BSN HESI 246 Health Assessment V1 Exam Questions And Answers Verified 100% Correct

BSN HESI 246 Health Assessment V1 Exam Questions And Answers Verified 100% Correct A male executive is seen in the primary care clinic for a physical examination. While obtaining the client's health history, the nurse inquires about his drug and alcohol use. The executive denies drug use, but reports that he has "two glasses of wine" per night. Which response is best for the nurse to provide? - ANSWER "What effect do you think your use of alcohol may have on you?" Which part of the body should the nurse examine when assessing for peripheral edema in a client with heart failure? - ANSWER -Ankles. A client reports feeling increasingly fatigued for several months, and the nurse observes that the client's lips are pale. Which additional data should the nurse collect based on this presentation? - ANSWER -Use of vitamin and iron supplements. What is the best place for the nurse to hear lower lobe lung sounds with a stethoscope? - ANSWER -Posterior chest below the 3rd intercostalspace. A registered nurse (RN) is performing a mini-mental state examination (MMSE) for a client who is being admitted to an assisted living community. Which communication techniques should the RN implement to decrease anxiety in the client? (Select all that apply.) - ANSWER -Use simple sentences during the examination. Reduce environmental detractors during the examination. Ask questions one at a time to decrease confusion. The nurse is interviewing a client who reports having a persistent, productive cough during the winter caused by bronchitis. Which additional finding should the nurse assess for bronchitis? - ANSWER -Phlegm production and wheezing. The nurse is assessing the posterior pharynx during a physical examination. Which technique should the nurse use? - ANSWER -Press the tongue down one side at a time with a tongue depressor. The nurse is assessing a client who has a history of mitral stenosis. How should the nurse assess this client with a stethoscope to listen for this condition? - ANSWER -Place the bell on the 5th intercostal space, left midclavicular line. Which statement is accurate about assessing the spleen? - ANSWER -It must be enlarged at least three times normal size for it to be palpable. During an external examination of the eyes, the nurse gently palpates the eyes while the client's eyelids are closed. The eyes are both very firm and resist movement back into the orbit. How should the nurse document this finding? - ANSWER -Abnormal finding. Which tool should the nurse use when assessing the neurological status of a client with traumatic brain injury? - ANSWER -Glasgow Coma Scale. The nurse is assessing a client with liver disease who is jaundice and exhibits scleral edema. During the health assessment, the nurse should implement which technique to determine evidence of hepatomegaly? - ANSWER -Use a bouncing motion to tap the middle finger placed within boundaries of the liver. What is the best nursing response to an older client who has not mentioned incontinence during a genitourinary assessment? - ANSWER -Ask the client specifically about any leakage of urine. The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response? - ANSWER -The client is treating the nurse with respect. The nurse is assessing a client for a hip flexion contracture. Which finding indicates a negative Thomas test when the client's right knee is brought toward the chest? - ANSWER -The left leg remains on the table *The Thomas test is performed by having the client bring one knee toward the chest while the other leg remains extended on the table. A positive Thomas test is elicited when the extended leg rises off the table when the opposite leg's knee is brought up to the client's chest, indicating hip flexor contracture. If the extended leg (the left leg, in this example) remains on the table, the test is negative. The nurse is assessing a client who has a history of aortic regurgitation. Where should the nurse place the stethoscope diaphragm to listen for this condition? - ANSWER -2nd intercostal space along the right sternal border. The nurse is assessing a client who has experienced a sudden onset of hearing loss in the right ear. Which finding should alert the nurse to a potentially serious medical condition that requires further evaluation? - ANSWER -There is no sign of associated infection. Which information should the nurse obtain to identify the client's self-perception of health status? - ANSWER -Health history During the initial assessment, the nurse notes that a client has blurred vision with cloudy lenses. Which condition should the nurse document? - ANSWER Cataracts. Which condition is indicated by a fluorescent, yellow-green color when the nurse uses a Wood's lamp toexamine a client's skin lesions? - ANSWER -Fungal infection. A client with dark skin is reporting a painful and itching area on the lower left leg. What should the nurse look for when assessing this client's skin for inflammation? - ANSWER -Change in consistency. A client reports pain when taking a deep breath. Which lung auscultation sound should the nurse anticipate hearing? - ANSWER -Pleural friction rub A nurse is completing a nutritional assessment with a client. What is the easiest method for the nurse to use to get information about the client's nutritional intake? - ANSWER -24-hour dietary recall The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply.) - ANSWER -Diminished hair on legs. Skin cool to touch. The nurse is completing a physical assessment of a client who feel from a tree. The client's abdomen is soft with hyperactive bowel sounds in all four quadrants. Which assessment technique should the nurse implement when evaluating the