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BSN 246 HESI Health Assessment Exam V1 (Latest Update) Questions and Verified Answers |100% Correct| Grade A- Nightingale 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?
Answer: Describe having a "body-wracking dry cough" of 6
weeks duration. Correct ANSWER: Describe having a "body-
wracking dry cough" of 6 weeks duration
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?
Answer: Hyperactive response consistent with an upper motor
neuron disorder. Correct ANSWER: 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?
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Answer: Firm mass palpated at bottom of left rib cage. Correct
ANSWER: Firm mass palpated at bottom of left rib cage
In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the stethoscope at which location?
Answer: Place bell of stethoscope over carotid artery. Correct
ANSWER: Place bell of stethoscope over carotid artery
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?
Answer: Press the stethoscope's diaphragm firmly on the skin
over each lung field. Correct ANSWER: Press the stethoscope's
diaphragm firmly on the skin over each lung field
A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a muffled voice. Which complication should the nurse suspect?Answer: Peritonsillar abscess. Correct ANSWER: Peritonsillar abscess
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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?
Answer: Ask specifically about alcohol, marijuana, cocaine,
heroin, and amounts. Correct ANSWER: Ask specifically about
alcohol, marijuana, cocaine, heroin, and amounts
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?
Answer: Notify the healthcare provider of the rebound
tenderness. Correct ANSWER: 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?
Answer: Observe the specific location and appearance of the
ulceration. Correct ANSWER: Observe the specific location and
appearance of the ulceration
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- What type of ulcer is this? Which pathophysiology? venous
or arterial?
Answer: Venous leg ulcers usually develop on the inner lower
leg, above the medial malleolus. Correct ANSWER: Venous leg
ulcers usually develop on the inner lower leg, above the medial malleolus
- What type of ulcer is this? Which pathophysiology? venous
or arterial?
Answer: Arterial wounds occur most often on the foot, in
between or at the tips of the toes, at pressure points from footwear, on the heels and around the lateral malleolus (the bone
on the outside of the ankle joint). Correct ANSWER: Arterial
wounds occur most often on the foot, in between or at the tips of the toes, at pressure points from footwear, on the heels and around the lateral malleolus
Condition of hair, nails, and skin.
Answer: [No specific answer provided; typically involves
inspection for abnormalities like dryness, brittleness, or
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