HESI RN HEALTH ASSESSMENT LATEST EXAM 2022-2024\/ HEALTH
ASSESSMENT HESI EXIT EXAM 2022-2023 REAL EXAM QUESTIONS
AND ANSWERS
1.During a mental status examination, the nurse wants to assess a patient\u2019s affect.
The nurse should askthe patient which question?
\u201cHow do you feel today?\u201d
2.The nurse is planning to assess new memory with a patient. The best way for
the nurse to do thiswould be to:
Give him the Four Unrelated Words Test.
3.A 45-year-old woman is at the clinic for a mental status assessment. In giving
her the Four UnrelatedWords Test, the nurse would be concerned if she could not
four unrelated words .
Recall; after a 30-minute delay
4.During a mental status assessment, which question by the nurse would
best assess a person\u2019sjudgment?
\u201cTell me what you plan to do once you are discharged from the hospital.\u201d
5.Which of these individuals would the nurse consider at highest risk for a suicide
attempt?
Older adult man who tells the nurse that he is going to \u201cjoin his wife in
heaven\u201d tomorrow andplans to use a gun
6.When reviewing the use of alcohol by older adults, the nurse notes that older
adults have severalcharacteristics that can increase the risk of alcohol use.
Which would increase the bioavailability ofalcohol in the blood for longer
periods in the older adult?
Decreased liver and kidney functioning
7.During an assessment, the nurse asks a female patient, \u201cHow many alcoholic
drinks do you have aweek?\u201d Which answer by the patient would indicate atrisk drinking?
\u201cI have seven or eight drinks a week, but I never get drunk.\u201d<\/p>\n\n\n\n
8.The nurse is asking an adolescent about illicit substance abuse. The
adolescent answers, \u201cYes, I\u2019veused marijuana at parties with my friends.\u201d
What is the next question the nurse should ask?
\u201cWhen was the last time you used marijuana?\u201d
9.The nurse has completed an assessment on a patient who came to the clinic for a
leg injury. As a resultof the assessment, the nurse has determined that the patient
has at-risk alcohol use. Which action by the nurse is most appropriate at this time?
State, \u201cYou are drinking more than is medically safe. I strongly
recommend that you quitdrinking, and I\u2019m willing to help you.\u201d<\/p>\n\n\n\n
lOMoAR cPSD|19500986
lOMoAR cPSD|19500986
2022 HESI HEALTH ASSESSMENT EXAM VERSION
COMPLETE EXAM QUESTIONS AND CORRECT ANSWERS
WITH RATIONALES|AGRADE
Question 1:
A 29 year old male client informs the nurse that he came to the clinic to see if, \u201cMaybe I have
lung cancer or something,\u201d and wants to get checked out since, \u201cI can\u2019t seem to get rid of this
body-wracking dry cough that has been hanging around for the last six weeks.\u201d Which
computer documentation of this client\u2019s concerns should the nurse enter?
A. Presents with a hacking non-productive cough of 6 weeks duration.
B. Describe having a \u201cbody-wracking dry cough\u201d of 6 weeks duration.
C. Expresses concern of \u201clung cancer\u201d symptoms for last 6 weeks.
D. Young adult male presents with fears that he has \u201clung cancer\u201d
Correct answer is B, as assessment process includes chief complaint which is how the patient
describe why he is here in the hospital or clinic and can\u2019t include diagnosis.
Question 2:
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?
A. A normal reflex response.
B. Absent or sluggish response consistent with a lower motor neuron lesion.
C. Flaccid paralysis.
D. Hyperactive response consistent with an upper motor neuron disorder.
Correct answer is D, brisk 4+ response is correlated with hyperactive response.
Question 3:
The nurse examines a client\u2019s abdomen. Which finding indicates an abnormal response when
palpating the spleen?
A. Pain notes when palpating McBurney\u2019s point.
B. Tip of spleen palpable when client is asked to forcefully exhale.
C. Rebound tenderness with compression over right upper quadrant.
D. Firm mass palpated at bottom of left rib cage.
Correct answer is D. McBurney\u2019s point is related to appendicitis and not spleen.<\/p>\n\n\n\n
lOMoAR cPSD|19500986
Question 4:
In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the
stethoscope at which location?
Question 5:
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?
