HESI HEALTH ASSESSMENT EXAM
During her annual OB/GYN exam, a 24-year-old woman asks the nurse when she
should perform her breast exams. The nurse's best response is:
Correct: "One week after your period starts, or when your breasts are least engorged."
b/c
In menstruating women, self breast exams are best performed 4-7 days after the start of
a woman's cycle, when the breasts are least engorged and painful.
While assessing for common signs and symptoms of benign prostatic
hypertrophy (BPH), the nurse should ask:
"Do you need to strain to start or maintain stream?"
b/c
Hesitancy, weak stream, and dribbling are common symptoms of BPH. The other
questions are not useful to determine BPH.
incorrect: "Are you urinating more than twice a day?", Is your urine bloody or cloudy?",
"Do you have to stand further from the toilet?"
A 19-year-old female post-miscarriage presents with "vaginal bleeding." What is a
priority health history question at this time?
How many pads are you soaking per hour?"
b/c
During the History of Present Illness, quantity or severity should be assessed and
documented. For example: "Vaginal bleeding soaking two pads per hour." Soaking one
or more pads per hour can indicate hemorrhage.
The nurse is educating an adolescent male about testicular self-examination
(TSE). The nurse includes which point in the teaching?
"If you notice an enlarged testicle or a lump, call your health care provider."
b/c
If the patient notices a firm painless lump, a hard area, or an overall enlarged testicle,
then he should call his health care provider for further evaluation. The testicle normally
feels rubbery with a smooth surface. A good time to examine the testicles is during the
shower or bath, when one's hands are warm and soapy and the scrotum is warm.
Testicular self-examination should be performed once a month.
During a complete physical exam, the RN notices that a female patient has an
inverted left nipple; the right one is everted. What should the nurse do next?
Ask the patient when she first noticed the inversion.
b/c
The nurse should distinguish between a recently retracted nipple from one that has
been inverted for many years or since puberty. Normal nipple inversion may be
unilateral or bilateral and usually can be pulled out; that is, if it is not fixed. Recent
nipple retraction signifies acquired disease.
When examining an adult patient presenting with "scrotal pain", the nurse notices
that a positive glow with transillumination. On the basis of this finding the nurse
would:
Suspect the presence of serous fluid in the scrotum.
b/c
,Normal scrotal contents do not allow light to pass through the scrotum. However, serous
fluid does transilluminate and shows as a red glow. Neither a mass nor a hernia would
transilluminate.
A 30 year-old female who is 4 weeks postpartum calls the OB/GYN clinic to report
that her left breast is red, swollen, and very tender. What should the nurse do
next?
Ask if the woman has had a fever, fatigue, or chills.
b/c
If the woman is also experiencing flu-like symptoms,it is suspicious for mastitis, which
stems from an infection or stasis caused by a plugged duct. A plugged duct does not
have infection present.
A new mother presses her call light to report that her baby "has had his first
poop." The nurse observes a dark green meconium stool. The RN understands
that:
The first stool indicates anal patency.
b/c
The first stool passed by the newborn is dark green meconium and occurs within 24 to
48 hours of birth, indicating anal patency. The other responses are not correct.
While assessing for hemorrhoids in a 28-year-old male, the nurse inspect the
anus while the client:
Performs a Valsalva maneuver.
b/c
While inspecting the perianal area, instruct the person to hold the breath and bear down
by performing a Valsalva maneuver. No break in skin integrity or protrusion through the
anal opening should be present.
To assess for common symptoms of Polycystic Ovary Syndrome (PCOS), the
nurse asks:
"How often do you have a period?"
b/c
Clients with PCOS will have amenorrhea or infrequent menses, infertility, acne,
hirsutism, and weight gain. Asking about family history does not assess for common
symptoms of PCOS.
When assessing muscle strength, the nurse observes that a patient maintain
biceps flexion against resistance. How should the nurse document muscle
strength?
"5/5" -correct
2+
bounding
full tone
b/c
Full strength against resistance is normal muscle strength and is recorded as grade 5/5
muscle strength. The other options are not correct.
