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2024 HESI HEALTH ASSESSMENT EXAM NEWEST VERSION -
2025/2026- 100+ QUESTIONS AND VERIFIED ANSWERS 100%
CORRECT GUARANTEED SUCCESS
The nurse is monitoring a client for signs of hypocalcemia after thyroidectomy.
Which sign or symptom, if noted in the client, would most likely indicate the
presence of hypocalcemia?
A. Bradycardia
B. Flaccid paralysis
C. Tingling around the mouth
D. Absence of Chvostek's sign
Correct Answer: C
Rationale:After thyroidectomy the nurse assesses the client for signs of
hypocalcemia and tetany. Early signs inclfingertips, muscle twitching or spasms,
palpitations or aude tingling around the mouth and in the rrhythmias, and
Chvostek's and Trousseau's signs. Bradycardia, flaccid paralysis, and absence of
Chvostek's sign are not signs of hypocalcemia.
The nurse is performing a neurological assessment on a client and elicits a positive
Romberg's sign. The nurse makes this determination based on which observation?
, 2
A. An involuntary rhythmic, rapid twitching of the eyeballs.
B. A dorsiflexion of the ankle and great toe with fanning of the other toes.
C. A significant sway when the client stands erect with feet together, arms at the
side and the eyes closed.
D. A lack of sense of position when the client is unable to return extended fingers
to a point of reference.
Correct Answer: C
Rationale:In Romberg's test, the client is asked to stand with the feet together and
the arms at the sides, and to close the eyes and hold the position; normally the
client can maintain posture and balance. A positive Romberg's sign is a vestibular
neurological sign that is found when a client exhibits a loss of balance when
closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and
loss of vestibular function. A lack of normal sense of position coupled with an
inability to return extended fingers to a point of reference is a finding that
indicates a problem with coordination. A positive gaze nystagmus evaluation
results in an involuntary rhythmic, rapid twitching of the eyeballs. A positive
Babinski's test results in dorsiflexion of the ankle and great toe with fanning of the
other toes; if this occurs in anyone older than 2 years, it indicates the presence of
central nervous system disease.
A client with pneumonia is admitted to the hospital with difficulty breathing.
Which is the best approach for the nurse to use in obtaining the client's health
history?
A.Focus only on the physical assessment.
B.Obtain all history information from the family members.
C.Plan short sessions with the client to obtain data.
D.Use the primary healthcare provider's medical history.
, 3
Correct Answer: C
Rationale:The best source of information is the client. Option 1 is incorrect; the
physical examination is not part of the health history. Option 2 is incorrect
because it refers to all information. Option 4 is incorrect because the primary
health care provider's medical history provides data that are different from the
nurse's assessment. All efforts need to be made to obtain as much information as
possible from the client, using short sessions and closed-ended questions.
The nurse is assessing a client for meningeal irritation and elicits a positive
Brudzinski's sign. Which finding did the nurse observe?
A.The client rigidly extends the arms with pronated forearms and plantar flexion
of the feet.
B.The client flexes a leg at the hip and knee and reports pain in the vertebral
column when the leg is extended.
C.The client passively flexes his hip and knee in response to neck flexion and
reports pain in the vertebral column.
D.The client's upper arms are flexed and held tightly to the sides of the body and
the legs are extended and internally rotated.
Correct Answer:C
Rationale:Brudzinski's sign is tested with the client in the supine position. The
nurse flexes the client's head (gently moves the head to the chest), and there
would be no reports of pain or resistance to the neck flexion. A positive
Brudzinski's sign is observed if the client passively flexes the hip and knee in
response to neck flexion and reports pain in the vertebral column. Kernig's sign
also tests for meningeal irritation and is positive when the client flexes the legs at
the hip and knee and complains of pain along the vertebral column when the leg
, 4
is extended. Decorticate posturing is abnormal flexion and is noted when the
client's upper arms are flexed and held tightly to the sides of the body and the
legs are extended and internally rotated. Decerebrate posturing is abnormal
extension and occurs when the arms are fully extended, forearms pronated, wrists
and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed.
The nurse is testing a client for astereognosis. The nurse would ask the client to
close the eyes and perform which action?
A.Identify three numbers or letters traced in the client's palm.
B.Identify an object in the client's hand.
C.State whether one or two pinpricks are felt when the skin is pricked bilaterally in
the same place.
D.Identify the smallest distance between two detectable pinpricks, made with two
pins held at various lengths.
Correct Answer: B
Rationale:Astereognosis is the inability to discern the form or configuration of
common objects using the sense of touch. Graphesthesia is the inability to
recognize the form of written symbols. The remaining options test for extinction
phenomena and two-point stimulation, respectively.
The nurse performing a neurological examination is assessing eye movement to
evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform
which action to obtain the assessment data?
A. Turn the flashlight on directly in front of the eye and watch for a response.
B. Check pupil size, and then ask the client to alternate looking at the flashlight
and the examiners finger.
