BSN 246 HESI HEALTH ASSESSMENT V1 EXAM 180 PLUS QUESTIONS
AND VERIFIED ANSWERS (NIGHTINGALE COLLEGE)
What is the best nursing response to an older client who has not mentioned
incontinence during a genitourinary assessment?
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?
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?
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?
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?
There is no sign of associated infection.
Which information should the nurse obtain to identify the client's self-
perception of health status?
Health history
During the initial assessment, the nurse notes that a client has blurred vision
with cloudy lenses. Which condition should the nurse document?
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?
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?
Change in consistency.
,A client reports pain when taking a deep breath. Which lung auscultation
sound should the nurse anticipate hearing?
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?
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.)
Diminished hair on legs.
Skin cool to touch.
The nurse is performing a thoracic assessment on a client with chronic
asthma and hyperinflation of the lungs. Which finding should be expected for
this client?
Barrel chest
The nurse is assessing bowel sounds for a hospitalized client. The nurse has
heard bowel sounds in the right upper quadrant. What action should the
nurse take next?
Note the character and frequency of bowel sounds
, During inspection of a client's mouth and pharynx, the nurse places a tongue
blade on the back of the tongue which causes the client to gag. After
removing the tongue blade, what action should the nurse take?
Document an intact gag reflex.
When teaching a client how to perform a monthly breast self-assessment, the
nurse should tell the client that it is most important to assess which part of
the breast more closely for changes?
Upper outer quadrant.
The nurse is assessing a postmenopausal client who has a BMI of 32. The
client has a chest measurement of 42 inches, waist measurement of 45
inches, and hip measurement of 50 inches. What important message should
the nurse explain to the client to promote health promotion?
A waist circumference is greater than 35 inches in women puts you at higher
risk for type 2 diabetes and heart disease."
The nurse performs a physical assessment on an older female client. Which
change from the prior exam may be an indication of osteoporosis?
Height reduction of 1.5 inches.
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?
Sit quietly to allow the client to respond comfortably.
AND VERIFIED ANSWERS (NIGHTINGALE COLLEGE)
What is the best nursing response to an older client who has not mentioned
incontinence during a genitourinary assessment?
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?
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?
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?
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?
There is no sign of associated infection.
Which information should the nurse obtain to identify the client's self-
perception of health status?
Health history
During the initial assessment, the nurse notes that a client has blurred vision
with cloudy lenses. Which condition should the nurse document?
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?
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?
Change in consistency.
,A client reports pain when taking a deep breath. Which lung auscultation
sound should the nurse anticipate hearing?
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?
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.)
Diminished hair on legs.
Skin cool to touch.
The nurse is performing a thoracic assessment on a client with chronic
asthma and hyperinflation of the lungs. Which finding should be expected for
this client?
Barrel chest
The nurse is assessing bowel sounds for a hospitalized client. The nurse has
heard bowel sounds in the right upper quadrant. What action should the
nurse take next?
Note the character and frequency of bowel sounds
, During inspection of a client's mouth and pharynx, the nurse places a tongue
blade on the back of the tongue which causes the client to gag. After
removing the tongue blade, what action should the nurse take?
Document an intact gag reflex.
When teaching a client how to perform a monthly breast self-assessment, the
nurse should tell the client that it is most important to assess which part of
the breast more closely for changes?
Upper outer quadrant.
The nurse is assessing a postmenopausal client who has a BMI of 32. The
client has a chest measurement of 42 inches, waist measurement of 45
inches, and hip measurement of 50 inches. What important message should
the nurse explain to the client to promote health promotion?
A waist circumference is greater than 35 inches in women puts you at higher
risk for type 2 diabetes and heart disease."
The nurse performs a physical assessment on an older female client. Which
change from the prior exam may be an indication of osteoporosis?
Height reduction of 1.5 inches.
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?
Sit quietly to allow the client to respond comfortably.
