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Hesi
Health Assessment
| Question | Answer |
|---|---|
| A client who does not speak English arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take? | Page an interpreter from the hospital’s interpreter services |
| The nurse is performing a neurological assessment on a client and notes a positive Romberg’s test. The nurse makes this determination based on which observation? | A significant sway when the client stands erect with feet together, arms at the sides, and the eyes closed |
| The nurse notes documentation that a client is exhibiting Cheyenne-Stokes respirations. On assessment of the client, the nurse would expect to note which finding? | Rhythmic respirations with periods of apnea |
| A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? | A physical obstruction to the transmission of sound waves |
| While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultation a murmur. The nurse documents the finding and describes the sound as which? | A blowing or swooshing noise |
| The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse would implement which assessment technique to assess for muscle weakness in the eye? | Test the six cardinal positions of gaze |
| The nurse is instructing a client on how to perform a testicular self-examination (TSE). The nurse would explain that which is the best time to perform this exam? | Af tear a shower or bath |
| The nurse is assessing a client suspected of having meningitis for meninges irritation and elicits a positive brudzinski’s sign. Which finding did the nurse observe? | The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. |
| A client with diagnosis of asthma is admitted to the hospital with the respiratory distress. Which type of adventitious lung sounds would the nurse expect to hear when performing a respiratory assessment on this client? | WHEEZES |
| The client prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which would the nurse include for this type of assessment? | - Auscultating lung sounds - Obtaining the clients temperature - Obtaining information about the client’s respirations |
| The nurse is assessing the visual acuity of a client who report should the client stand? (enter whole number) | 20 |
| The client is a 73-year-old male with history of left sided stroke. Right side has increasing weakness and a decrease in range of motion (ROM). Lives in an assisted living facility. Has minimal confusion and is able to answer simple questions. | Joint Type of Range of Motion Abduction Wrist - able to bend wrist back toward forearm Extension Adduction Flexion Abduction Elbow - only able to straighten joint 20 Degree abduction, adduction, extention |
| When assessing a clients lower extremities, which finding requires attention? | Right calf swelling and tenderness |
| While obtaining a health history, a client tells the nurse that he sometimes experiences clients respirations are regular and deep, respiratory breath is 14/ min | Ask the client to describe the episodes of dyspnea in more detail |
| in assessing a client's sensory nerve function, the nurse prepares to assess, what does the nurse include in the assessment? | Instruct the client to close both eyes |
| To assess muscle atrophy in the legs, which action ..... | compare the appearance of the legs bilaterally |
| Nurse is obtaining a health history for a client wishing to obtain a life .... taking several antacids for heartburn that only occur at night. What should the nurse ask the client to identify? | Heartburn occurs when lying down at night |
| A client is concerned about developing carpal tunnel syndrome. What is useful information? | Instruct the client to place backs of the hands together |
| When assessing an adult client, the nurse notes that the client has.... most likely to be accurate? | The client has a collapsed lung |
| Which method should the nurse use to assess response to painful stir (LOC)? | Press firmly on the center of the sternum |
| While the nurse is taking health history, the client announces, response is best for the nurse to provide? | "You sound angry. Would you like to tell me about it?" |
| A 57 year old client presents with joint pain and stiffness in their hands. History of hypertension and type 2 diabetes. | Rheumatoid Arthritis: Pain increases w/ motion - NA Small joints of hands - RA Fatigue and fever - RA Symmetrical Involvement - RA Morning Stiffness quickly - NA Joint Swelling - RA Herberden Nodes - NA |
| The nurse places the warmed stethoscope on a clients abdomen, what is considered normal? | irregular clicks and gurgles |
| Nurse is completing an assessment for a client with uncontrolled diabetes mellitus ination. Which screen test should the nurse perform first? | Urine dipstick |
| The nurse is assessing a client for goiter and is unable to observe the..... | Ask the client to swallow while palpating along the sides of the ..... |
| To confirm the presence of steatorrhea which action should the ...... | Observe the appearance of the clients stool |
| The nurse is examining the abdomen of an older male client who sometimes feels like there is still pressure in that area after urinatir interview of the client? | a weak urinary stream |
| While assessing the client the nurse notes and audible expiratory wheezes should the nurse implement? | Auscultate all lobes of the clients lungs |
| During the assessment of a young adult female clients gyneol ulates the clients body mass as 16kg | Tgins competition and runs 12 miles a day |
| During a routine physical examination of a middle aged female client chest pa diameter area of crepitus over the upper right anterior chest. which is the most..... | Crepitus is always abnormal and should be followed up with a more |