An adult male presents to the clinic with flank pain and blood in the urine. During
examination, the nurse notices the presence of hard, painless nodules over the
great toe; one has burst open with a chalky discharge. The nurse suspects:
, Gout.
b/c
Tophi are collections of monosodium urate crystals resulting from chronic gout in and
around the joint that cause extreme swelling and joint deformity. Kidney stones are
common in gout as well. Tophi appear as hard, painless nodules over the
metatarsophalangeal joint of the first toe and they sometimes burst with a chalky
discharge.
The nurse is examining a newborn who was born with assistance of forceps.
Which assessment finding alerts the nurse to the possibility of a fractured
clavicle?
Limited movement on one side during the Moro reflex
b/c
For a fractured clavicle, the nurse should observe for limited arm range of motion and
unilateral response to the Moro reflex.
A patient is reporting pain in most of his joints that is worse in the morning but
gets better after he moves around for a while or takes a warm bath. The nurse
should assess for other signs of what problem?
Rheumatoid arthritis.
b/c
Rheumatoid arthritis pain is worse in the morning when a person arises and then
improves with movement. Movement increases most other types of joint pain.
An elderly woman presents to the clinic. She has no specific complaints but says
she "can't get around as much as she used to." Which technique is best to
assess for motor dysfunction in her hip?
Abduct her hip while she is lying on her back.
b/c
Limited abduction of the hip while supine is the most common motion dysfunction found
in hip disease. The other options are not correct.
other options Externally rotate her hip while she is standing; Internally rotate her hip
while she is sitting; Adduct her hip while she is lying on her stomach.
The nurse is performing a completing neurological examination on an adult. How
should the nurse assess cognitive function?
"Tell me where you are right now."
When assessing cerebellar function on an adult client, the nurse should ask the
client to:
Alternate touching your nose and my finger."
b/c
The finger-nose-finger test is an assessment of cerebellar function. The other options
will help to assess strength, CN function, and sensation
The nurse is caring for a patient who has just had neurosurgery for a brain
aneurysm. What should the nurse include in the hourly neurological rechecks?
Level of consciousness, motor function, pupillary response, and vital signs
b/c
People who have a neurologic deficit from a systemic disease process, head trauma, or
neurosurgery are at increased risk for developing increased intracranial pressure.
These people must be closely monitored for any improvement or deterioration in
During her annual OB/GYN exam, a 24-year-old woman asks the nurse when she
should perform her breast exams. The nurse's best response is:
Correct: "One week after your period starts, or when your breasts are least engorged."
b/c
In menstruating women, self breast exams are best performed 4-7 days after the start of
a woman's cycle, when the breasts are least engorged and painful.
While assessing for common signs and symptoms of benign prostatic
hypertrophy (BPH), the nurse should ask:
"Do you need to strain to start or maintain stream?"
b/c
Hesitancy, weak stream, and dribbling are common symptoms of BPH. The other
questions are not useful to determine BPH.
incorrect: "Are you urinating more than twice a day?", Is your urine bloody or cloudy?",
"Do you have to stand further from the toilet?"
A 19-year-old female post-miscarriage presents with "vaginal bleeding." What is a
priority health history question at this time?
How many pads are you soaking per hour?"
b/c
During the History of Present Illness, quantity or severity should be assessed and
documented. For example: "Vaginal bleeding soaking two pads per hour." Soaking one
or more pads per hour can indicate hemorrhage.
The nurse is educating an adolescent male about testicular self-examination
(TSE). The nurse includes which point in the teaching?
"If you notice an enlarged testicle or a lump, call your health care provider."
b/c
If the patient notices a firm painless lump, a hard area, or an overall enlarged testicle,
then he should call his health care provider for further evaluation. The testicle normally
feels rubbery with a smooth surface. A good time to examine the testicles is during the
shower or bath, when one's hands are warm and soapy and the scrotum is warm.
Testicular self-examination should be performed once a month.
During a complete physical exam, the RN notices that a female patient has an
inverted left nipple; the right one is everted. What should the nurse do next?
Ask the patient when she first noticed the inversion.
b/c
The nurse should distinguish between a recently retracted nipple from one that has
been inverted for many years or since puberty. Normal nipple inversion may be
unilateral or bilateral and usually can be pulled out; that is, if it is not fixed. Recent
nipple retraction signifies acquired disease.
