HESI- HEALTH ASSESSMENT EXAM QUESTIONS AND
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ANSWERS GRADED A+ 100% VERIFIED
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1. The nurse is setting up the physical environment for an interview with a
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client and plans to obtain subjective data regarding the client's health. Which
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interventions are appropriate? Select all that apply.
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A. Set the room temperature at a comfortable level.
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,B. Remove distracting objects from the interviewing area.
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C. Place a chair for the client across from the nurse's desk.
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D. Ensure comfortable seating at eye level for the client and nurse.
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E. Provide seating for the so that the faces a strong light.
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F. Ensure that the distance between the client and the nurse is at least
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ss 7 feet.: Correct Answers: A, B, and D
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Rationale:When preparing the physical environment for an interview, the nurse ss ss ss ss ss ss ss ss ss
would set the room temperature at a comfortable level. The nurse would provide
ss ss ss ss ss ss ss ss ss ss ss ss ss
sufficient lighting for the client and nurse to see each other. The nurse would
ss ss ss ss ss ss ss ss ss ss ss s ss ss
avoid having the client face a strong light because the client would have to squint
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
into the full light. Distracting objects and equipment need to be removed from the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
interview area. The nurse would arrange seating so that the nurse and client are
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
seated comfortably at eye level, and the nurse avoids facing the client across a
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
desk or table, because this creates a barrier.The distance between the nurse and
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the client would be set by the nurse at 4 to 5 feet (1.2 to 1.5 meters). If the nurse
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
places the client any closer, the nurse will be invading the client's private space and
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
may create anxiety in the client. If the nurse places the client farther away, the
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nurse may be seen as distant and aloof by the client.
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2. After performing an initial abdominal assessment on a client with nausea
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,and vomiting, the nurse would expect to note which finding?
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A. Waves of loud gurgles auscultated in all four quadrants.
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B. Low-pitched swishing auscultated in one or two quadrants.
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C. Relatively high-pitched clicks or gurgles auscultated in one or two quad-
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rants.
D. Very high pitched, loud rushes auscultated in especially in one or two
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ss quadrants.: Correct Answer: A ss ss ss
Rationale:Although frequency and intensity of bowel sounds vary, depending on the
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phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles.
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Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly
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associated with nausea and vomiting. A swishing or buzzing sound represents
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turbulent blood flow associated with a bruit. Bruits are not normal sounds. Bowel
ss ss ss ss ss ss ss ss ss ss ss ss ss
sounds are very
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, high-pitched and loud (hyperresonance) when the intestines are under tension, such
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as in intestinal obstruction. Therefore, options 2, 3, and 4 are incorrect.
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3. The nurse is performing a neurological assessment on a client and elicits a
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positive Romberg's sign. The nurse makes this determination based on which
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observation?
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A. An involuntary rhythmic, rapid twitching of the eyeballs.
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B. A dorsiflexion of the ankle and great toe with fanning of the other toes.
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C. A significant sway when the client stands erect with feet together, arms at
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ss the side and the eyes closed.
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D. A lack of sense of position when the client is unable to return
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ss extended fingers to a point of reference.: Correct Answer: C
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Rationale:In Romberg's test, the client is asked to stand with the feet together and
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the arms at the sides, and to close the eyes and hold the position; normally the
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ss ss ss ss ss ss
ANSWERS GRADED A+ 100% VERIFIED
ss ss ss ss ss
1. The nurse is setting up the physical environment for an interview with a
ss ss ss ss ss ss ss ss ss ss ss ss
client and plans to obtain subjective data regarding the client's health. Which
ss ss ss ss ss ss ss ss ss ss ss s
interventions are appropriate? Select all that apply.
ss ss ss ss ss ss ss
A. Set the room temperature at a comfortable level.
ss ss ss ss ss ss ss
,B. Remove distracting objects from the interviewing area.