2024 HESI HEALTH ASSESSMENT EXAM NEWEST VERSION -
2025/2026- 100+ QUESTIONS AND VERIFIED ANSWERS 100%
CORRECT GUARANTEED SUCCESS
The nurse is monitoring a client for signs of hypocalcemia after thyroidectomy.
Which sign or symptom, if noted in the client, would most likely indicate the
presence of hypocalcemia?
A. Bradycardia
B. Flaccid paralysis
C. Tingling around the mouth
D. Absence of Chvostek's sign
Correct Answer: C
Rationale:After thyroidectomy the nurse assesses the client for signs of
hypocalcemia and tetany. Early signs inclfingertips, muscle twitching or spasms,
palpitations or aude tingling around the mouth and in the rrhythmias, and
Chvostek's and Trousseau's signs. Bradycardia, flaccid paralysis, and absence of
Chvostek's sign are not signs of hypocalcemia.
The nurse is performing a neurological assessment on a client and elicits a positive
Romberg's sign. The nurse makes this determination based on which observation?
, 2
A. An involuntary rhythmic, rapid twitching of the eyeballs.
B. A dorsiflexion of the ankle and great toe with fanning of the other toes.
C. A significant sway when the client stands erect with feet together, arms at the
side and the eyes closed.
D. A lack of sense of position when the client is unable to return extended fingers
to a point of reference.
Correct Answer: C
Rationale:In Romberg's test, the client is asked to stand with the feet together and
the arms at the sides, and to close the eyes and hold the position; normally the
client can maintain posture and balance. A positive Romberg's sign is a vestibular
neurological sign that is found when a client exhibits a loss of balance when
closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and
loss of vestibular function. A lack of normal sense of position coupled with an
inability to return extended fingers to a point of reference is a finding that
indicates a problem with coordination. A positive gaze nystagmus evaluation
results in an involuntary rhythmic, rapid twitching of the eyeballs. A positive
Babinski's test results in dorsiflexion of the ankle and great toe with fanning of the
other toes; if this occurs in anyone older than 2 years, it indicates the presence of
central nervous system disease.
A client with pneumonia is admitted to the hospital with difficulty breathing.
Which is the best approach for the nurse to use in obtaining the client's health
history?
A.Focus only on the physical assessment.
B.Obtain all history information from the family members.
C.Plan short sessions with the client to obtain data.
D.Use the primary healthcare provider's medical history.
, 3
Correct Answer: C
Rationale:The best source of information is the client. Option 1 is incorrect; the
physical examination is not part of the health history. Option 2 is incorrect
because it refers to all information. Option 4 is incorrect because the primary
health care provider's medical history provides data that are different from the
nurse's assessment. All efforts need to be made to obtain as much information as
possible from the client, using short sessions and closed-ended questions.
The nurse is assessing a client for meningeal irritation and elicits a positive
Brudzinski's sign. Which finding did the nurse observe?
A.The client rigidly extends the arms with pronated forearms and plantar flexion
of the feet.
B.The client flexes a leg at the hip and knee and reports pain in the vertebral
column when the leg is extended.
C.The client passively flexes his hip and knee in response to neck flexion and
reports pain in the vertebral column.
D.The client's upper arms are flexed and held tightly to the sides of the body and
the legs are extended and internally rotated.
Correct Answer:C
Rationale:Brudzinski's sign is tested with the client in the supine position. The
nurse flexes the client's head (gently moves the head to the chest), and there
would be no reports of pain or resistance to the neck flexion. A positive
Brudzinski's sign is observed if the client passively flexes the hip and knee in
response to neck flexion and reports pain in the vertebral column. Kernig's sign
also tests for meningeal irritation and is positive when the client flexes the legs at
the hip and knee and complains of pain along the vertebral column when the leg
, 4
is extended. Decorticate posturing is abnormal flexion and is noted when the
client's upper arms are flexed and held tightly to the sides of the body and the
legs are extended and internally rotated. Decerebrate posturing is abnormal
extension and occurs when the arms are fully extended, forearms pronated, wrists
and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed.
The nurse is testing a client for astereognosis. The nurse would ask the client to
close the eyes and perform which action?
A.Identify three numbers or letters traced in the client's palm.
B.Identify an object in the client's hand.
C.State whether one or two pinpricks are felt when the skin is pricked bilaterally in
the same place.
D.Identify the smallest distance between two detectable pinpricks, made with two
pins held at various lengths.
Correct Answer: B
Rationale:Astereognosis is the inability to discern the form or configuration of
common objects using the sense of touch. Graphesthesia is the inability to
recognize the form of written symbols. The remaining options test for extinction
phenomena and two-point stimulation, respectively.
The nurse performing a neurological examination is assessing eye movement to
evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform
which action to obtain the assessment data?
A. Turn the flashlight on directly in front of the eye and watch for a response.
B. Check pupil size, and then ask the client to alternate looking at the flashlight
and the examiners finger.
