& VERIFIED ANSWERS (UPDATED TO PASS)
1. A 29 year old male client tendon reflexes on the
informs the nurse that he right side and elicits a brisk
came to the clin- ic to see if, 4+ response. Which
"Maybe I have lung can- cer interpreta- tion of this
or something," and wants to finding is accurate?
get A. A normal reflex
checked out since, "I can't seem response.
to get rid of this body-wracking B. Absent or sluggish
dry cough that has been response con- sistent with
hanging around for the last six a lower motor neuron le-
weeks." Which computer doc- sion.
umentation of this client's C. Flaccid paralysis.
concerns should the nurse
enter?
A. Presents with a hacking non-
pro- ductive 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"
2. A 75-year-old client with a
recent his- tory of a
cerebrovascular accident (CVA)
presents with right hemipare-
sis. The nurse tests the deep
, HESI V2 HEALTH ASSESSMENT WITH ALL CORRECT
& VERIFIED ANSWERS (UPDATED TO PASS)
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.
Correct answer is D, brisk 4+ response is correlated
with hyperactive response.
, HESI V2 HEALTH ASSESSMENT WITH ALL CORRECT
& VERIFIED ANSWERS (UPDATED TO PASS)
D. Hyperactive response
consistent with an upper motor
neuron disorder.
Correct answer is D. McBurney's point is
3. The nurse examines a client's related to appendicitis and not spleen.
ab- domen. Which finding
indicates an abnormal
response when palpating the
spleen?
A. Pain notes when palpating
McBur- ney's point.
B. Tip of spleen palpable when
client is asked to forcefully
exhale.
C. Rebound tenderness with
com- pression over right upper
quadrant. *under mandible towards lymph nodes.
D. Firm mass palpated at transverse to trachea
bottom of left rib cage.
4. In auscultating for the
presence of a carotid artery Correct answer is C. The nurse should listen to
bruit, the nurse places the bell all
of the stethoscope at which
location?
5. A male client arrives at the clinic
for
follow-up health assessment after re- lungs fields during assessment and
move from side
cent antibiotic treatment for should the nurse imple-
pneu- monia without ment to assess for
hospitalization. Which technique adventitious lung sounds?
, HESI V2 HEALTH ASSESSMENT WITH ALL CORRECT
& VERIFIED ANSWERS (UPDATED TO PASS)
A. Use the bell of the to side during auscultation.
stethoscope to listen to the lung
fields over lower lobes. B. Have
the client lay flat while listening
to the anterior surface of the