HESI Health Assessment Exam 2 Study Guide
Objective. - ✔ During the interview portio of the health assessment, a nurse notes
the person's posture, physical appearance, and ability to converse. How should the
nurse document these findings?
A round smooth mass that slides between the fingers - ✔ As a part of a routine
health assessment, the nurse assesses the kidneys as part of the abdominal
assessment. Which assessment finding should the nurse conclude is normal when
palpating the client's right kidney?
Upper outer quadrant. - ✔ When teaching a client how to perform a monthly breast
self-assessment, the nurse should tell the client that it is most important to assess
which part of the breast more closely for changes?
Gland is not palpable - ✔ The nurse is completing a physical exam on an adult
client. Which thyroid finding is considered normal?
4th intercostal space, right midclavicular line. Correct - ✔ The nurse is assessing a
client's middle lung lobe. What is the best location for the nurse to place a
stethoscope diaphragm to hear normal lung sounds in this lobe?
Document a normal finding. - ✔ 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 convergence
of the axes of the eyes. What action should the nurse implement next?
A consensual response in the opposite eye. - ✔ The nurse is performing a head-to-
toe assessment on a client. The nurse is assessing the client's pupillary light reflex
by first darkening the room and asking the person to gaze into the distance. Then,
the nurse advances a light toward one eye from the client's side. What would the
nurse expect to see at this time?
Inspect the scalp looking for nits - ✔ A client presents with a rash along the
occipital area of the hairline and reports intense itching. How should the nurse begin
the objective part of the examination?
, Have you had sudden and severe pain in the toes or feet? - ✔ A client has come to
the clinic for a routine health assessment. What is the best assessment question for
the nurse to ask a client after observing tophi on the client's ear cartilage?
Measure bilateral ankle circumference with a non-stretchable tape measure. - ✔
How should the nurse assess for lower extremity edema in a client who has been
diagnosed with heart failure?
Seek the assistance of a healthcare team member who speaks the client's preferred
language. - ✔ The nurse is conducting an interview with a client who speaks
limited English. What action should the nurse implement?
Ask whether the client has been in a foreign country recently. - ✔ A client reports a
recent onset of nausea and vomiting. What subjective information is important for
the nurse to ascertain?
Document at least 3 generations of the client's family medical history. Correct - ✔
The nurse is conducting a family history as part of the assessment interview. Which
action should the nurse take to ensure that sufficient information about the client's
blood relatives is obtained?
Verbal descriptor scale. - ✔ An older client has just returned to the room following
a surgical procedure. Which pain scale should the nurse use when assessing the
client's pain level?
Dull sound percussed over bladder. - ✔ A client reports lower abdominal pain and a
feeling of pressure in the bladder. Which assessment finding indicates acute urinary
retention?
Nocturia. - ✔ Which term should the nurse use to document the condition of a
client who reports waking up frequently during the night to urinate?
Measure the apical pulse and compare it to the peripheral pulse. - ✔ Which
procedure should the nurse use to assess for a pulse deficit?
Ask the client to urinate before beginning the examination. - ✔ A client is in the
clinical for a yearly physical examination. Which action should the nurse take when
preparing to examine the client's abdomen?
Objective. - ✔ During the interview portio of the health assessment, a nurse notes
the person's posture, physical appearance, and ability to converse. How should the
nurse document these findings?
A round smooth mass that slides between the fingers - ✔ As a part of a routine
health assessment, the nurse assesses the kidneys as part of the abdominal
assessment. Which assessment finding should the nurse conclude is normal when
palpating the client's right kidney?
Upper outer quadrant. - ✔ When teaching a client how to perform a monthly breast
self-assessment, the nurse should tell the client that it is most important to assess
which part of the breast more closely for changes?
Gland is not palpable - ✔ The nurse is completing a physical exam on an adult
client. Which thyroid finding is considered normal?
4th intercostal space, right midclavicular line. Correct - ✔ The nurse is assessing a
client's middle lung lobe. What is the best location for the nurse to place a
stethoscope diaphragm to hear normal lung sounds in this lobe?
Document a normal finding. - ✔ 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 convergence
of the axes of the eyes. What action should the nurse implement next?
A consensual response in the opposite eye. - ✔ The nurse is performing a head-to-
toe assessment on a client. The nurse is assessing the client's pupillary light reflex
by first darkening the room and asking the person to gaze into the distance. Then,
the nurse advances a light toward one eye from the client's side. What would the
nurse expect to see at this time?
Inspect the scalp looking for nits - ✔ A client presents with a rash along the
occipital area of the hairline and reports intense itching. How should the nurse begin
the objective part of the examination?
, Have you had sudden and severe pain in the toes or feet? - ✔ A client has come to
the clinic for a routine health assessment. What is the best assessment question for
the nurse to ask a client after observing tophi on the client's ear cartilage?
Measure bilateral ankle circumference with a non-stretchable tape measure. - ✔
How should the nurse assess for lower extremity edema in a client who has been
diagnosed with heart failure?
Seek the assistance of a healthcare team member who speaks the client's preferred
language. - ✔ The nurse is conducting an interview with a client who speaks
limited English. What action should the nurse implement?
Ask whether the client has been in a foreign country recently. - ✔ A client reports a
recent onset of nausea and vomiting. What subjective information is important for
the nurse to ascertain?
Document at least 3 generations of the client's family medical history. Correct - ✔
The nurse is conducting a family history as part of the assessment interview. Which
action should the nurse take to ensure that sufficient information about the client's
blood relatives is obtained?
Verbal descriptor scale. - ✔ An older client has just returned to the room following
a surgical procedure. Which pain scale should the nurse use when assessing the
client's pain level?
Dull sound percussed over bladder. - ✔ A client reports lower abdominal pain and a
feeling of pressure in the bladder. Which assessment finding indicates acute urinary
retention?
Nocturia. - ✔ Which term should the nurse use to document the condition of a
client who reports waking up frequently during the night to urinate?
Measure the apical pulse and compare it to the peripheral pulse. - ✔ Which
procedure should the nurse use to assess for a pulse deficit?
Ask the client to urinate before beginning the examination. - ✔ A client is in the
clinical for a yearly physical examination. Which action should the nurse take when
preparing to examine the client's abdomen?
