HESI Health Assessment Nightingale
College Fall 2022
A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I have lung
cancer or something," and wants to get checked out since, "I can't seem to get rid of this body-wracking
dry cough that has been hanging around for the last six weeks." Which computer documentation of this
client's concerns should the nurse enter? - ANS Describe having a "body-wracking dry cough" of 6 weeks
duration.
A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right
hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response.
Which interpretation of this finding is accurate? - ANS Hyperactive response consistent with an upper
motor neuron disorder.
The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating
the spleen? - ANS Firm mass palpated at bottom of left rib cage.
In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the stethoscope at
which location? - ANS Place bell of stethoscope over carotid artery
A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for
pneumonia without hospitalization. Which technique should the nurse implement to assess for
adventitious lung sounds? - ANS Press the stethoscope's diaphragm firmly on the skin over each lung
field.
A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a muffled voice.
Which complication should the nurse suspect? - ANS Peritonsillar abscess.
The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While
interviewing the client, which assessment technique should the nurse use when asking about the client's
use of illegal drugs and alcohol? - ANS Ask specifically about alcohol, marijuana, cocaine, heroin, and
amounts.
, The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client
denies pain upon palpation, but reports pain when the pressure is released. What action should the
nurse implement? - ANS Notify the healthcare provider of the rebound tenderness.
The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or
arterial insufficiency. Which assessment technique should the nurse use to differentiate the
pathophysiology causing the ulcer? - ANS Observe the specific location and appearance of the
ulceration.
A. What type of ulcer is this? Which pathophysiology? venous or arterial? - ANS Venous leg ulcers
usually develop on the inner lower leg, above the medial malleolus.
B. What type of ulcer is this? Which pathophysiology? venous or arterial? - ANS Arterial wounds occur
most often on the foot, in between or at the tips of the toes, at pressure points from foot wear, on the
heels and around the lateral malleolus (the bone on the outside of the ankle joint).
The nurse is conducting a physical assessment of a young adult. Which information provides the
best indication of the individual's nutritional status? - ANS Condition of hair, nails, and skin.
The nurse is assessing a healthy adult male during an annual physical examination. The nurse
auscultates the client's abdomen and hears gurgling sound every ten seconds. What action should the
nurse take in response to this finding? - ANS Document this normal bowel sound activity in the record.
In observing a client's face, which assessment finding requires the most immediate intervention by the
nurse? - ANS Oral mucosa is cyanotic.
While obtaining a health history, a male client tells the nurse that he sometimes experiences shortness
of breath. The nurse determines that the client's respirators are regular and deep, and his respiratory
rate is 14 breaths/minutes. What is the best nursing action? - ANS Ask the client to describe the
episodes of dyspnea in more detail.
College Fall 2022
A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I have lung
cancer or something," and wants to get checked out since, "I can't seem to get rid of this body-wracking
dry cough that has been hanging around for the last six weeks." Which computer documentation of this
client's concerns should the nurse enter? - ANS Describe having a "body-wracking dry cough" of 6 weeks
duration.
A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right
hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response.
Which interpretation of this finding is accurate? - ANS Hyperactive response consistent with an upper
motor neuron disorder.
The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating
the spleen? - ANS Firm mass palpated at bottom of left rib cage.
In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the stethoscope at
which location? - ANS Place bell of stethoscope over carotid artery
A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for
pneumonia without hospitalization. Which technique should the nurse implement to assess for
adventitious lung sounds? - ANS Press the stethoscope's diaphragm firmly on the skin over each lung
field.
A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a muffled voice.
Which complication should the nurse suspect? - ANS Peritonsillar abscess.
The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While
interviewing the client, which assessment technique should the nurse use when asking about the client's
use of illegal drugs and alcohol? - ANS Ask specifically about alcohol, marijuana, cocaine, heroin, and
amounts.
, The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client
denies pain upon palpation, but reports pain when the pressure is released. What action should the
nurse implement? - ANS Notify the healthcare provider of the rebound tenderness.
The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or
arterial insufficiency. Which assessment technique should the nurse use to differentiate the
pathophysiology causing the ulcer? - ANS Observe the specific location and appearance of the
ulceration.
A. What type of ulcer is this? Which pathophysiology? venous or arterial? - ANS Venous leg ulcers
usually develop on the inner lower leg, above the medial malleolus.
B. What type of ulcer is this? Which pathophysiology? venous or arterial? - ANS Arterial wounds occur
most often on the foot, in between or at the tips of the toes, at pressure points from foot wear, on the
heels and around the lateral malleolus (the bone on the outside of the ankle joint).
The nurse is conducting a physical assessment of a young adult. Which information provides the
best indication of the individual's nutritional status? - ANS Condition of hair, nails, and skin.
The nurse is assessing a healthy adult male during an annual physical examination. The nurse
auscultates the client's abdomen and hears gurgling sound every ten seconds. What action should the
nurse take in response to this finding? - ANS Document this normal bowel sound activity in the record.
In observing a client's face, which assessment finding requires the most immediate intervention by the
nurse? - ANS Oral mucosa is cyanotic.
While obtaining a health history, a male client tells the nurse that he sometimes experiences shortness
of breath. The nurse determines that the client's respirators are regular and deep, and his respiratory
rate is 14 breaths/minutes. What is the best nursing action? - ANS Ask the client to describe the
episodes of dyspnea in more detail.