ss ss ss ss ss ss
C. Place a chair for the client across from the nurse's desk.
ss ss ss ss ss ss ss ss ss ss
D. Ensure comfortable seating at eye level for the client and nurse.
ss ss ss ss ss ss ss ss ss ss
E. Provide seating for the so that the faces a strong light.
ss ss ss ss ss ss ss ss ss ss
F. Ensure that the distance between the client and the nurse is at least
ss ss ss ss ss ss ss ss ss ss ss ss
ss 7 feet.: Correct Answers: A, B, and D
ss ss ss ss ss ss ss
Rationale:When preparing the physical environment for an interview, the nurse ss ss ss ss ss ss ss ss ss
would set the room temperature at a comfortable level. The nurse would provide
ss ss ss ss ss ss ss ss ss ss ss ss ss
sufficient lighting for the client and nurse to see each other. The nurse would
ss ss ss ss ss ss ss ss ss ss ss s ss ss
avoid having the client face a strong light because the client would have to squint
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
into the full light. Distracting objects and equipment need to be removed from the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
interview area. The nurse would arrange seating so that the nurse and client are
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
seated comfortably at eye level, and the nurse avoids facing the client across a
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
desk or table, because this creates a barrier.The distance between the nurse and
ss ss ss ss ss ss ss ss s ss ss ss ss ss
the client would be set by the nurse at 4 to 5 feet (1.2 to 1.5 meters). If the nurse
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
places the client any closer, the nurse will be invading the client's private space and
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
may create anxiety in the client. If the nurse places the client farther away, the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
nurse may be seen as distant and aloof by the client.
ss ss ss ss ss ss ss ss ss ss ss
2. After performing an initial abdominal assessment on a client with nausea
ss ss ss ss ss ss ss ss ss ss
,and vomiting, the nurse would expect to note which finding?
ss ss ss ss ss ss ss ss ss
A. Waves of loud gurgles auscultated in all four quadrants.
ss ss ss ss ss ss ss ss
B. Low-pitched swishing auscultated in one or two quadrants.
ss ss ss ss ss ss ss
C. Relatively high-pitched clicks or gurgles auscultated in one or two quad-
ss ss ss ss ss ss ss ss ss ss
rants.
D. Very high pitched, loud rushes auscultated in especially in one or two
ss ss ss ss ss ss ss ss ss ss ss
ss quadrants.: Correct Answer: A ss ss ss
Rationale:Although frequency and intensity of bowel sounds vary, depending on the
ss ss ss ss ss ss ss ss ss ss
phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles.
ss ss ss ss ss ss ss ss ss ss ss ss
Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly
ss ss ss ss ss ss ss ss
associated with nausea and vomiting. A swishing or buzzing sound represents
ss ss ss ss ss ss ss ss ss ss ss
turbulent blood flow associated with a bruit. Bruits are not normal sounds. Bowel
ss ss ss ss ss ss ss ss ss ss ss ss ss
sounds are very
ss ss ss
, high-pitched and loud (hyperresonance) when the intestines are under tension, such
ss ss ss ss ss ss ss ss ss ss
as in intestinal obstruction. Therefore, options 2, 3, and 4 are incorrect.
ss ss ss ss ss ss ss ss ss ss ss ss
3. The nurse is performing a neurological assessment on a client and elicits a
ss ss ss ss ss ss ss ss ss ss ss ss
positive Romberg's sign. The nurse makes this determination based on which
ss ss ss ss ss ss ss ss ss ss ss
observation?
ss
A. An involuntary rhythmic, rapid twitching of the eyeballs.
ss ss ss ss ss ss ss
B. A dorsiflexion of the ankle and great toe with fanning of the other toes.
ss ss ss ss ss ss ss ss ss ss ss ss ss
C. A significant sway when the client stands erect with feet together, arms at
ss ss ss ss ss ss ss ss ss ss ss ss
ss the side and the eyes closed.
ss ss ss ss ss
D. A lack of sense of position when the client is unable to return
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ss extended fingers to a point of reference.: Correct Answer: C
ss ss ss ss ss ss ss ss ss
Rationale:In Romberg's test, the client is asked to stand with the feet together and
ss ss ss ss ss ss ss ss ss ss ss ss ss
the arms at the sides, and to close the eyes and hold the position; normally the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
