Physical Health Assessment HESI Ultimate Review Packet 2024

Question 1: 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 last 6 weeks. D. Young adult male presents with fears that he has “lung cancer” 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’t 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’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. D. Firm mass palpated at bottom of left rib cage. Correct answer is D. McBurney’s point is related to appendicitis and not spleen. 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’s 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. 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’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. 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’s 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. Question 9: 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. Correct answer is C. Location and appearance of the ulcer would give us the type (venous vs arterial) Venous Ulcers Location: Venous leg ulcers usually develop on the inner lower leg, above the medial malleolus, gaiter area. Size and shape: Wounds are often shallow, but large, and typically have irregular edges that may also slope. Color: Typically, venous wounds appear ruddy red, with granular tissue. There may also be discoloration with yellow slough present. Appearance: Surrounding skin may be shiny, warm or scaly. Tunneling is uncommon. Arterial Wounds Location: Arterial wounds occur most often on the foot, in between or at the tips of the toes, at pressure points from foot wear, on the heels and around lateral malleolus (the bone on the outside of the ankle joint). Size and shape: Most likely round, with a “punched out” appearance. They may range in size from small to large, with well-defined edges. Color: Often occur yellow, brown or black in color. Skin may also appear pale and non- granulating. Appearance: Arterial ulcers are often deep, but may also appear shallow in early stages. Skin surrounding the wound is often thin, smooth, taut, and dry. Loss of hair on the leg is also common. Question 10: 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. Correct answer is D. Hair, nail, and skin are the most important reflection of nutritional status. NursingHero® Question 11: 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. 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. Question 12: 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. D. Face is flushed and diaphoretic. 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. When the skin becomes a bluish color, the symptom is called cyanosis. Most commonly, blue lips are caused by a lack of oxygen in the blood. Most causes of cyanosis are serious and a symptom of your body not getting enough oxygen. Over time, this condition will become life- threatening. It can lead to respiratory failure, heart failure, and even death, if left untreated. Question 13: 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.” Correct answer is C. Both respiratory rate and breath sounds are normal. Further assessment is needed by asking the client to describe his SOB. NursingHero® Question: 14: 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. Correct answer is D. Observation is the way to detect barrel chest which is associated with COPD. Question 15: 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. Correct answer is A. 2+ pitting edema indicate swelling in the lower extremities. Homans's sign is often used in the diagnosis of deep venous thrombosis of the leg. A positive Homans's sign (calf pain at dorsiflexion of the foot) is thought to be associated with the presence of thrombosis. Question 16: 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. D. Assess the spinal reflexes for demyelination symptoms. Correct answer is C. Full cranial nurses assessment should be completed before considering the other options. NursingHero® Q17. When performing a neurologic assessment on an alert client, the nurse observes that the client’s pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment? A. PERRL. B. GCS of 15. C. PERLA. D. Neuro status intact. Correct answer is A. “Pupils Equal, Round, and Reactive to Light”. Q18. Which assessment technique provides the nurse with the best data related to the client’s level of peripheral perfusion? Correct answer is C Q19. The nurse is assessing a female client who states that her hemorrhoids are inflamed and hurt constantly. Which intervention is best for the nurse to complete a focused assessment? A. Ask the client how long she has experienced discomfort related to hemorrhoids. B. Place the client in a standing position, leaning over the exam bed for inspection. C. Determine if the client uses any over-the-counter preparation for hemorrhoids. D. Position client in left lateral position to inspect perianal area for fissures or sacs. Correct answer is D. A focused assessment collects relevant information pertaining to the current condition of the patient after a change or new symptom develops. NursingHero® Q20. The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. What question should the nurse ask first? “Have you A. Been depressed lately?” B. Had everything to eat in the last 24 hours?” C. Ever had problems with you blood sugar?” D. Been sleeping well?” Correct answer is D. To rule out symptoms for lack of sleep, asking the client if he slept well would help determining why he has the presented symptoms. Q21. After checking a client’s pupillary