Hesi V2 Health Assessment Exam | Questions & Answers (Verified) | Latest Update | Graded A+

HESI V2 HEALTH ASSESSMENT
EXAM | QUESTIONS & ANSWERS (VERIFIED) |
LATEST UPDATE | GRADED A+




A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I
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have lung cancer or something," and wants to get checked out since, "I can't seem to
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get rid of this body-wracking dry cough that has been hanging around for the last six
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weeks." Which computer documentation of this client's concerns should the nurse
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enter?

A. Presents with a hacking non-productive cough of 6 weeks duration.
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B. Describe having a "body-wracking dry cough" of 6 weeks duration.
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C. Expresses concern of "lung cancer" symptoms for last 6 weeks.
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D. Young adult male presents with fears that he has "lung cancer"
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Correct Answer is B, as assessment process includes chief complaint which is how the
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patient describe why he is here in the hospital or clinic and can't include diagnosis.
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,A 75-year-oldclientwitha recenthistory ofacerebrovascular accident(CVA)presents
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with right hemiparesis. The nurse tests the deep tendon reflexes on the right side and
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elicits a brisk 4+ response. Which interpretation of this finding is accurate?
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A. A normal reflex response.
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B. Absent or sluggish response consistent with a lower motor neuron lesion.
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C. Flaccid paralysis.
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, D. Hyperactive response consistent with an upper motor neuron disorder.
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Correct Answer is D, brisk 4+ response is correlated with hyperactive response.
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The nurse examines a client's abdomen. Which finding indicates an abnormal response
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when palpating the spleen?,/ ,/ ,/




A. Pain notes when palpating McBurney's point.
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B. Tip of spleen palpable when client is asked to forcefully exhale.
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C. Rebound tenderness with compression over right upper quadrant. D. Firm mass
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palpated at bottom of left rib cage. ,/ ,/ ,/ ,/ ,/ ,/




Correct Answer is D. McBurney's point is related to appendicitis and not spleen.
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In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the
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stethoscope at which location? ,/ ,/ ,/




*under mandible towards lymph nodes. transverse to trachea
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A male client arrives at the clinic for follow-up health assessment after recent antibiotic
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treatment for pneumonia without hospitalization. Which technique should the nurse
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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
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the client lay flat while listening to the anterior surface of the chest.
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C. Press the stethoscope's diaphragm firmly on the skin over each lung field.
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D. Shave all chest hair that may distort sounds heard through the diaphragm.
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