HESI HEALTH ASSESSMENT LATEST 2024-2025 TEST BANK REAL EXAM 200+QUESTIONS AND DETAILED ANSWERS |AGRADE
A 29 year old male client informs the nurse that he came to the clinic to see if, \Maybe I have lung cancer or something
A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response. Which interpretation of this finding is accurate?\nA. A normal reflex response.\nB. Absent or sluggish response consistent with a lower motor neuron lesion.\nC. Flaccid paralysis.\nD. Hyperactive response consistent with an upper motor neuron disorder.
The nurse examines a client’s abdomen. Which finding indicates an abnormal response when palpating the spleen?\nA. Pain notes when palpating McBurney’s point.\nB. Tip of spleen palpable when client is asked to forcefully exhale.\nC. Rebound tenderness with compression over right upper quadrant. D. Firm mass palpated at bottom of left rib cage.
A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?\nA. Use the bell of the stethoscope to listen to the lung fields over lower lobes. B. Have the client lay flat while listening to the anterior surface of the chest.\nC. Press the stethoscope’s diaphragm firmly on the skin over each lung field.\nD. Shave all chest hair that may distort sounds heard through the diaphragm.
The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client’s use of illegal drugs and alcohol?\nA. Obtain a drug using screen to verify legitimacy of client’s stated history.\nB. Allow the client to decline answering social questions.\nC. Ask specifically about alcohol, marijuana, cocaine, her\nD. Use the term illegal or illicit to describe street drug.
The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. What action should the nurse implement?\nA. Offer to administer a laxative prescribed for PRN use.\nB. Obtain a prescription to catheterize the client’s bladder.\nC. Instruct the client in distraction and relation techniques.\nD. Notify the healthcare provider of the rebound tenderness.
The nurse is assessing an ulcer on a client’s lower extremity, which is likely the result of either venous or arterial insufficiency. Which assessment technique should the nurse use to differentiate the pathophysiology causing the ulcer?\nA. Measure the degree of join range of motion in the extremity.\nB. Compare the skin turgor of the client’s upper and lower leg.\nC. Observe the specific location and appearance of the ulceration.\nD. Note any change in the color of the ulcer when the leg is moved
The nurse is assessing a healthy adult male during an annual physical examination. The nurse auscultates the client’s abdomen and hears gurgling sound every ten seconds. What action should the nurse take in response to this finding?\nA. Document this normal bowel sound activity in the record.\nB. Encourage increased consumption of fiber in the diet.\nC. Observe the next bowel movement for signs of bleeding.\nD. Report the hyperactivity to the healthcare provider.
While obtaining a health history, a male client tells the nurse that he sometimes experiences shortness of breath. The nurse determines that the client’s respirators are regular and deep, and his respiratory rate is 14 breaths/minutes. What is the best nursing action?\nA. Ask the client to perform light exercise and observe the respiratory effect.\nB. Document \dyspnea on exertion\” in the client’s medical record.\nC. Ask the client to describe the episodes of dyspnea in more detail.\nD. Explain to the client the possible causes of dyspnea or \”shortness of breath.\””
The nurse is performing a cranial nerve exam on an 87-year-old client. The nurse notes that the client has a reduced upward gaze, a decreased corneal reflex, a high frequency hearing loss, and a reduced gag reflex. What action should the nurse take next? A. Review past history for any episodes of a cerebral cortex lesion. B. Implement neuro vital signs every 2 hours to detect Cushing’s Triad. C. Continue the assessment to the next pairs of cranial nerves. D. Assess the spinal reflexes for demyelination symptoms.
The nurse is assessing a female client who states that her hemorrhoids are inflamed and hurt constantly. Which intervention is best for the nurse to complete a focused assessment? A. Ask the client how long she has experienced discomfort related to hemorrhoids. B. Place the client in a standing position, leaning over the exam bed for inspection. C. Determine if the client uses any over-the-counter preparation for hemorrhoids. D. Position client in left lateral position to inspect perianal area for fissures or sacs.
The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. What question should the nurse ask first? \Have you A. Been depressed lately?\” B. Had everything to eat in the last 24 hours?\” C. Ever had problems with you blood sugar?\” D. Been sleeping well?\””
After checking a client’s pupillary response to light, the practical nurse (PN) tells the nurse that the client’s pupils are constricted with minimal response to light. Before verifying the PN’s findings, which action should the nurse take? A. Brighten the light in the client’s room. B. Assess the client’s visual fields. C. Review the client’s medication list. D. Administer PRN saline eye solution.
