HEALTH ASSESSMENT - HESI PREP 2 |
QUESTIONS AND ANSWERS | RATIONALES
| BRAND NEW| 2024
The nurse is performing a vision examination. Which of these charts is most widely
used for vision examinations?
A) Snellen
B) Shetllen
C) Smoollen
D) Schwellon - A) Snellen
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. -
d) Consider this a normal finding for a child this age and proceed with the examination.
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's 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. -
b) Percuss the thorax bilaterally, noting any differences in percussion tones.
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. - b) The
stethoscope does not magnify sound but does block out extraneous room noise.
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's skin to block out low-
pitched sounds.
d) The diaphragm should be held lightly against the person's skin to listen for extra heart
sounds
and murmurs. - a) The diaphragm is used to listen for high-pitched sounds.
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 - d) Check the temperature of the room and offer blankets to the patient if he or
she feels cold
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 - a) Palpation
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. - d)
The otoscope directs light into the ear canal and onto the tympanic membrane.
An examiner is using an ophthalmoscope to examine a patient's 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) Usi
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
ng 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 - d) Rotating the lens
selector dial to bring the object into focus
The nurse is unable to palpate the right radial pulse on a patient. The best action would
be to:
d) hCheck hfor hthe hpresence hof hpulsations hwith ha hstethoscope h- h hc) hUse ha hDoppler hdevice
hto hcheck hfor hpulsations hover hthe harea
The hnurse his hpreparing hto hperform ha hphysical hassessment. hThe hcorrect haction hby hthe
hnurse his hreflected hby hwhich hstatement?
a) hThe hnurse hperforms hthe hexamination hfrom hthe hleft hside hof hthe hbed.
b) hThe hnurse hexamines htender hor hpainful hareas hfirst hto hhelp hrelieve hthe hpatient's
hanxiety.
c) hThe hnurse hfollows hthe hsame hexamination hsequence hregardless hof hthe hpatient's hage
hor hcondition.
d) hThe hnurse horganizes hthe hassessment hso hthat hthe hpatient hdoes hnot hchange hpositions
htoo hoften. h- h hd) hThe hnurse horganizes hthe hassessment hso hthat hthe hpatient hdoes hnot
hchange hpositions htoo hoften.
A hman his hat hthe hclinic hfor ha hphysical hexamination. hHe hstates hthat hhe his h"very hanxious"
habout hthe hphysical hexamination. hWhat hsteps hcan hthe hnurse htake hto hmake hhim hmore
hcomfortable?
a) hAppear hunhurried hand hconfident hwhen hexamining hhim.
b) hStay hin hthe hroom hwhen hhe hundresses hin hcase hhe hneeds hassistance.
c) hAsk hhim hto hchange hinto han hexamining hgown hand htake hoff hhis hundergarments.
d) hDefer hmeasuring hvital hsigns huntil hthe hend hof hthe hexamination, hwhich hallows hhim htime
hto hbecome hcomfortable. h- h ha) hAppear hunhurried hand hconfident hwhen hexamining hhim.
When hperforming ha hphysical hexamination, hsafety hmust hbe hconsidered hto hprotect hthe
hexaminer hand hthe hpatient hagainst hthe hspread hof hinfection. hWhich hof hthese hstatements
hdescribes hthe hmost happropriate haction hthe hnurse hshould htake hwhen hperforming ha
hphysical hexamination?
a) hThere his hno hneed hto hwash hone's hhands hafter hremoving hgloves, has hlong has hthe hgloves
hare hstill
intact.
b) hWash hhands hbefore hand hafter hevery hphysical hpatient hencounter.
QUESTIONS AND ANSWERS | RATIONALES
| BRAND NEW| 2024
The nurse is performing a vision examination. Which of these charts is most widely
used for vision examinations?
A) Snellen
B) Shetllen
C) Smoollen
D) Schwellon - A) Snellen
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. -
d) Consider this a normal finding for a child this age and proceed with the examination.
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's 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. -
b) Percuss the thorax bilaterally, noting any differences in percussion tones.
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. - b) The
stethoscope does not magnify sound but does block out extraneous room noise.
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's skin to block out low-
pitched sounds.
d) The diaphragm should be held lightly against the person's skin to listen for extra heart
sounds
and murmurs. - a) The diaphragm is used to listen for high-pitched sounds.
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 - d) Check the temperature of the room and offer blankets to the patient if he or
she feels cold
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 - a) Palpation
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. - d)
The otoscope directs light into the ear canal and onto the tympanic membrane.
An examiner is using an ophthalmoscope to examine a patient's 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) Usi
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
ng 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 - d) Rotating the lens
selector dial to bring the object into focus
The nurse is unable to palpate the right radial pulse on a patient. The best action would
be to:
d) hCheck hfor hthe hpresence hof hpulsations hwith ha hstethoscope h- h hc) hUse ha hDoppler hdevice
hto hcheck hfor hpulsations hover hthe harea
The hnurse his hpreparing hto hperform ha hphysical hassessment. hThe hcorrect haction hby hthe
hnurse his hreflected hby hwhich hstatement?
a) hThe hnurse hperforms hthe hexamination hfrom hthe hleft hside hof hthe hbed.
b) hThe hnurse hexamines htender hor hpainful hareas hfirst hto hhelp hrelieve hthe hpatient's
hanxiety.
c) hThe hnurse hfollows hthe hsame hexamination hsequence hregardless hof hthe hpatient's hage
hor hcondition.
d) hThe hnurse horganizes hthe hassessment hso hthat hthe hpatient hdoes hnot hchange hpositions
htoo hoften. h- h hd) hThe hnurse horganizes hthe hassessment hso hthat hthe hpatient hdoes hnot
hchange hpositions htoo hoften.
A hman his hat hthe hclinic hfor ha hphysical hexamination. hHe hstates hthat hhe his h"very hanxious"
habout hthe hphysical hexamination. hWhat hsteps hcan hthe hnurse htake hto hmake hhim hmore
hcomfortable?
a) hAppear hunhurried hand hconfident hwhen hexamining hhim.
b) hStay hin hthe hroom hwhen hhe hundresses hin hcase hhe hneeds hassistance.
c) hAsk hhim hto hchange hinto han hexamining hgown hand htake hoff hhis hundergarments.
d) hDefer hmeasuring hvital hsigns huntil hthe hend hof hthe hexamination, hwhich hallows hhim htime
hto hbecome hcomfortable. h- h ha) hAppear hunhurried hand hconfident hwhen hexamining hhim.
When hperforming ha hphysical hexamination, hsafety hmust hbe hconsidered hto hprotect hthe
hexaminer hand hthe hpatient hagainst hthe hspread hof hinfection. hWhich hof hthese hstatements
hdescribes hthe hmost happropriate haction hthe hnurse hshould htake hwhen hperforming ha
hphysical hexamination?
a) hThere his hno hneed hto hwash hone's hhands hafter hremoving hgloves, has hlong has hthe hgloves
hare hstill
intact.
b) hWash hhands hbefore hand hafter hevery hphysical hpatient hencounter.
