HESI HEALTH ASSESSMENT NURSING RN V1 | 100 Questions With Correct Answers | Latest Update 2023/2024.

HESI HEALTH ASSESSMENT NURSING RN V1 | 100 Questions With Correct Answers | Latest Update 2023/2024. The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is comparison. Side-to-side  When auscultating the lungs of an adult patient, the nurse notes that lowpitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets that these sounds are: Vesicular breath sounds and normal in that location.  The nurse is auscultating the chest in an adult. Which technique is correct? Firmly holding the diaphragm of the stethoscope against the chest  The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs will reveal: Dullness.  During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate: Displacement of the heart from elevation of the diaphragm.  In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the: Bell of the stethoscope at the apex with the patient in the lef t lateral position.  A 70-year-old patient with a history of hypertension has a blood pressure of 180/100 mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at the apex immediately before the S1. The sound is heard only with the bell of the stethoscope while the patient is in the left lateral position. With these findings and the patient’s history, the nurse knows that this extra heart sound is most likely a(n): Atrial gallop.  The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction (MI). Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a highpitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse suspects: Inflammation of the precordium.  When the nurse is testing the triceps reflex, what is the expected response Extension of the forearm  The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding? Plantar reflex present  OTC decongestants - - can increase ICP - can Increase HR and BP  The nurse is assessing a patient’s pain. The nurse knows that the most reliable indicator of pain would be the: Subjective report.  A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is “bad this morning” and rates it at an 8 on a 1-to-10 scale. What does the nurse suspect? The patient: Has experienced chronic pain for years and has adapted to it.  The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system? Neuropathic  The nurse he A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? Color variation  sarcoidosis - autoimmune inflammatory disease affecting multiple organs - improved pulse oximetry values  A 19-year-old college student is brought to the emergency department with a severe headache he describes as, “Like nothing I’ve ever had before.” His temperature is 40° C, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem? Meningeal inflammation  During a well-baby checkup, the nurse notices that a 1-week-old infant’s face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notices dilated scalp veins and downcast or “setting sun” eyes. The nurse suspects which condition? Hydrocephalus  ars bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. The nurse should: Consider this finding as normal for a child this age, and proceed with the examination.  When assessing the quality of a patient’s pain, the nurse should ask which question? “What does your pain feel like?”  When assessing a patient’s pain, the nurse knows that an example of visceral pain would be: Cholecystitis.  A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because: The woman could be at increased risk for infection and lesions because of her chronic disease.  The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a person’s: Circulatory status.  A patient comes in for a physical examination and complains of “freezing to death” while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: Peripheral vasoconstriction.  A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find: