HESI HEALTH ASSESSMENT ASSIGNMENT EXAM
The client reports a recent exposure to the mumps. Which assessment finding
suggests the client has contracted the mumps?
A) Enlargement centered along the anterior lower neck region.
B) Swelling anterior to the ear lobe on one side of the face.
C) Generalized rounded shape of the face.
D) Paralysis on one side of the face.
B) Swelling anterior to the ear lobe on one side of the face.
The parotid salivary gland is not normally palpable, but the mumps infection may cause
swelling and tenderness of these glands. The swelling of the parotid glands can be
either unilateral or bilateral in appearance. When a client reports recent exposure to
mumps, the nurse should check for parotid tenderness by palpating in a line from the
outer corner of the eye to the lobule of the ear.
The nurse is assessing the posterior pharynx during a physical examination.
Which technique should the nurse use?
A) Press the tongue down one side at a time with a tongue depressor.
B) Ask the client to open the mouth and say "ah."
C) Listen for hoarseness after asking the client to speak.
D) Palpate the neck and ask the client to swallow.
A) Press the tongue down one side at a time with a tongue depressor.
When assessing the posterior pharynx, a tongue depressor should be used to press
down one side of the tongue at a time to avoid stimulating the gag reflex.
What is the best place for the nurse to hear lower lobe lung sounds with a
stethoscope?
A) Posterior chest below the 3rd intercostal space.
B) Posterior-axillary line at the 4th intercostal space.
C) Anterior chest at the level of the 4th intercostal space.
D) Anterior-axillary line at the 5th intercostal space.
A) Posterior chest below the 3rd intercostal space.
The posterior chest below the level of the 3rd intercostal space is occupied entirely by
the lower lobes. This makes the posterior chest the best place for the nurse to hear
lower lobe lung sounds with a stethoscope.
Which tool should the nurse use when assessing the neurological status of a
client with traumatic brain injury?
A) Glasgow Coma Scale.
B) Braden scale.
, C) Numerical pain scale.
D) Cranial nerve examination.
A) Glasgow Coma Scale.
(Note: higher score = response better neurologically)
The Glasgow Coma Scale is the best method for assessing the neurological status and
level of consciousness following a traumatic brain injury. The Glasgow Coma Scale
assesses eye opening, motor responses, and verbal responses and has a scale of 3 to
15 (15 is awake, alert, and oriented).
The nurse is interviewing a female client who states she has a persistent
productive cough during the winter caused by bronchitis. Which additional
finding should the nurse assess for?
A) Phlegm production and wheezing.
B) Smoking history.
C) Hemoptysis.
D) Night sweats.
A) Phlegm production and wheezing.
A chronic seasonal cough related to bronchitis is likely accompanied with phlegm
production and wheezing. Although smoking can contribute to a chronic cough, the
typical seasonal cough is an inflammatory reaction to seasonal changes.
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?
A) You have benign fibroid tumors, a common occurrence in women your age.
B) This is a sign of uterine cancer and I will report this to the healthcare provider.
C) This is a sign of endometriosis, so we will need to biopsy the lesions.
D) This is a very common finding in pregnancy and it will go away.
A) You have benign fibroid tumors, a common occurrence in women your age.
With myomas (uterine fibroids), subjective findings are varied depending on the size
and location of the lesions. Often there are no symptoms. Symptoms that may occur
include vague discomfort, bloating, heaviness, pelvic pressure, dyspareunia, urinary
frequency, backache, or excessive uterine bleeding and anemia if myoma disturbs
endometrium. Objective findings include: the uterus is irregularly enlarged, firm, mobile,
and nodular with hard, painless nodules in the uterine wall. These benign tumors are
common after the age of 50.
Which findings can the nurse determine by palpating a client's skin? (Select all
that apply.)
A) Pruritus. (itching)
B) Diaphoresis. (sweating)
The client reports a recent exposure to the mumps. Which assessment finding
suggests the client has contracted the mumps?
A) Enlargement centered along the anterior lower neck region.
B) Swelling anterior to the ear lobe on one side of the face.
C) Generalized rounded shape of the face.
D) Paralysis on one side of the face.
B) Swelling anterior to the ear lobe on one side of the face.
The parotid salivary gland is not normally palpable, but the mumps infection may cause
swelling and tenderness of these glands. The swelling of the parotid glands can be
either unilateral or bilateral in appearance. When a client reports recent exposure to
mumps, the nurse should check for parotid tenderness by palpating in a line from the
outer corner of the eye to the lobule of the ear.
The nurse is assessing the posterior pharynx during a physical examination.
Which technique should the nurse use?
A) Press the tongue down one side at a time with a tongue depressor.
B) Ask the client to open the mouth and say "ah."
C) Listen for hoarseness after asking the client to speak.
D) Palpate the neck and ask the client to swallow.
A) Press the tongue down one side at a time with a tongue depressor.
When assessing the posterior pharynx, a tongue depressor should be used to press
down one side of the tongue at a time to avoid stimulating the gag reflex.
What is the best place for the nurse to hear lower lobe lung sounds with a
stethoscope?
A) Posterior chest below the 3rd intercostal space.
B) Posterior-axillary line at the 4th intercostal space.
C) Anterior chest at the level of the 4th intercostal space.
D) Anterior-axillary line at the 5th intercostal space.
A) Posterior chest below the 3rd intercostal space.
The posterior chest below the level of the 3rd intercostal space is occupied entirely by
the lower lobes. This makes the posterior chest the best place for the nurse to hear
lower lobe lung sounds with a stethoscope.
Which tool should the nurse use when assessing the neurological status of a
client with traumatic brain injury?
A) Glasgow Coma Scale.
B) Braden scale.
, C) Numerical pain scale.
D) Cranial nerve examination.
A) Glasgow Coma Scale.
(Note: higher score = response better neurologically)
The Glasgow Coma Scale is the best method for assessing the neurological status and
level of consciousness following a traumatic brain injury. The Glasgow Coma Scale
assesses eye opening, motor responses, and verbal responses and has a scale of 3 to
15 (15 is awake, alert, and oriented).
The nurse is interviewing a female client who states she has a persistent
productive cough during the winter caused by bronchitis. Which additional
finding should the nurse assess for?
A) Phlegm production and wheezing.
B) Smoking history.
C) Hemoptysis.
D) Night sweats.
A) Phlegm production and wheezing.
A chronic seasonal cough related to bronchitis is likely accompanied with phlegm
production and wheezing. Although smoking can contribute to a chronic cough, the
typical seasonal cough is an inflammatory reaction to seasonal changes.
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?
A) You have benign fibroid tumors, a common occurrence in women your age.
B) This is a sign of uterine cancer and I will report this to the healthcare provider.
C) This is a sign of endometriosis, so we will need to biopsy the lesions.
D) This is a very common finding in pregnancy and it will go away.
A) You have benign fibroid tumors, a common occurrence in women your age.
With myomas (uterine fibroids), subjective findings are varied depending on the size
and location of the lesions. Often there are no symptoms. Symptoms that may occur
include vague discomfort, bloating, heaviness, pelvic pressure, dyspareunia, urinary
frequency, backache, or excessive uterine bleeding and anemia if myoma disturbs
endometrium. Objective findings include: the uterus is irregularly enlarged, firm, mobile,
and nodular with hard, painless nodules in the uterine wall. These benign tumors are
common after the age of 50.
Which findings can the nurse determine by palpating a client's skin? (Select all
that apply.)
A) Pruritus. (itching)
B) Diaphoresis. (sweating)