response to light, the practical nurse (PN) tells the nurse that the client’s pupils are constricted with minimal response to light. Before verifying the PN’s findings, which action should the nurse take? A. Brighten the light in the client’s room. B. Assess the client’s visual fields. C. Review the client’s medication list. D. Administer PRN saline eye solution. Correct answer is B. PERRLA: Accommodation is the following step which refers to your eyes' ability to see things that are both close up and far away. Q22. The nurse completes inspection of the abdomen on an adult client. Which finding is considered normal for this client? A. Masses. B. Peristaltic waves. C. Heterogeneous color. D. Homogeneous color. Correct answer is D. Symmetry is a great value of normal body imagine while performing inspection. Q23. Which skill should the nurse have an older client demonstrate to evaluate performance of daily living activities? A. Opening a bar soap package. B. Sorting a collection of socks. C. Reading a short paragraph. D. Telephoning a family member. Correct answer is B. ADL is used as an indicator of a person’s functional status. The inability to perform ADLs results in the dependence of other individuals and/or mechanical devices. The inability to accomplish essential activities of daily living may lead to unsafe conditions and poor quality of life. Basic ADLs The basic ADL include the following categories: • Ambulating: The extent of an individual’s ability to move from one position to another and walk independently. • Feeding: The ability of a person to feed oneself. • Dressing: The ability to select appropriate clothes and to put the clothes on. • Personal hygiene: The ability to bathe and groom oneself and to maintaining dental hygiene, nail and hair care. • Continence: The ability to control bladder and bowel function • Toileting: The ability to get to and from the toilet, using it appropriately, and cleaning oneself. Q24. A client sustained a subconjunctival hemorrhage. The presence of which set of symptoms indicate that the client needs to be seen for further evaluation by an ophthalmologist? A. Acute pain, change in visual acuity, and foreign body sensation. B. Frequent burning, irritation and tearing of the eyes. C. Bilateral itchy, red eyes with watery discharge/ D. Diminished ability to focus on close work and excessive illumination required. Correct answer is D. Diminished ability to focus on close work could be a sign of cranial nerve damage and could lead to reduced visual acuity, due to a reduced ability of the lens in the eye to focus light on the retina, results in images that appear blurry. Q25. To assess a female client for hirsutism, which action should the nurse take? A. Lightly palpate over the client’s entire scalp. B. Apply and release light pressure to the skin. C. Assess the appearance of the client’s face. D. Observe the hair shafts on the client’s scalp. Correct answer is C. Hirsutism is a condition in women that results in excessive growth of dark or coarse hair in a male-like pattern like face, chest and back. Q26. An older adult client is admitted to the medical unit because of loss of appetite and generalized malaise. To analyze the client medical condition, which laboratory value is most important for the nurse to review? A. Hematocrit. B. Serum Calcium. C. Hemoglobin. D. Serum pre-albumin. Correct answer is C. Hemoglobin is the main lab value to check for anemia. Anemia is a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues. Having anemia can make you feel tired and weak. There are many forms of anemia, each with its own cause. Anemia can be temporary or long term, and it can range from mild to severe. Q27. A male client returns to the clinic for a follow-up visit after being treated for a bladder infection. While examining the client, which finding indicated an expected response to the treatment? A. Orange sized prostate gland. B. Post-voided residual volume of 50 mL. C. Pain score of 1 out of 10 with urination. D. Decreasing sperm cell count. Correct answer is C. NursingHero® Q28. The nurse completes palpitation of the abdomen on an older adult client. Which finding is considered normal for the client? A. Non-tender. B. Gallop. C. Thrill. D. Peristaltic waves. Correct answer is D. The small intestine undergoes segmental contractions and peristaltic waves Segmental contractions occur for short distances only along the small intestine Peristaltic waves occur for variable distances to cause the chyme to move along the small intestine. Q29. The nurse has just completed palpitation maneuvers for lymph nodes on a 75-year-old female client. Which findings are considered normal for this elderly client? A. Nodes are non-palpable. B. Axillary nodes feel soft and fatty. C. Nodes feel ropey and rubbery. D. Inguinal nodes are enlarged and warm to the touch. Correct answer is A. Normal lymph nodes are non-palpable. Q30. A women comes to the clinic for her first prenatal visit. The nurse is conducting a health history and the women begins to cry when asked about previous pregnancies. Which response is best for the nurse to provide? A. “Why don’t I come back in a few minutes after you are more composed.” B. Offer a tissue and sit quietly until the crying subsides. C. Allow the client to compose herself then change the subject. D. “I’m so sorry that I made you cry. I didn’t mean to upset you.” Correct answer is C. Try always to listen to the patient when she is in a bad mood or wants to express her feeling.