HESI Health Assessment Exam 4 2024
A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I have
lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this
body-wracking dry cough that has been hanging around for the last six weeks." Which
computer documentation of this client's concerns should the nurse enter?
A. Presents with a hacking non-productive 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" - 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.
A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with
right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk
4+ response. Which interpretation of this finding is accurate? A. A normal reflex response.
B. Absent or sluggish response consistent with a lower motor neuron lesion.
C. Flaccid paralysis.
D. Hyperactive response consistent with an upper motor neuron disorder. - Correct answer is
D, brisk 4+ response is correlated with hyperactive response.
The nurse examines a client's abdomen. Which finding indicates an abnormal response when
palpating the spleen?
A. Pain notes when palpating McBurney's point.
B. Tip of spleen palpable when client is asked to forcefully exhale.
C. Rebound tenderness with compression over right upper quadrant. D. Firm mass palpated at
bottom of left rib cage. - Correct answer is D. McBurney's point is related to appendicitis
and not spleen.
In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the
stethoscope at which location? - *under mandible towards lymph nodes. transverse to trachea
A male client arrives at the clinic for follow-up health assessment after recent antibiotic
treatment for pneumonia without hospitalization. Which technique should the nurse
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 the
client lay flat while listening to the anterior surface of the chest.
C. Press the stethoscope's diaphragm firmly on the skin over each lung field.
D. Shave all chest hair that may distort sounds heard through the diaphragm. - Correct answer
is C. The nurse should listen to all lungs fields during assessment and move from side to
side during auscultation.
A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a
muffled voice. Which complication should the nurse suspect?
A. Foreign body obstruction.
, B. Laryngeal polyps.
C. Peritonsillar abscess.
D. Nasal polyps - Correct answer is C. Since infections are associated with abscesses and pus.
The rnurse ris robtaining ra rhealth rhistory rfor ra rclient rprior rto ra rscheduled rcholecystectomy.
rWhile rinterviewing rthe rclient, rwhich rassessment rtechnique rshould rthe rnurse ruse rwhen
rasking rabout rthe rclient's ruse rof rillegal rdrugs rand ralcohol? r r
A. Obtain ra rdrug rusing rscreen rto rverify rlegitimacy rof rclient's rstated rhistory. r r
B. Allow rthe rclient rto rdecline ranswering rsocial rquestions. r r
C. Ask rspecifically rabout ralcohol, rmarijuana, rcocaine, rher r
D. Use rthe rterm rillegal ror rillicit rto rdescribe rstreet rdrug. r- rCorrect ranswer ris rC. rWhen
rinterviewing rthe rpatient, rquestions rshould rbe rclear rand rspecific. r
r
The rnurse rapplies rpressure rover ran rarea rof rthe rlower rabdomen rwhere rthe rclient rreports
rpain. rThe rclient rdenies rpain rupon rpalpation, rbut rreports rpain rwhen rthe rpressure ris
rreleased. rWhat raction rshould rthe rnurse rimplement? r
A. Offer rto radminister ra rlaxative rprescribed rfor rPRN ruse. r r
B. Obtain ra rprescription rto rcatheterize rthe rclient's rbladder. r r
C. Instruct rthe rclient rin rdistraction rand rrelation rtechniques. r r
D. Notify rthe rhealthcare rprovider rof rthe rrebound rtenderness. r- rCorrect ranswer ris rD. rAs
rthis rcould rbe ra rsign rof rappendicitis. r
r
The rnurse ris rassessing ran rulcer ron ra rclient's rlower rextremity, rwhich ris rlikely rthe rresult rof
reither rvenous ror rarterial rinsufficiency. rWhich rassessment rtechnique rshould rthe rnurse ruse
rto rdifferentiate rthe rpathophysiology rcausing rthe rulcer? r
A. Measure rthe rdegree rof rjoin rrange rof rmotion rin rthe rextremity. r r
B. Compare rthe rskin rturgor rof rthe rclient's rupper rand rlower rleg. r r
C. Observe rthe rspecific rlocation rand rappearance rof rthe rulceration. r r
D. Note rany rchange rin rthe rcolor rof rthe rulcer rwhen rthe rleg ris rmoved r- rCorrect ranswer ris
rC. rLocation rand rappearance rof rthe rulcer rwould rgive rus rthe rtype r(venous rvs rarterial) r
r
The rnurse ris rconducting ra rphysical rassessment rof ra ryoung radult. rWhich rinformation
rprovides rthe rbest rindication rof rthe rindividual's rnutritional rstatus? rA. rStatus rof rcurrent
rappetite. r r
B. A r24-hour rdiet rhistory. r r
C. History rof ra rrecent rweight rloss. r r
D. Condition rof rhair, rnails, rand rskin. r- rCorrect ranswer ris rD. rHair, rnail, rand rskin rare rthe
rmost rimportant rreflection rof rnutritional rstatus. r
r
The rnurse ris rassessing ra rhealthy radult rmale rduring ran rannual rphysical rexamination. rThe
rnurse rauscultates rthe rclient's rabdomen rand rhears rgurgling rsound revery rten rseconds. rWhat
raction rshould rthe rnurse rtake rin rresponse rto rthis rfinding? r
A. Document rthis rnormal rbowel rsound ractivity rin rthe rrecord. r r
B. Encourage rincreased rconsumption rof rfiber rin rthe rdiet. r r
C. Observe rthe rnext rbowel rmovement rfor rsigns rof rbleeding. r r
D. Report rthe rhyperactivity rto rthe rhealthcare rprovider. r- rCorrect ranswer ris rA. rNormal
rBowel rsound rconsist rof rclicks rand rgurgles rand r5-30 rper rminute. rAn roccasional
rborborygmus r(Loud rprolonged rgurgle) rmay rbe rhear. r
A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I have
lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this
body-wracking dry cough that has been hanging around for the last six weeks." Which
computer documentation of this client's concerns should the nurse enter?