When examining an adult patient presenting with "scrotal pain", the nurse notices
that a positive glow with transillumination. On the basis of this finding the nurse
would:
Suspect the presence of serous fluid in the scrotum.
b/c
,Normal scrotal contents do not allow light to pass through the scrotum. However, serous
fluid does transilluminate and shows as a red glow. Neither a mass nor a hernia would
transilluminate.
A 30 year-old female who is 4 weeks postpartum calls the OB/GYN clinic to report
that her left breast is red, swollen, and very tender. What should the nurse do
next?
Ask if the woman has had a fever, fatigue, or chills.
b/c
If the woman is also experiencing flu-like symptoms,it is suspicious for mastitis, which
stems from an infection or stasis caused by a plugged duct. A plugged duct does not
have infection present.
A new mother presses her call light to report that her baby "has had his first
poop." The nurse observes a dark green meconium stool. The RN understands
that:
The first stool indicates anal patency.
b/c
The first stool passed by the newborn is dark green meconium and occurs within 24 to
48 hours of birth, indicating anal patency. The other responses are not correct.
While assessing for hemorrhoids in a 28-year-old male, the nurse inspect the
anus while the client:
Performs a Valsalva maneuver.
b/c
While inspecting the perianal area, instruct the person to hold the breath and bear down
by performing a Valsalva maneuver. No break in skin integrity or protrusion through the
anal opening should be present.
To assess for common symptoms of Polycystic Ovary Syndrome (PCOS), the
nurse asks:
"How often do you have a period?"
b/c
Clients with PCOS will have amenorrhea or infrequent menses, infertility, acne,
hirsutism, and weight gain. Asking about family history does not assess for common
symptoms of PCOS.
When assessing muscle strength, the nurse observes that a patient maintain
biceps flexion against resistance. How should the nurse document muscle
strength?
"5/5" -correct
2+
bounding
full tone
b/c
Full strength against resistance is normal muscle strength and is recorded as grade 5/5
muscle strength. The other options are not correct.
An adult male presents to the clinic with flank pain and blood in the urine. During
examination, the nurse notices the presence of hard, painless nodules over the
great toe; one has burst open with a chalky discharge. The nurse suspects:
, Gout.
b/c
Tophi are collections of monosodium urate crystals resulting from chronic gout in and
around the joint that cause extreme swelling and joint deformity. Kidney stones are
common in gout as well. Tophi appear as hard, painless nodules over the
metatarsophalangeal joint of the first toe and they sometimes burst with a chalky
discharge.
The nurse is examining a newborn who was born with assistance of forceps.
Which assessment finding alerts the nurse to the possibility of a fractured
clavicle?
Limited movement on one side during the Moro reflex
b/c
For a fractured clavicle, the nurse should observe for limited arm range of motion and
unilateral response to the Moro reflex.
A patient is reporting pain in most of his joints that is worse in the morning but
gets better after he moves around for a while or takes a warm bath. The nurse
should assess for other signs of what problem?
Rheumatoid arthritis.
b/c
Rheumatoid arthritis pain is worse in the morning when a person arises and then
improves with movement. Movement increases most other types of joint pain.
An elderly woman presents to the clinic. She has no specific complaints but says
she "can't get around as much as she used to." Which technique is best to
assess for motor dysfunction in her hip?
Abduct her hip while she is lying on her back.
b/c
Limited abduction of the hip while supine is the most common motion dysfunction found
in hip disease. The other options are not correct.
other options Externally rotate her hip while she is standing; Internally rotate her hip
while she is sitting; Adduct her hip while she is lying on her stomach.
The nurse is performing a completing neurological examination on an adult. How
should the nurse assess cognitive function?
"Tell me where you are right now."
When assessing cerebellar function on an adult client, the nurse should ask the
client to:
Alternate touching your nose and my finger."
b/c
The finger-nose-finger test is an assessment of cerebellar function. The other options
will help to assess strength, CN function, and sensation
The nurse is caring for a patient who has just had neurosurgery for a brain
aneurysm. What should the nurse include in the hourly neurological rechecks?
Level of consciousness, motor function, pupillary response, and vital signs
b/c
People who have a neurologic deficit from a systemic disease process, head trauma, or
neurosurgery are at increased risk for developing increased intracranial pressure.
These people must be closely monitored for any improvement or deterioration in