| in assessing a male client's level of consciousness, the nurse which should the nurse do next? | Observe for eye opening to a painful stimulus |
| The client is a 46 year old male who comes to the emergency department having difficulty breathing which has worsened over the last 24 hours. | Pleural Effusion Auscultate lungs for adventitious lung sounds Assess for tactile fremitus Monitor Respiratory rate Monitor crackles |
| A nurse is conducting a physical assessment of a young adult. Which formal nutritional status? | Condition of hair, nails and skin |
| While percussing the abdomen of an adult male client, the nurse encounters a musica indicate? | Gas |
| A male client reports and onset of a burning sensation in his hands and le medical record EMR? | parasthesia reported |
| Which finding should raise greatest concern for a nurse who is performing an ear nose and throat? | An ulceration under the tongue that has been present for the last 3 weeks |
| When inspecting a clients skin, the nurse observes an area of erythema on the arm. Which.... | palpate the area for warmth and swelling |
| During a routine health screening of an adult female, the nurse notes indicate the need for a bone density screening? | Decreased height |
| The nurse assesses a client with a sleep pattern disturbance. in developing a plan of..... | usual bed times and time of awakening |
| in assessing a clients nail beds, the nurse notes that the nurse take? | hold up arms at 90 degrees while arms are pushed downward |
| adult comes in for annual physical - heart sounds loudest? | heart sounds are loudest at apex of heart s1 base s2 |
| During the admission assessment, the nurse observes that a client complete next? | Ask about pain while bearing weight |
| The nurse auscultates the precordium of a client who is when documenting the comparison of systolic murmur | Loud at the apex associated with palpable thrill |
| the nurse is assessing a licent with diabetes mellitus which finding should the nurse document which is consistent.... | loss of peripheral sensation |
| While performing a mental status examination which question | Do you write checks if you know the bank account is..... |
| A client who recently underwent a routine surgical procedure ma best for the nurse to ask this client? | What brought you to the clinic? |
| The nurse is assessing older clients in the community | a change in awareness of surroundings |
| Nurse asks a 50 year old client what her natural hair color is. Client replies not sure, i just know its ravishing red. based on this information the nurse as ng this client's scalp hair? | Course dry brittle |
| the nurse has completed palpation maneuvers for lymph nodes on an for this elderly client | nodes are non-palpable |
| The client is a 76 year old female who arrived at the emergency department via ambulance from an assisted living facility after a fall. The client called for help using her medical alert necklace | pupil size loc glascow rombergs |
| The nurse assesses a male client who is brought to the emergency, which finding is the best indicator that a client is experiencing | a pain in neck and jaw or medial side of the left arm |
| While performing a health history the nurse asks which response from the client? | no, of course not...... |
| The nurse examines a client admitted with a deep constant for the nurse to report to the healthcare worker | an audible abdominal bruit |
| Which assessment technique should the nurse use to confirm the ....... | inspection |
| When assessing a 24 year old body builder the nurse.... | continue with the cardiac exam |
| When assessing a client's skin Which finding should the nurse report | bluish discoloration of the nail beds |
| an older adult client with a history of heart failure is brought to that the client is experiencing an exacerbation of HP .... select all | Dyspnea Peripheral edema jugular venous distention |
| The nurse reorients a male client to the correct time, day, date. Based on these findings Which should the nurse document? | oriented x 2 |
| While assessing a client the nurse observes that the client has a frequent evaluate first? | sputum characteristics |
| The client is a 76 year old male brought in by his daughter...... | Aortic Stenosis Apply stethoscope at level twoon neck assess loudness of sound parameter: bruit Parameter: pulses |
| The nurse examines a client's abdomen. Which findings indicate | Firm mass palpated at bottom of left rib cage |
| when assessing a clients loc the nur up assessment should the nurse complete next? | complete a mental status exam |
| A client reports to the healthcare providers office for a routine post surgic approach should the nurse use to gather information ? | collect information about the Clients activities since surgery |
| When entering a male clients room the nurse observes that he is splinting nurse complete? | numeric pain intensity |
| a homeless male client with a history of alcohol abi today he is reporting pain in his left leg is afebrile action should the nurse implement first? | inspect legs for infection or trauma |
| The nurse is assessing an ulcer on the clients lower extremity. which is likely the ree assessment technique should the nurse use the differentiate the pathophysiology | Observe the specific location and appearance of the ulceration |
| The nurse is assessing a female client who states that her hemmroids: nurse implement to complete a focused assessment? | position client on left lateral position |
| a 75 year old client with a recent history of cerebrovascular accident tendon reflexes on the right side and elicits a brisk 4+ response | hyperactive response consistent with an upper motor neuro |
Created by:
Dianacova