HEALTH ASSESSMENT HESI PRACTICE UPDATE|EXAM QUESTIONS WITH MULTIPLE CHOICES |VERIFIED & REVISED ANSWERS (NEW)!!!

HEALTH ASSESSMENT HESI
PRACTICE UPDATE|EXAM
QUESTIONS WITH MULTIPLE
CHOICES |VERIFIED & REVISED
ANSWERS (NEW)!!!
Amnursemconductingmamphysicalmassessmentmismobservingmthemclient'smbalancemandmperformingmte
stsmtomdeterminemthemclient'smsensemofmequilibrium.mWhichmcranialmnervemismthemnursemassessing
?



1.mCranialmnervemII

2.mCranialmnervemIX

3.mCranialmnervemVII

4.mCranialmnervemVIIIm-mCORRECTmANSWERm4.mCranialmnervemVIII



CranialmnervemVIIImismthemacousticmnerve.mHearingmtestsmaremperformedmtomassessmthemcochlearmp
ortionmofmthismnerve.mTestsmtomassessmequilibrium,msuchmasmobservationmofmthemclient'smbalancem
whenmthemclientmismwalkingmormstanding,minvolvemthemvestibularmportion.



Amnursemperformingmamneurologicalmassessmentmofmamclientmwhomhasmsustainedmamstrokem(brainma
ttack)mismpreparingmtomcheckmformstereognosis.mWhichmactionmshouldmthemnursemtakemtomperformm
thismassessment?



1.mPlacingmanmobjectminmthemclient'smhandmandmaskingmthemclientmtomidentifymit

2.mTracingmamnumbermonmthemclient'smhandmandmaskingmthemclientmtomidentifymit

3.mMovingmthemclient'smfingermupmandmdownmandmaskingmthemclientmwhichmwaymitmismbeingmmoved

4.mMakingmtwomsimultaneousmpinpricksmonmthemskinmandmaskingmthemclientmtomdistinguishmthemm-
mCORRECTmANSWERm1.mPlacingmanmobjectminmthemclient'smhandmandmaskingmthemclientmtomidentifym


it

,Stereognosismismthemclient'smabilitymtomrecognizemobjectsmplacedminmhismormhermhand.



Amnursemperformingmanmabdominalmassessmentmofmamclientmismpreparingmtomauscultatemformbowel
msounds.mInmwhichmpartmofmthemabdomenmshouldmthemnursemplacemthemstethoscopemfirst?




1.mLeftmuppermquadrant

2.mLeftmlowermquadrant

3.mRightmuppermquadrant

4.mRightmlowermquadrantm-mCORRECTmANSWERm4.mRightmlowermquadrant



Tomauscultatemformbowelmsounds,mthemnursemplacesmthemdiaphragmmendpiecemofmthemstethoscope
mlightlymagainstmthemskin,mthenmbeginsmtomauscultateminmthemrightmlowermabdominalmquadrant,minm


themareamofmthemileocecalmvalve,mbecausembowelmsoundsmaremalwaysmpresentmtheremnormally.



Amnursemperformingmamphysicalmassessmentmofmamclientmismcheckingmthemclient'smmouthmandmthro
at.mAsmpartmofmthemassessment,mthemnursemplansmtomassessmthemfunctionmofmcranialmnervemXII.mWh
atmshouldmthemnursemaskmthemclientmtomdomasmammeansmofmassessingmthismnerve?



1.mFrown

2.mShowmthemteeth

3.mStickmoutmthemtongue

4.mSaym"ah"masmthemtonguemismdepressedmwithmamtonguembladem-
mCORRECTmANSWERm3.mStickmoutmthemtongue




TomassessmthemfunctionmofmcranialmnervemXIIm(themhypoglossalmnerve),mthemnursemasksmthemclientmt
omstickmoutmthemtongue.mThemnursemthenmnotesmthemforwardmthrustminmthemmidlinemasmthemclientm
protrudesmthemtongue.mThemnursemalsomasksmthemclientmtomverbalizemcertainmwordsmandmthenmlist
enmformclear,mdistinctmspeech.

,Discontinuousmhigh-
pitchedmcracklingmsoundsmheardmduringminspirationmthatmdomnotmclearmwithmcoughingm-
mCORRECTmANSWERmFinemCrackles




Loud,mlow-
pitchedmbubblingmandmgurglingmsoundsmheardmonminspirationm(maymbempresentmonmexpiration);mm
aymdecreasemwithmcoughingmormsuctioningmbutmreappearm-mCORRECTmANSWERmCoarsemCrackles



High-pitched,mcontinuousmmusicalmsoundsmheardmduringminspirationmormexpirationm-
mCORRECTmANSWERmWheezing




Loud,mlow-
pitched,mcoarsemrumblingmsoundsmheardmduringminspirationmormexpiration;mmaymbemclearedmbymco
ughingm-mCORRECTmANSWERmRhonchi



Dry,mgratingmqualitymsoundsmheardmbestmduringminspiration;mdoesmnotmclearmwithmcoughingm-
mCORRECTmANSWERmPleuralmFrictionmRub




Moderatelympitched;mheardmovermthemmajormbronchim-
mCORRECTmANSWERmBronchovesicularmsounds




Low-pitchedmrustling;mheardmovermthemperipheralmlungmfieldsm-
mCORRECTmANSWERmVesicularmsounds




High-pitched,mwithmamharsh,mhollow,mtubularmqualitymheardmovermthemtracheamandmlarynxm-
mCORRECTmANSWERmBronchialmsounds

, Amnursempreparingmtomperformmamrespiratorymassessmentmofmanmadultmclientmismreadingmthemclient
'smmedicalmrecord.mThemnursemseesmthatmthemhealthmcaremprovidermnotedmresonancemonmpercussi
onmofmthemclient'smposteriormchest.mWhatminterpretationmdoesmthemnursemmakemofmthismfinding?



1.mThemclientmhasmnormal,mhealthymlungs.

2.mThemclientmmaymhavemampneumothorax.

3.mThemclientmmostmlikelymhasmamlungmtumor.

4.mAnmexcessivemamountmofmairmismpresentminmthemlungs.m-
mCORRECTmANSWERm1.mThemclientmhasmnormal,mhealthymlungs.




Resonancemonmpercussionmpredominatesminmhealthymadultmlungmtissue.



Whenmtoommuchmairmismpresentmsuchmasminmthemcasemofmemphysemamwheremitmismtrappedminmthem
alveolimandmpneumothoraxmwheremitmismtrappedminmthempleuralmspacemleadingmtomlungmcollapse.m-
mCORRECTmANSWERmHyperresonance




Indicatesmanmabnormalmdensityminmthemlungs,msuchmasmthatmnotedminmpneumonia,mpleuralmeffusio
n,mormatelectasismorminmthempresencemofmamtumor.m-
mCORRECTmANSWERmDullmnotemonmpercussionmofmthemlungs




Amnursemperformingmambreastmexaminationmismpreparingmtompalpatemthemclient'smbreasts.mIntomwh
ichmpositionmshouldmthemnursemassistmthemclientmtomperformmpalpation?



1.mAmstandingmposition,mwithmthemclientmholdingmbothmarmsmabovemhermhead

2.mAmstandingmposition,mwithmthemclientmholdingmhermhandsmfirmlymonmhermhips

3.mAmsupinemposition,mwithmthemarmmonmthemsidembeingmexaminedmpositionedmacrossmthemchest

4.mAmsupinemposition,mwithmthemarmmonmthemsidembeingmexaminedmpositionedmbehindmthemheadma
ndmamsmallmpillowmplacedmundermthemshouldermonmthemsamemsidem-