HESI Practice: Health Assessment/Physical Assessment Solved: CORRECT ANSWERS 100

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? An involuntary rhythmic, rapid, twitching of the eyeballs A dorsiflexion of the great toe with fanning of the other toes A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed A lack of normal sense of position when the client is unable to return extended fingers to a point of reference A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? Rhythmic respirations with periods of apnea Regular rapid and deep, sustained respirations Totally irregular respiration in rhythm and depth Irregular respirations with pauses at the end of inspiration and expiration 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 defect in the cochlea A defect in cranial nerve VIII A physical obstruction to the transmission of sound waves A defect in the sensory fibers that lead to the cerebral cortex A physical obstruction to the transmission of sound waves While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? Lub-dub sounds Scratchy, leathery heart noise A blowing or swooshing noise Abrupt, high-pitched snapping noise 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 should implement which assessment technique to assess for muscle weakness in the eye? Test the corneal reflexes. Test the 6 cardinal positions of gaze. Test visual acuity, using a Snellen eye chart. Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin. Test the 6 cardinal positions of gaze. The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? After a shower or bath While standing to void After having a bowel movement While lying in bed before arising After a shower or bath The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? Stridor Crackles Wheezes Diminished Wheezes The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. Auscultating lung sounds Obtaining the client's temperature Assessing the strength of peripheral pulses Obtaining information about the client's respirations Performing a musculoskeletal and neurological examination Asking the client about a family history of any illness or disease Auscultating lung sounds Obtaining the client's temperature Obtaining information about the client's respirations The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure? To examine the testicles while lying down That the best time for the examination is after a shower To gently feel the testicle with one finger to feel for a growth That TSEs should be done at least every 6 months That the best time for the examination is after a shower The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time? At the onset of menstruation Every month during ovulation Weekly at the same time of day One week after menstruation begins One week after menstruation begins The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? The right eye is tested, followed by the left eye, and then both eyes are tested. Both eyes are assessed together, followed by an assessment of the right eye and then the left eye. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the largest line on the chart. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read 200 feet (60 meters) away by an individual with unimpaired vision. The right eye is tested, followed by the left eye, and then both eyes are tested.