A client sustained a subconjunctival hemorrhage. The presence of which set of symptoms indicate that the client needs to be seen for further evaluation by an ophthalmologist?\nA. Acute pain, change in visual acuity, and foreign body sensation.\nB. Frequent burning, irritation and tearing of the eyes.\nC. Bilateral itchy, red eyes with watery discharge\nD. Diminished ability to focus on close work and excessive illumination required.
A male client returns to the clinic for a follow-up visit after being treated for a bladder infection. While examining the client, which finding indicated an expected response to the treatment?\nA. Orange sized prostate gland.\nB. Post-voided residual volume of 50 mL. C. Pain score of 1 out of 10 with urination. D. Decreasing sperm cell count.
The nurse has just completed palpitation maneuvers for lymph nodes on a 75-year-old female client. Which findings are considered normal for this elderly client?\nA. Nodes are non-palpable.\nB. Axillary nodes feel soft and fatty.\nC. Nodes feel ropey and rubbery.\nD. Inguinal nodes are enlarged and warm to the touch.
A women comes to the clinic for her first prenatal visit. The nurse is conducting a health history and the women begins to cry when asked about previous pregnancies. Which response is best for the nurse to provide?\nA. \Why don’t I come back in a few minutes after you are more composed.\” B. Offer a tissue and sit quietly until the crying subsides.\nC. Allow the client to compose herself then change the subject.\nD. \”I’m so sorry that I made you cry. I didn’t mean to upset you.\””
A homeless male client with a history of alcohol abuse had a cerebrovascular accident (CVA) 10 years ago that resulted in left hemiparesis. Today he is complaining of pain in his left leg, is afebrile, has 4+ pitting edema in the lower left leg, and minimal swelling of the right leg. Which action should the nurse implement first?\nA. Inspect legs for infection of trauma.\nB. Obtain a blood alcohol level.\nC. Complete a mental status exam.\nD. Inquire about dietary salt intake.
The nurse is assessing a client for goiter and is unable to observe the thyroid gland. Which action should the nurse take?\nA. Defer the thyroid exam and observe the client for signs of myxedema.\nB. Document that thyroid gland size is normal with no visible goiter.\nC. Ask the client to swallow while palpating along the sides of the trachea. D. Palpate deeply and firmly over the location of the thyroid gland.
While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perineal area and anus. Which findings indicates a normal appearance of the anus?\nA. Increased pigmentation and coarse skin.\nB. Flap of tissue at sphincter.\nC. Hypotonic tone of the anal sphincter. D. Dimpled area above anus.
A client comes to the clinic due to shoulder discomfort and intermittent pain while swimming today. To assist normal range of motion (ROM) of the client’s shoulder, which assessment techniques should the nurse ask the client to perform?\nA. Alternate both index fingers to tough the tip of nose accurately.\nB. Extend arms up to 180 degrees besides the ears.\nC. Extend arms straight out and hold without drifting.\nD. Hold arms up at 90 degree while arms are pushed downward
A client reports to the healthcare provider’s office for a routine post-surgical evaluation six weeks after a hysterectomy. Which history-taking approach should the nurse use to gather the needed information?\nA. Conduct a comprehensive review of systems.\nB. Perform a head-to-toe physical assessment.\nC. Prepare to collect a vaginal specimen for Papanicolaou smear.\nD. Collect information about the client’s activities since surgery.
In assessing a male client’s level of consciousness, the nurse determines that the client does not open his eyes spontaneously. What should the nurse do next?\nA. Notify the healthcare provider.\nB. Observe for eye opening to a painful stimulus.\nC. Check the pupillary response to light. D. Ask the client to open his eyes
In assessing a client’s sensory nerve function, the nurse prepares to assess the client’s response to temperature. What action should the nurse include during this assessment?\nA. Darken the client’s room environment. B. Cover the client with a warmed blanket.\nC. Measure the client’s body temperature.\nD. Instruct the client to close both eyes.
The nurse is obtaining a health history for a client during an annual physical examination. When evaluating the client for menopausal symptoms, which finding indicates the client is perimenopausal? A. Drenching night sweats.\nB. Excessive vaginal moisture.\nC. Increase in sexual desire.\nD. Cessation of menstruation.
