripheral pulse. Ans- Which procedure should the nurse use to assess for a pulse deficit? Ask the client to urinate before beginning the examination. Ans- A client is in the clinical for a yearly physical examination. Which action should the nurse take when preparing to examine the client's abdomen? Friction rub. Ans- Which term should the nurse use to document in the client's medical record for a highpitched scratchy sound during auscultation of the heart? Use abdominal muscles to sit up. Ans- The nurse is assessing for the presence of a hernia. Which action should the nurse ask the client to perform while lying supine? Note the character and frequency of bowel sounds. Ans- The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel sounds in the right upper quadrant. What action should the nurse take next? Inspect the hair and skin. Ans- A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing to complete a head-to-toe assessment and will begin at the head of the client. Which technique should the nurse use to begin the assessment? Height reduction of 1.5 inches. Ans- The nurse performs a physical assessment on an older female client. Which change from the prior exam may be an indication of osteoporosis? Lentigines. Ans- The nurse examines the skin of an older adult client. Which skin variation is considered a normal finding for a client in this age group? Inability to slowly lower the arm when abducted. Ans- The nurse is assessing a client who reports having shoulder pain. Which sign is the best indicator of a rotator cuff tear? Pharynx. Ans- The nurse uses a tongue depressor to assess a client's mouth. Which structure should the nurse be able to visualize? Stridor. Ans- When assessing a client with dyspnea, the nurse hears an audible inspiratory crowing sound. Which lung sound should the nurse document? Bradypnea. Ans- Which respiratory condition should the nurse document after measuring a respiratory rate of 8 breaths/minute? VIII Ans- The nurse performs the Weber and Rinne tests to assess which cranial nerve? Have you noticed any unusual bleeding?" Ans- During a skin assessment, the nurse notes, round and discrete lesions that are dark red in color and will not blanch. The lesions range from 1 to 3 mm in size. What is the first question the nurse should ask the client? Document the normal finding. Ans- The nurse is requesting the client to perform a Romberg Test to assess neurological status. During the test, the nurse notes that the client sways slightly. What is the nurses next action? A waist circumference is greater than 35 inches in women puts you at higher risk for type 2 diabetes and heart disease." Ans- The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a chest measurement of 42 inches, waist measurement of 45 inches, and hip measurement of 50 inches. What important message should the nurse explain to the client to promote health promotion? Observe the direction of movement. Ans- The nurse observes peristaltic movement in the left lower quadrant of a client's abdomen. Which further assessment of the area should the nurse perform? Calculate the client's pack year history. Ans- During a health history interview, a male client reports that he smokes cigarettes and does not plan to quit. Which action is most important for the nurse to take? Dull, thud-like. Ans- A client has been diagnosed with bilateral lower lobe atelectasis. What percussion sound should the nurse expect to hear when percussing over the client's lower lobes? Listen to the sound while observing the client's respirations. Ans- During cardiac auscultation, the nurse hears a split in the second heart sound when listening at the second left intercostal space of a male client. To assess this sound more fully, what action should the nurse implement? Request a male nurse or healthcare provider to perform the exam. Ans- A Muslim male client refuses to let the female registered nurse (RN) listen to his breath sounds during the examination. How should the RN respond? Skin cool to touch. Diminished hair on legs. Ans- The registered nurse (RN) 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.) Attention to details. Ans- The registered nurse (RN) uses the mini-mental