HESI 1 - V1 and V2 REVIEW - Health Assessment 1 100% Solved

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? - ANSWER 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? - ANSWER 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? - ANSWER 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? - ANSWER 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? - ANSWER 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? - ANSWER 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? - ANSWER Sit quietly to allow the client to respond comfortably. A client is in the clinical for a yearly physical examination. Which action should the nurse take when preparing to examine the client's abdomen? - ANSWER Ask the client to urinate before beginning the examination. Which respiratory condition should the nurse document after measuring a respiratory rate of 8 breaths/minute? - ANSWER Bradypnea. Which procedure should the nurse use to assessfor a pulse deficit? - ANSWER Measure the apical pulse and compare it to the peripheral pulse. *A pulse deficit is a palpable difference between the apical pulse at the point of maximal impulse and the radial pulse palpated at the wrist. A client has been diagnosed with bilateral lower lobe atelectasis. What percussion sound should the nurse expect to hear when percussing over the client's lower lobes? - ANSWER Dull, thud-like. A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing to complete a head-to-toe assessment and will begin at the head of the client. Which technique should the nurse use to begin the assessment? - ANSWER Inspect the hair and skin. The nurse is assessing a healthy young adult during an annual physical examination. Which assessment technique should the nurse implement when palpating the abdominal aorta? - ANSWER Deep palpation above and to the left of the umbilicus. The nurse is conducting a family history as part of the assessment interview. Which action should the nurse take to ensure that sufficient information about the client's blood relatives is obtained? - ANSWER Document at least 3 generations of the client's family medical history. The nurse is testing the client's shoulders for range of motion. What should the nurse document to record normal internal rotation? - ANSWER Range of 90 degrees when the hands are placed at the small of the back. A client presents with a rash along the occipital area of the hairline and reports intense itching. How should the nurse begin the objective part of the examination? - ANSWER Inspect the scalp looking for nits. The nurse is assessing a client's range of motion as the client bends the right knee up to the chest while keeping the left leg straight, but is unable to keep the left thigh on the table. The assessment is repeated for the left knee, and the client is unable to keep the right thigh on the table. How should the nurse document this finding? - ANSWER A flexion deformity referred to as a positive Thomas test. During a skin asssessment, the nurse notes, round and discrete lesions that are dark red in color and will not blanch. The lesions range from 1 to 3 mm in size. What is the first question the nurse should ask the client? - ANSWER Have you notice any irregular bleeding A client with progressive hearing loss appears distressed when the registered nurse (RN) asks open-ended questions about the client's health history. Which forms of communication should the RN use? - ANSWER Face the client so the client can see the RN's mouth. Check if the client's hearing aides are working properly. Reduce environmental noise surrounding the client. A client states that she had a mastectomy of her left breast last year and now experiences lymphedema. What should the nurse expect to find when examining the client? - ANSWER Swelling of the left arm and non-pitting edema. A client has just returned from the recovery room and asks to get out of bed to go to the bathroom. The nurse decides to obtain orthostatic vital signs first. How will the nurse position the client to begin this procedure? - ANSWER Lying. A postmenopausal female client is undergoing a routine physical examination. She has reported nothing out of the ordinary. When performing the examination of the genitourinary system, the nurse finds an irregularly enlarged uterus with firm, mobile, painless nodules in the uterine wall. How should the nurse explain this finding to the client? - ANSWER You have benign fibroid tumors, a common occurrence in women your age. A client is reporting chest pain. What statement made by the client, helps the nurse to understand this client has a naturalistic belief in the cause of illness? - ANSWER "My life is really out of balance." The nurse is preparing to assess the hearing of a client with a history of prolonged exposure to occupational noise. Which hearing test provides the most reliable assessment of hearing status? - ANSWER Audiometry. The nurse is performing a routine physical examination on an adult client. When gathering a health history, which question is included in the CAGE questionnaire? - ANSWER Have you ever felt guilty about your drinking? *CAGE is the acronym for Cut down, Annoyed, Guilty, and Eye-opener. Nurse can use it to assess for possible alcohol abuse. The nurse is examining the hip joint of a client who reports hip pain. Which other assessment is most helpful in determining the cause of the client's pain? - ANSWER Knee joint evaluation. The nurse performs a series of cranial nerve tests on a client with a head injury. Which test should the nurse use to assess damage to the first cranial nerve? - ANSWER Occlude one nostril and have the client identify various odors. The client reports to the nurse a recent exposure to the mumps. Which assessment finding suggests the client has contracted the mumps? - ANSWER Swelling anterior to the ear lobe on one side of the face A nurse is working in a healthcare facility that serves a diverse population. What action(s) by the nurse will allow the nurse to empathize with and understand this population? (Select all that apply.) - ANSWER Be open to people who are different. Have a curiosity about people. Become culturally competent. Which findings can the nurse determine by palpating a client's skin? (Select all that apply.) - ANSWER Diaphoresis. Scaling. Which question should the nurse ask in order to test a client's remote memory? - ANSWER What is your date of birth? While assessing level of consciousness, the nurse finds that a client localizes to pain, is confused during conversation, and opens the eyes to sound. How should the nurse document the Glasgow score of this client? - ANSWER 12. The Glasgow Coma Scale is used to establish baseline data based on eye opening, motor response, and verbal response. The lowest possible score is 3 and thehighest is 15. This client's Glasgow Coma Scale (GCS) score is 12: Opening eyes to sound is a score of 3, localizing to pain is a 5, and confusion during a conversation is a 4 (3 + 5 + 4 = 12). A client is in the clinic and is reporting lower abdominal pain and constipation. Which information is of greatest concern to the nurse when obtaining the health history from this client? - ANSWER Family history of colon cancer on mother's side. An adult client is in the clinic for a regular physical examination. The nurse is assessing the client's hydration status by pinching then releasing the client's skin. Which finding is indicative of good hydration status? - ANSWER The skin immediately returns to normal position. A client comes to the clinic with a report of fever and a recent exposure to someone who was diagnosed with meningitis. Which nursing assessment should be completed during the initial examination of this client? - ANSWER Level of consciousness. While palpating a client's breasts, the nurse detects a nontender, solitary, round lobular mass that is solid and firm and slides easily through the breast tissue . The findings of this breast exam are consistent with which condition? - ANSWER Fibroadenoma. The client is experiencing severe pruritus and small papules and burrows on areas over one hand and the inner thighs. Which assessment data best explains the condition the client is experiencing? - ANSWER The client works in a daycare setting that has had a scabies outbreak. When assessing facial nerve function of a 96-year-old, the nurse asks the client to smile in an exaggerated manner. Which finding is most important for the nurse to further asses? - ANSWER Only one side of the mouth moves when smiling. When performing range of motion exercises on the joints of an older adult client, the nurse notes that joint range is greater with passive ranging than with active ranging. A goniometer indicates that this difference is as much as 15% in some joints. How should this finding be documented? - ANSWER Abnormal. Which action should the registered nurse (RN) implement to complete an assessment for a client while using an interpreter? - ANSWER Maintain eye contact with the client while listening to the translation.