NUR 245 HESI Practice Quiz Questions
with Rationale
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?
A) "My life is really out of balance."
B) "I knew I should have changed my diet."
C) "I should have gone to church last week."
D) "I forgot to take my medicines last night." - A.
Rationale
The cause of disease may be viewed in three ways: biomedical, naturalistic, and magicoreligious. People
who conform to the naturalistic perspective of disease causation, believe that the forces of nature must
be kept in a natural balance or harmony.
A Muslim male client refuses to let the female nurse listen to his breath sounds during the examination.
How should the nurse respond?
A) Explain how the nursing skill will be performed before proceeding.
B) Examine client with an additional healthcare provider for support.
,C) Request a male nurse or healthcare provider to perform the exam.
D) Avoid any skills that involve touching the client during the exam. - C.
Rationale
Modesty is an important value in the Muslim community, and Muslims are reluctant to expose any part
of their body to healthcare members. Muslim clients are accustomed to examination by "same-sex"
healthcare providers.
A client reports lower abdominal pain and a feeling of pressure in the bladder. Which assessment finding
indicates acute urinary retention?
Hyperactive bowel sounds.
Dull sound percussed over bladder.
Bruits auscultated in left lower quadrant.
Tenderness with palpation of lower back. - B.
Rationale
Clients with acute urinary retention may present with lower abdominal pain and bladder distension.
Percussion (tapping on the body wall) is performed to detect differences in pitch. A dull sound produced
when percussing a distended urinary bladder is an indication of urinary retention.
While performing a head-to-toe assessment, the nurse assesses the client's pupillary accommodation.
During the second portion of the test, the nurse notes that the client's pupils constrict and there is a
convergence of the axes of the eyes. What action should the nurse implement next?
,A) Document a normal finding.
B) Request a referral to an opthamologist.
C) Repeat the test after having the client rest for 5 minutes.
D)Ask the client, "Have you noticed that you cannot see things close up?" - A. Document a normal
finding
When testing for pupillary accommodation, the nurse asks the client to focus on a distant object and
then shift the gaze to a penlight tip near the nose. Focusing on a distant object causes both pupils to
dilate; shifting the gaze to a near object (a finger or a penlight tip), which is held about 7 to 8 cm (3
inches) from the client's nose, should result in bilateral pupillary constriction with both eyes focused on
the object simultaneously.
The nurse performs a physical assessment on an older female client. Which change from the prior exam
may be an indication of osteoporosis?
A) Thick and brittle fingernails.
B) Decreased range of motion.
C) Weight gain of 15 pounds.
D) Height reduction of 1.5 inches - D.
Rationale
Osteoporosis is a loss of bone density that causes brittle bones and an increased risk for fractures.
Reduced height in older female clients with osteoporosis is generally the result of the shortening of the
vertebral column due to loss of water and thinning of the intervertebral discs.
The nurse is testing the client's shoulders for range of motion. What should the nurse document to
record normal internal rotation?
A) Ability to lift both arms over the head and swing each arm across the front of the body.
, B) Range of 90 degrees when the hands are placed at the small of the back.
C) A 90 degree range with both hands behind the head with elbows out.
D) Rolling of shoulders in a circular motion clockwise and counter clockwise. - B.
Rationale
To document normal internal rotation of the shoulders, the client should be able to demonstrate a
range of 90 degrees when the hands are placed at the small of the back.
Which technique should the nurse use to assess a client for scoliosis?
A) Watch gait while the client ambulates down the hallway.
B) Observe spine while the client is erect and bent forward.
C) Palpate neck while the client rotates head from side to side.
D) Assess for presence of pain when the client twists the torso. - B.
Rationale
Scoliosis is a lateral curvature of the spine seen upon inspection of the spine while the client stands
erect and then bends forward.
The nurse is conducting an interview with a client who speaks limited English. Which action should the
nurse implement?
A) Seek the assistance of a healthcare team member who speaks the client's preferred language.
B) Continue with the client's assessment interview using simple English words. C) Have the client
reschedule for a time when a family member can be there to interpret.
with Rationale
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?