A. 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.
C. Press the stethoscope\u2019s diaphragm firmly on the skin over each lung field.
D. Shave all chest hair that may distort sounds heard through the diaphragm.
Correct answer is C. The nurse should listen to all lungs fields during assessment and move from
side to side during auscultation.<\/p>\n\n\n\n
lOMoAR cPSD|19500986
Question 6:
A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a muffled
voice. Which complication should the nurse suspect?
A. Foreign body obstruction.
B. Laryngeal polyps.
C. Peritonsillar abscess.
D. Nasal polyps.
Correct answer is C. Since infections are associated with abscesses and pus.
Question 7:
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\u2019s use of illegal drugs and alcohol?
A. Obtain a drug using screen to verify legitimacy of client\u2019s stated history.
B. Allow the client to decline answering social questions.
C. Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts.
D. Use the term illegal or illicit to describe street drugs.
Correct answer is C. When interviewing the patient, questions should be clear and specific.
Question 8:
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?
A. Offer to administer a laxative prescribed for PRN use.
B. Obtain a prescription to catheterize the client\u2019s bladder.
C. Instruct the client in distraction and relation techniques.
D. Notify the healthcare provider of the rebound tenderness.
Correct answer is D. As this could be a sign of appendicitis.<\/p>\n\n\n\n
lOMoAR cPSD|19500986
lOMoAR cPSD|19500986
2023 HESI HEALTH ASSESSMENT EXAM
VERSION 3 COMPLETE EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS|AGRADE<\/p>\n\n\n\n
1) The nurse hears bilateral louder, longer, and lower tones when percussing over the lungs of a
4-year old child. What should the nurse do next?
a) Palpate over the area for increased pain and tenderness.
b) Ask the child to take shallow breaths and percuss over the area again.
c) Refer the child immediately because of an increased amount of air in the lungs.
d) Consider this a normal finding for a child this age and proceed with the examination.
2) A patient has suddenly developed shortness of breath and appears to be in significant
respiratory distress. After putting a call in to the physician and placing the patient on oxygen,
which of these is the best action for the nurse to take when assessing the patient further?
a) Count the patient\u2019s respirations.
b) Percuss the thorax bilaterally, noting any differences in percussion tones.
c) Call for a chest x-ray and wait for the results before beginning an assessment.
d) Inspect the thorax for any new masses and bleeding associated with respirations.
3) The nurse is teaching a class on basic assessment skills. Which of these statements is true
regarding the stethoscope and its use?
a) The slope of the earpieces should point posteriorly (toward the occiput).<\/p>\n\n\n\n
lOMoAR cPSD|19500986
b) The stethoscope does not magnify sound but does block out extraneous room noise.
c) The fit and quality of the stethoscope are not as important as its ability to magnify sound.
d) The ideal tubing length should be 22 inches to dampen distortion of sound.
4) The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding
the diaphragm of the stethoscope?
a) The diaphragm is used to listen for high-pitched sounds.
b) The diaphragm is used to listen for low-pitched sounds.
c) The diaphragm should be held lightly against the person\u2019s skin to block out low-pitched
sounds.
d) The diaphragm should be held lightly against the person\u2019s skin to listen for extra heart sounds
and murmurs.
5) Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse
should:
a) Warm the end piece of the stethoscope by placing it in warm water
b) Leave the gown on so that the patient does not get chilled during the examination
c) Make sure that the bell side of the stethoscope is turned to the \u2015on\u2016 position
d) Check the temperature of the room and offer blankets to the patient if he or she feels
cold
6) The nurse will use which technique of assessment to determine the presence of crepitus,
swelling, and pulsations?
a) Palpation b) Inspection
c) Percussion d) Auscultation<\/p>\n\n\n\n
lOMoAR cPSD|19500986
7) The nurse is preparing to use an otoscope for an examination. Which statement is true
regarding the otoscope?
a) The otoscope is often used to direct light onto the sinuses.
b) The otoscope uses a short, broad speculum to help visualize the ear.
c) The otoscope is used to examine the structures of the internal ear.
d) The otoscope directs light into the ear canal and onto the tympanic membrane.
8) An examiner is using an ophthalmoscope to examine a patient\u2019s eyes. The patient has
astigmatism and is nearsighted. The use of which of these techniques would indicate that the
examination is being performed correctly?
a) Using the large full circle of light when assessing pupils that are not dilated
b) Rotating the lens selector dial to the black numbers to compensate for astigmatism
c) Using the grid on the lens aperture dial to visualize the external structures of the eye
d) Rotating the lens selector dial to bring the object into focus
9) The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:
a) Auscultate over the area with a fetoscope
b) Use a goniometer to measure the pulsations
c) Use a Doppler device to check for pulsations over the area
d) Check for the presence of pulsations with a stethoscope
10) The nurse is preparing to perform a physical assessment. The correct action by the nurse is
reflected by which statement?
a) The nurse performs the examination from the left side of the bed.<\/p>\n\n\n\n
lOMoAR cPSD|19500986
b) The nurse examines tender or painful areas first to help relieve the patient\u2019s anxiety.
c) The nurse follows the same examination sequence regardless of the patient\u2019s age or condition.
d) The nurse organizes the assessment so that the patient does not change positions too
often.
11) A man is at the clinic for a physical examination. He states that he is \u2015very anxious\u2016 about
the physical examination. What steps can the nurse take to make him more comfortable?
a) Appear unhurried and confident when examining him.
b) Stay in the room when he undresses in case he needs assistance.
c) Ask him to change into an examining gown and take off his undergarments.
d) Defer measuring vital signs until the end of the examination, which allows him time to
become comfortable.
12) When performing a physical examination, safety must be considered to protect the examiner
and the patient against the spread of infection. Which of these statements describes the most
appropriate action the nurse should take when performing a physical examination?
a) There is no need to wash one\u2019s hands after removing gloves, as long as the gloves are still
intact.
b) Wash hands before and after every physical patient encounter.
c) Wash hands between the examination of each body system to prevent the spread of bacteria
from one part of the body to another.<\/p>\n\n\n\n
lOMoAR cPSD|19500986
lOMoAR cPSD|19500986
2023 HESI HEALTH ASSESSMENT EXAM
VERSION 2 COMPLETE EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS|AGRADE<\/p>\n\n\n\n
1) The nurse hears bilateral louder, longer, and lower tones when percussing over the lungs of a
4-year old child. What should the nurse do next?
a) Palpate over the area for increased pain and tenderness.
b) Ask the child to take shallow breaths and percuss over the area again.
c) Refer the child immediately because of an increased amount of air in the lungs.
d) Consider this a normal finding for a child this age and proceed with the examination.
2) A patient has suddenly developed shortness of breath and appears to be in significant
respiratory distress. After putting a call in to the physician and placing the patient on oxygen,
which of these is the best action for the nurse to take when assessing the patient further?
a) Count the patient9srespirations.
b) Percuss the thorax bilaterally, noting any differences in percussion tones.
c) Call for a chest x-ray and wait for the results before beginning an assessment.
d) Inspect the thorax for any new masses and bleeding associated with respirations.
3) The nurse is teaching a class on basic assessment skills. Which of these statements is true
regarding the stethoscope and its use?
a) The slope of the earpieces should point posteriorly (toward the occiput).
b) The stethoscope does not magnify sound but does block out extraneous room noise.
c) The fit and quality of the stethoscope are not as important as its ability to magnify sound.
d) The ideal tubing length should be 22 inches to dampen distortion of sound.
4) The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding
the diaphragm of the stethoscope?
a) The diaphragm is used to listen for high-pitched sounds.
b) The diaphragm is used to listen for low-pitched sounds.
c) The diaphragm should be held lightly against the person9s skin to block out low-pitched
sounds.
d) The diaphragm should be held lightly against the person9s skin to listen for extra heart sounds
and murmurs.
5) Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse
should:
a) Warm the end piece of the stethoscope by placing it in warm water
b) Leave the gown on so that the patient does not get chilled during the examination
c) Make sure that the bell side of the stethoscope is turned to the <on= position
d) Check the temperature of the room and offer blankets to the patient if he or she feels
cold<\/p>\n\n\n\n
lOMoAR cPSD|19500986
6) The nurse will use which technique of assessment to determine the presence of crepitus,
swelling, and pulsations?
a) Palpation b) Inspection
c) Percussion d) Auscultation
<\/p>\n\n\n\n
lOMoAR cPSD|19500986
lOMoAR cPSD|19500986
2023 HESI HEALTH ASSESSMENT EXAM
VERSION 1 COMPLETE EXAM 160 QUESTIONS
AND CORRECT ANSWERS WITH
RATIONALES|AGRADE<\/p>\n\n\n\n
lOMoAR cPSD|19500986
D) Monitor the urine output
The correct answer is B: Have the client turn to the left side<\/p>\n\n\n\n
lOMoAR cPSD|19500986<\/p>\n\n\n\n
HESI HEALTH ASSESSMENT LATEST 2023 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,” and wants to get checked out since, “I
can’t seem to get rid of this body-wracking dry cough that has been hanging around
for the last six weeks.” Which computer documentation of this client’s concerns
should the nurse enter?
A. Presents with a hacking non-productive cough of 6 weeks duration.
B. Describe having a “body-wracking dry cough” of 6 weeks duration.
C. Expresses concern of “lung cancer” symptoms for the last 6 weeks.
D. Young adult male presents with fears that he has “lung cancer” – ANSWERCorrect answer is B, as assessment process includes chief complaint which is how
the patient describe why he is here in the hospital or clinic and can’t include
diagnosis.
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?
A. A normal reflex response.
B. Absent or sluggish response consistent with a lower motor neuron lesion.
C. Flaccid paralysis.
D. Hyperactive response consistent with an upper motor neuron disorder. –
ANSWER- Correct answer is D, brisk 4+ response is correlated with hyperactive
response
The nurse examines a client’s abdomen. Which finding indicates an abnormal
response when palpating the spleen?
A. Pain notes when palpating McBurney’s point.
B. Tip of spleen palpable when client is asked to forcefully exhale.
C. Rebound tenderness with compression over right upper quadrant.<\/p>\n\n\n\n
D. Firm mass palpated at bottom of left rib cage. – ANSWER- Correct answer is D.
McBurney’s point is related to appendicitis and not spleen
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?
A. 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.
C. Press the stethoscope’s diaphragm firmly on the skin over each lung field. D.
Shave all chest hair that may distort sounds heard through the diaphragm. –
ANSWER- Correct answer is C. The nurse should listen to all lungs fields during
assessment and move from side to side during auscultation
A client with streptococcus pharyngitis reports high fever, difficulty swallowing
and a muffled voice. Which complication should the nurse suspect?
A. Foreign body obstruction.
B. Laryngeal polyps.
C. Peritonsillar abscess.
D. Nasal polyps. – ANSWER- Correct answer is C. Since infections are associated
with abscesses and pus
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?
A. Obtain a drug using screen to verify legitimacy of client’s stated history.
B. Allow the client to decline answering social questions.
C. Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts.
D. Use the term illegal or illicit to describe street drugs – ANSWER- Correct
answer is C. When interviewing the patient, questions should be clear and specific
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?
A. Offer to administer a laxative prescribed for PRN use.
B. Obtain a prescription to catheterize the client’s bladder.
C. Instruct the client in distraction and relation techniques.
D. Notify the healthcare provider of the rebound tenderness – ANSWER- Correct
answer is D. As this could be a sign of appendicitis<\/p>\n\n\n\n
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? A.
Measure the degree of join range of motion in the extremity.
B. Compare the skin turgor of the client’s upper and lower leg.
C. Observe the specific location and appearance of the ulceration.
D. Note any change in the color of the ulcer when the leg is moved – ANSWERCorrect answer is C. Location and appearance of the ulcer would give us the type
(venous vs arterial)
Venous: develop on the inner lower leg, shallow wounds that are large and
irregular edges that slope, red with granular tissue, discoloration with yellow
slough present, shiny skin warm or scaly
Arterial: occur most often on the foot, on the heels and around lateral malleolus,
round shaped, well-defined edges, yellow, brown or black in color, skin pale and
non granulating, deep but may also appear shallow in early stages, skin is thin,
smooth, taut, and dry. Loss of hair on the leg is also common
The nurse is conducting a physical assessment of a young adult. Which
information provides the best indication of the individual’s nutritional status? A.
Status of current appetite.
B. A 24-hour diet history.
C. History of a recent weight loss.
D. Condition of hair, nails, and skin – ANSWER- Correct answer is D. Hair, nail,
and skin are the most important reflection of nutritional status
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?
