HESI Health Assessment
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1. The nurse is conducting an interview with a client who speaks limited English.
Which action should the nurse implement?
Seek the assistance of a healthcare team member who speaks the client's
preferred language.
Continue with the client's assessment interview using simple English words.
Have the client reschedule for a time when a family member can be there to
interpret.
Ask the client to call a friend who speaks English and is able to interpret.: Seek
the assistance of a healthcare team member who speaks the client's preferred language.
Rationale:
A healthcare team member who speaks the client's preferred language or a medical interpreter must be provided
whenever English is not the preferred language of the client.
2. While conducting an interview to obtain a health history, the nurse notices
that the client pauses frequently and looks at the nurse expectantly. Which
response is best for the nurse to provide?
Reassure the client that there are no wrong answers.
Tell the client to return later for another interview.
Continue to ask questions until the client responds.
Sit quietly to allow the client to respond comfortably.: Sit quietly to allow the client to respond
comfortably.
Rationale
, HESI Health Assessment
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A silent attentiveness or intelligent repose communicates that the nurse has time and is willing to listen to the client's
responses.
3. A client has been diagnosed with bilateral lower lobe atelectasis. Which
percussion sound should the nurse expect to hear when percussing over the
client's lower lobes?
Dull, thud-like.
Hyperresonant, booming.
Tympanic, drum like.
Flat, extremely dull.: Dull, thud-like.
Rationale
An atelectatic or consolidated lung will produce a dullness or thud-like sound when percussed during an assessment.
4. A client reports a recent onset of nausea and vomiting. What subjective
information is important for the nurse to ascertain?
Ask how much weight the client gained on vacation.
Ask whether the client has been in a foreign country recently.
Observe the symmetry of the abdomen.
Count the bowel sounds in each abdominal quadrant.: Ask whether the client has been in
a foreign country recently.
Rationale
GI upset and diarrhea occur when exposed to new local pathogens in developing countries. The water supply may be
contaminated.
, HESI Health Assessment
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5. A client is being assessed upon admission to the medical-surgical unit. The
nurse is preparing to complete a head-to-toe assessment and will begin at
the head of the client. Which technique should the nurse use to begin the
assessment?
Inspect the hair and skin.
Palpate the temperature of the skin.
Percuss for tenderness.
Auscultate the temporal arteries.: Inspect the hair and skin.
Rationale
The usual order for a physical assessment is inspection, palpation, percussion, and auscultation. When beginning a
physical assessment, the nurse should perform an inspection, which is a general survey of the individual as a whole
and of each body system.
6. While performing a head-to-toe assessment, the nurse assesses the client's
pupillary accommodation. During the second portion of the test, the nurse
notes that the client's pupils constrict and there is a convergence of the axes
of the eyes. What action should the nurse implement next?
Document a normal finding.
Request a referral to an opthamologist.
Repeat the test after having the client rest for 5 minutes.
Ask the client, "Have you noticed that you cannot see things close up?": Document
a normal finding.
Rationale
Study online at https://quizlet.com/_dfyj7t
1. The nurse is conducting an interview with a client who speaks limited English.
Which action should the nurse implement?
Seek the assistance of a healthcare team member who speaks the client's
preferred language.
Continue with the client's assessment interview using simple English words.
Have the client reschedule for a time when a family member can be there to
interpret.
Ask the client to call a friend who speaks English and is able to interpret.: Seek
the assistance of a healthcare team member who speaks the client's preferred language.
Rationale:
A healthcare team member who speaks the client's preferred language or a medical interpreter must be provided
whenever English is not the preferred language of the client.
2. While conducting an interview to obtain a health history, the nurse notices
that the client pauses frequently and looks at the nurse expectantly. Which
response is best for the nurse to provide?
Reassure the client that there are no wrong answers.
Tell the client to return later for another interview.
Continue to ask questions until the client responds.
Sit quietly to allow the client to respond comfortably.: Sit quietly to allow the client to respond
comfortably.
Rationale
, HESI Health Assessment
Study online at https://quizlet.com/_dfyj7t
A silent attentiveness or intelligent repose communicates that the nurse has time and is willing to listen to the client's
responses.
3. A client has been diagnosed with bilateral lower lobe atelectasis. Which
percussion sound should the nurse expect to hear when percussing over the
client's lower lobes?
Dull, thud-like.
Hyperresonant, booming.
Tympanic, drum like.
Flat, extremely dull.: Dull, thud-like.
Rationale
An atelectatic or consolidated lung will produce a dullness or thud-like sound when percussed during an assessment.
4. A client reports a recent onset of nausea and vomiting. What subjective
information is important for the nurse to ascertain?
Ask how much weight the client gained on vacation.
Ask whether the client has been in a foreign country recently.
Observe the symmetry of the abdomen.
Count the bowel sounds in each abdominal quadrant.: Ask whether the client has been in
a foreign country recently.
Rationale
GI upset and diarrhea occur when exposed to new local pathogens in developing countries. The water supply may be
contaminated.
, HESI Health Assessment
Study online at https://quizlet.com/_dfyj7t
5. A client is being assessed upon admission to the medical-surgical unit. The
nurse is preparing to complete a head-to-toe assessment and will begin at
the head of the client. Which technique should the nurse use to begin the
assessment?
Inspect the hair and skin.
Palpate the temperature of the skin.
Percuss for tenderness.
Auscultate the temporal arteries.: Inspect the hair and skin.
Rationale
The usual order for a physical assessment is inspection, palpation, percussion, and auscultation. When beginning a
physical assessment, the nurse should perform an inspection, which is a general survey of the individual as a whole
and of each body system.
6. While performing a head-to-toe assessment, the nurse assesses the client's
pupillary accommodation. During the second portion of the test, the nurse
notes that the client's pupils constrict and there is a convergence of the axes
of the eyes. What action should the nurse implement next?
Document a normal finding.
Request a referral to an opthamologist.
Repeat the test after having the client rest for 5 minutes.
Ask the client, "Have you noticed that you cannot see things close up?": Document
a normal finding.
Rationale