A) "My life is really out of balance."
B) "I knew I should have changed my diet."
C) "I should have gone to church last week."
D) "I forgot to take my medicines last night." - A.
Rationale
The cause of disease may be viewed in three ways: biomedical, naturalistic, and magicoreligious. People
who conform to the naturalistic perspective of disease causation, believe that the forces of nature must
be kept in a natural balance or harmony.
A Muslim male client refuses to let the female nurse listen to his breath sounds during the examination.
How should the nurse respond?
A) Explain how the nursing skill will be performed before proceeding.
B) Examine client with an additional healthcare provider for support.
,C) Request a male nurse or healthcare provider to perform the exam.
D) Avoid any skills that involve touching the client during the exam. - C.
Rationale
Modesty is an important value in the Muslim community, and Muslims are reluctant to expose any part
of their body to healthcare members. Muslim clients are accustomed to examination by "same-sex"
healthcare providers.
A client reports lower abdominal pain and a feeling of pressure in the bladder. Which assessment finding
indicates acute urinary retention?
Hyperactive bowel sounds.
Dull sound percussed over bladder.
Bruits auscultated in left lower quadrant.
Tenderness with palpation of lower back. - B.
Rationale
Clients with acute urinary retention may present with lower abdominal pain and bladder distension.
Percussion (tapping on the body wall) is performed to detect differences in pitch. A dull sound produced
when percussing a distended urinary bladder is an indication of urinary retention.
While performing a head-to-toe assessment, the nurse assesses the client's pupillary accommodation.
During the second portion of the test, the nurse notes that the client's pupils constrict and there is a
convergence of the axes of the eyes. What action should the nurse implement next?
,A) Document a normal finding.
B) Request a referral to an opthamologist.
C) Repeat the test after having the client rest for 5 minutes.
D)Ask the client, "Have you noticed that you cannot see things close up?" - A. Document a normal
finding
When testing for pupillary accommodation, the nurse asks the client to focus on a distant object and
then shift the gaze to a penlight tip near the nose. Focusing on a distant object causes both pupils to
dilate; shifting the gaze to a near object (a finger or a penlight tip), which is held about 7 to 8 cm (3
inches) from the client's nose, should result in bilateral pupillary constriction with both eyes focused on
the object simultaneously.
The nurse performs a physical assessment on an older female client. Which change from the prior exam
may be an indication of osteoporosis?
A) Thick and brittle fingernails.
B) Decreased range of motion.
C) Weight gain of 15 pounds.
D) Height reduction of 1.5 inches - D.
Rationale
Osteoporosis is a loss of bone density that causes brittle bones and an increased risk for fractures.
Reduced height in older female clients with osteoporosis is generally the result of the shortening of the
vertebral column due to loss of water and thinning of the intervertebral discs.
The nurse is testing the client's shoulders for range of motion. What should the nurse document to
record normal internal rotation?
A) Ability to lift both arms over the head and swing each arm across the front of the body.
, B) Range of 90 degrees when the hands are placed at the small of the back.
C) A 90 degree range with both hands behind the head with elbows out.
D) Rolling of shoulders in a circular motion clockwise and counter clockwise. - B.
Rationale
To document normal internal rotation of the shoulders, the client should be able to demonstrate a
range of 90 degrees when the hands are placed at the small of the back.
Which technique should the nurse use to assess a client for scoliosis?
A) Watch gait while the client ambulates down the hallway.
B) Observe spine while the client is erect and bent forward.
C) Palpate neck while the client rotates head from side to side.
D) Assess for presence of pain when the client twists the torso. - B.
Rationale
Scoliosis is a lateral curvature of the spine seen upon inspection of the spine while the client stands
erect and then bends forward.
The nurse is conducting an interview with a client who speaks limited English. Which action should the
nurse implement?
A) Seek the assistance of a healthcare team member who speaks the client's preferred language.
B) Continue with the client's assessment interview using simple English words. C) Have the client
reschedule for a time when a family member can be there to interpret.