A. Document this normal bowel sound activity in the record.
B. Encourage increased consumption of fiber in the diet.
C. Observe the next bowel movement for signs of bleeding.
D. Report the hyperactivity to the healthcare provider. – ANSWER- Correct answer
is A. Normal Bowel sound consist of clicks and gurgles and 5-30 per minute. An
occasional borborygmus (loud prolonged gurgle) may be heard
In observing a client’s face, which assessment finding requires the most immediate
intervention by the nurse?
A. Eyelids are matted and crusted.
B. Cornea are jaundiced.
C. Oral mucosa is cyanotic.<\/p>\n\n\n\n
D. Face is flushed and diaphoretic. – ANSWER- Answer is C. Blue lips occur
when the skin on the lips takes on a bluish tint or color. This generally is due to
either a lack of oxygen in the blood or to extremely cold temperatures.
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?
A. Ask the client to perform light exercise and observe the respiratory effect. B.
Document “dyspnea on exertion” in the client’s medical record.
C. Ask the client to describe the episodes of dyspnea in more detail.
D. Explain to the client the possible causes of dyspnea or “shortness of breath.” –
ANSWER- Correct answer is C. Both respiratory rate and breath sounds are
normal. Further assessment is needed by asking the client to describe his SOB.
When assessing a male client’s respiratory status, which technique should the nurse
use to assess his anterior- posterior (AP) chest diameter?
A. Auscultation.
B. Percussion.
C. Palpation.
D. Observation. – ANSWER- Correct answer is D. Observation is the way to detect
barrel chest which is associated with COPD.
Which assessment finding supports the client statement, “My feet swell all the
time?”
A. 2+ pitting edema of ankles bilaterally.
B. Capillary refill both feet > 3 seconds.
C. Pedal pulses weak and thread.
D. Positive Homan’s sign bilaterally. – ANSWER- Correct answer is A. 2+ pitting
edema indicate swelling in the lower extremities
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.<\/p>\n\n\n\n
HESI HEALTH ASSESSMENT 2023 EXAM QUESTIONS
AND CORRECT ANSWERS|ALREADY GRADED A+<\/p>\n\n\n\n
HESI HEALTH ASSESSMENT LATEST 2023 TEST BANK
REAL EXAM 300 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES
|AGRADE(BRAND NEW!!)
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,” and wants to get checked out since, “I
can’t seem to get rid of this body-wracking dry cough that has been hanging around
for the last six weeks.” Which computer documentation of this client’s concerns
should the nurse enter?
A. Presents with a hacking non-productive cough of 6 weeks duration.
B. Describe having a “body-wracking dry cough” of 6 weeks duration.
C. Expresses concern of “lung cancer” symptoms for the last 6 weeks.
D. Young adult male presents with fears that he has “lung cancer” – ANSWERCorrect answer is B, as assessment process includes chief complaint which is how
the patient describe why he is here in the hospital or clinic and can’t include
diagnosis.
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?
A. A normal reflex response.
B. Absent or sluggish response consistent with a lower motor neuron lesion.
C. Flaccid paralysis.
D. Hyperactive response consistent with an upper motor neuron disorder. –
ANSWER- Correct answer is D, brisk 4+ response is correlated with hyperactive
response
The nurse examines a client’s abdomen. Which finding indicates an abnormal
response when palpating the spleen?
A. Pain notes when palpating McBurney’s point.
B. Tip of spleen palpable when client is asked to forcefully exhale.
C. Rebound tenderness with compression over right upper quadrant.<\/p>\n\n\n\n
D. Firm mass palpated at bottom of left rib cage. – ANSWER- Correct answer is D.
McBurney’s point is related to appendicitis and not spleen
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?
A. 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.
C. Press the stethoscope’s diaphragm firmly on the skin over each lung field. D.
Shave all chest hair that may distort sounds heard through the diaphragm. –
ANSWER- Correct answer is C. The nurse should listen to all lungs fields during
assessment and move from side to side during auscultation
A client with streptococcus pharyngitis reports high fever, difficulty swallowing
and a muffled voice. Which complication should the nurse suspect?
A. Foreign body obstruction.
B. Laryngeal polyps.
C. Peritonsillar abscess.
D. Nasal polyps. – ANSWER- Correct answer is C. Since infections are associated
with abscesses and pus
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?