A client states that he is legally blind. Which assessment techniques should the nurse use to obtain data to support the client’s statement?\nA. Observe the client’s optic disc through an ophthalmoscope.\nB. Assess the client’s ability to read a Snellen chart from a distance of 20 feet. C. Observe the client’s pupillary response to a penlight.\nD. Observe the client’s eye movements through the cardinal fields of vision.
Which question by the nurse is likely to elicit the most information regarding a client’s use of medications to treat a chronic cough?\nA. What medications are you currently taking?\nB. Have you tried any generic brands of cough syrup?\nC. Have you been prescribed any medications for your cough?\nD. What medications have you used for your cough?
After a young adult woman describes feeling palpitations when she lies on her left side it is most important for the nurse to auscultate heart sounds at which anatomical location?\nA. Second intercostal space, left of the sternal border.\nB. Left third intercostal space, left lateral sternal border.\nC. Base of the heart at second intercostal space, right of the sternal border.\nD. Apex of the heart at the left fifth intercostal space at the midclavicular line
While assessing the legs of a female client, the nurse observes leathery-looking skin. The client reports aching tired legs that swell if she stands for long periods of time. To screen for venous insufficiency, the nurse should ask the client if she has experienced which subject finding?\nA. Decreased pain when legs are elevated.\nB. Deep, continuous pain in the calf muscles.\nC. Cool, pale skin below the knees.\nD. Painful symptoms alleviated by warmth.
After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high pitched almost continuous gurgling in two quadrants. What action should the nurse implement?\nA. Use the bell of the stethoscope to auscultate again.\nB. Elevate the head of the client’s bed immediately.\nC. Document the presence of borborygmi.\nD. Auscultate the remaining two quadrants.
To objectively confirm the presence of fever, before taking the client’s temperature, which action should the nurse take?\nA. Ask the client to describe any other related symptoms.\nB. Use both hands to hold and palpate the client’s hands.\nC. Lightly pinch a fold of skin over the client’s sternum.\nD. Place the dorsum of the hand on the client’s forehead.
A male client who is admitted for an acute brain attack reports the onset of a burning sensation in his hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client’s paresthesia?\nA. Evaluate client’s muscle strength and hand grips.\nB. Observe skin for erythema, edema, and warmth.\nC. Review the client’s serum electrolytes. D. Check distal phalanges capillary refill
A client is being evaluated for environmental allergies. While examining the client’s nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?\nA. Purulent secretions from eyes and nares.\nB. Eye tearing and thick yellow nasal drainage.\nC. Snoring and bilateral, pale gray nodules.\nD. Intranasal edema and swelling of turbinates.
During a health assessment, the client reports being treated for osteoarthritis. The nurse examines a client’s hands and finds Heberden’s nodes. Which finding should the nurse document in the client’s medical record?\nA. Proximal intertarsal join swelling of big toe.\nB. Non-painful enlarged interphalangeal joints.\nC. Distal interphalangeal joint nodules that deviate.\nD. Frozen, non-movable phalangeal joints.
The nurse asks a 50-year-old female client what her natural hair color is. The client replies, \I’ve been dying my hair for so long
The school nurse is interviewing a 13-year-old girl who wants to go home from school because of \back pain\”. Which question should the nurse ask the adolescent first?\nA. \”Have you taken any medications to relieve the pain?\”\nB. \”What were you doing when you first noticed the problem?\”\nC. \”Do you remember ever having this type of pain in the past?\”\nD. \”Does changing your position make the pain worse?\””
During a health assessment for a young adult female client’s gynecological annual screening, the client reports amenorrhea. The nurse calculates the client body mass index (BMI) as 16. Which finding should the nurse document in the electronic medical record that indicates an expected rationale for this condition?\nA. Increased calcium intake with 3 glasses if non-fat milk daily.\nB. Reports a history of chronic urinary tract infections.\nC. Trains for competition and runs 12 miles every day.\nD. Received an implanted intrauterine device (IUD) last month.
The nurse prepares to begin a systematic assessment of a client’s heart sounds. Upon positioning the stethoscope as seen in the picture what should the nurse do first?\nA. Identify S1 and S2 heart sounds.\nB. Change to the bell of the stethoscope.\nC. Move the stethoscope to the apical site.\nD. Listen for abnormal sounds
During assessment of a client’s neck, the nurse prepares to assess for jugular vein distention (JVD) as seen in the picture. What should the nurse do next?\nA. Listen to swishing sound during systole.\nB. Use the bell of the stethoscope to auscultate.\nC. Remove the stethoscope to observe the site.\nD. Palpate the site of erythema and tenderness.