A. Obtain a drug using screen to verify legitimacy of client’s stated history.
B. Allow the client to decline answering social questions.
C. Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts.
D. Use the term illegal or illicit to describe street drugs – ANSWER- Correct
answer is C. When interviewing the patient, questions should be clear and specific
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?
A. Offer to administer a laxative prescribed for PRN use.
B. Obtain a prescription to catheterize the client’s bladder.
C. Instruct the client in distraction and relation techniques.
D. Notify the healthcare provider of the rebound tenderness – ANSWER- Correct
answer is D. As this could be a sign of appendicitis<\/p>\n\n\n\n
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? A.
Measure the degree of join range of motion in the extremity.
B. Compare the skin turgor of the client’s upper and lower leg.
C. Observe the specific location and appearance of the ulceration.
D. Note any change in the color of the ulcer when the leg is moved – ANSWERCorrect answer is C. Location and appearance of the ulcer would give us the type
(venous vs arterial)
Venous: develop on the inner lower leg, shallow wounds that are large and
irregular edges that slope, red with granular tissue, discoloration with yellow
slough present, shiny skin warm or scaly
Arterial: occur most often on the foot, on the heels and around lateral malleolus,
round shaped, well-defined edges, yellow, brown or black in color, skin pale and
non granulating, deep but may also appear shallow in early stages, skin is thin,
smooth, taut, and dry. Loss of hair on the leg is also common
The nurse is conducting a physical assessment of a young adult. Which
information provides the best indication of the individual’s nutritional status? A.
Status of current appetite.
B. A 24-hour diet history.
C. History of a recent weight loss.
D.Condition of hair, nails, and skin – ANSWER- Correct answer is D. Hair, nail,
and skin are the most important reflection of nutritional status
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?
A. Document this normal bowel sound activity in the record.
B. Encourage increased consumption of fiber in the diet.
C. Observe the next bowel movement for signs of bleeding.
D. Report the hyperactivity to the healthcare provider. – ANSWER- Correct answer
is A. Normal Bowel sound consist of clicks and gurgles and 5-30 per minute. An
occasional borborygmus (loud prolonged gurgle) may be heard
In observing a client’s face, which assessment finding requires the most immediate
intervention by the nurse?
A. Eyelids are matted and crusted.
B. Cornea are jaundiced.
C. Oral mucosa is cyanotic.<\/p>\n\n\n\n
D. Face is flushed and diaphoretic. – ANSWER- Answer is C. Blue lips occur
when the skin on the lips takes on a bluish tint or color. This generally is due to
either a lack of oxygen in the blood or to extremely cold temperatures.
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?
A. Ask the client to perform light exercise and observe the respiratory effect. B.
Document “dyspnea on exertion” in the client’s medical record.
C. Ask the client to describe the episodes of dyspnea in more detail.
D. Explain to the client the possible causes of dyspnea or “shortness of breath.” –
ANSWER- Correct answer is C. Both respiratory rate and breath sounds are
normal. Further assessment is needed by asking the client to describe his SOB.
When assessing a male client’s respiratory status, which technique should the nurse
use to assess his anterior- posterior (AP) chest diameter?
A. Auscultation.
B. Percussion.
C. Palpation.
D. Observation. – ANSWER- Correct answer is D. Observation is the way to detect
barrel chest which is associated with COPD.
Which assessment finding supports the client statement, “My feet swell all the
time?”
A. 2+ pitting edema of ankles bilaterally.
B. Capillary refill both feet > 3 seconds.
C. Pedal pulses weak and thread.
D. Positive Homan’s sign bilaterally. – ANSWER- Correct answer is A. 2+ pitting
edema indicate swelling in the lower extremities
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.<\/p>\n","protected":false},"excerpt":{"rendered":"
HESI RN HEALTH ASSESSMENT LATEST EXAM 2022-2024\/ HEALTHASSESSMENT HESI EXIT EXAM 2022-2023 REAL EXAM QUESTIONSAND ANSWERS1.During a mental status examination, the nurse wants to assess a patient\u2019s affect.The nurse should askthe patient which question?\u201cHow do you feel today?\u201d2.The nurse is planning to assess new memory with a patient. The best way forthe nurse to do […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-116927","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/116927","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=116927"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/116927\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=116927"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=116927"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=116927"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}