A. Presents with a hacking non-productive 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" - 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.
A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with
right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk
4+ response. Which interpretation of this finding is accurate? A. A normal reflex response.
B. Absent or sluggish response consistent with a lower motor neuron lesion.
C. Flaccid paralysis.
D. Hyperactive response consistent with an upper motor neuron disorder. - Correct answer is
D, brisk 4+ response is correlated with hyperactive response.
The nurse examines a client's abdomen. Which finding indicates an abnormal response when
palpating the spleen?
A. Pain notes when palpating McBurney's point.
B. Tip of spleen palpable when client is asked to forcefully exhale.
C. Rebound tenderness with compression over right upper quadrant. D. Firm mass palpated at
bottom of left rib cage. - Correct answer is D. McBurney's point is related to appendicitis
and not spleen.
In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the
stethoscope at which location? - *under mandible towards lymph nodes. transverse to trachea
A male client arrives at the clinic for follow-up health assessment after recent antibiotic
treatment for pneumonia without hospitalization. Which technique should the nurse
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 the
client lay flat while listening to the anterior surface of the chest.
C. Press the stethoscope's diaphragm firmly on the skin over each lung field.
D. Shave all chest hair that may distort sounds heard through the diaphragm. - Correct answer
is C. The nurse should listen to all lungs fields during assessment and move from side to
side during auscultation.
A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a
muffled voice. Which complication should the nurse suspect?
A. Foreign body obstruction.
, B. Laryngeal polyps.
C. Peritonsillar abscess.
D. Nasal polyps - Correct answer is C. Since infections are associated with abscesses and pus.
The rnurse ris robtaining ra rhealth rhistory rfor ra rclient rprior rto ra rscheduled rcholecystectomy.
rWhile rinterviewing rthe rclient, rwhich rassessment rtechnique rshould rthe rnurse ruse rwhen
rasking rabout rthe rclient's ruse rof rillegal rdrugs rand ralcohol? r r
A. Obtain ra rdrug rusing rscreen rto rverify rlegitimacy rof rclient's rstated rhistory. r r
B. Allow rthe rclient rto rdecline ranswering rsocial rquestions. r r
C. Ask rspecifically rabout ralcohol, rmarijuana, rcocaine, rher r
D. Use rthe rterm rillegal ror rillicit rto rdescribe rstreet rdrug. r- rCorrect ranswer ris rC. rWhen
rinterviewing rthe rpatient, rquestions rshould rbe rclear rand rspecific. r
r
The rnurse rapplies rpressure rover ran rarea rof rthe rlower rabdomen rwhere rthe rclient rreports
rpain. rThe rclient rdenies rpain rupon rpalpation, rbut rreports rpain rwhen rthe rpressure ris
rreleased. rWhat raction rshould rthe rnurse rimplement? r
A. Offer rto radminister ra rlaxative rprescribed rfor rPRN ruse. r r
B. Obtain ra rprescription rto rcatheterize rthe rclient's rbladder. r r
C. Instruct rthe rclient rin rdistraction rand rrelation rtechniques. r r
D. Notify rthe rhealthcare rprovider rof rthe rrebound rtenderness. r- rCorrect ranswer ris rD. rAs
rthis rcould rbe ra rsign rof rappendicitis. r
r
The rnurse ris rassessing ran rulcer ron ra rclient's rlower rextremity, rwhich ris rlikely rthe rresult rof
reither rvenous ror rarterial rinsufficiency. rWhich rassessment rtechnique rshould rthe rnurse ruse
rto rdifferentiate rthe rpathophysiology rcausing rthe rulcer? r
A. Measure rthe rdegree rof rjoin rrange rof rmotion rin rthe rextremity. r r
B. Compare rthe rskin rturgor rof rthe rclient's rupper rand rlower rleg. r r
C. Observe rthe rspecific rlocation rand rappearance rof rthe rulceration. r r
D. Note rany rchange rin rthe rcolor rof rthe rulcer rwhen rthe rleg ris rmoved r- rCorrect ranswer ris
rC. rLocation rand rappearance rof rthe rulcer rwould rgive rus rthe rtype r(venous rvs rarterial) r
r
The rnurse ris rconducting ra rphysical rassessment rof ra ryoung radult. rWhich rinformation
rprovides rthe rbest rindication rof rthe rindividual's rnutritional rstatus? rA. rStatus rof rcurrent
rappetite. r r
B. A r24-hour rdiet rhistory. r r
C. History rof ra rrecent rweight rloss. r r
D. Condition rof rhair, rnails, rand rskin. r- rCorrect ranswer ris rD. rHair, rnail, rand rskin rare rthe
rmost rimportant rreflection rof rnutritional rstatus. r
r
The rnurse ris rassessing ra rhealthy radult rmale rduring ran rannual rphysical rexamination. rThe
rnurse rauscultates rthe rclient's rabdomen rand rhears rgurgling rsound revery rten rseconds. rWhat
raction rshould rthe rnurse rtake rin rresponse rto rthis rfinding? r
A. Document rthis rnormal rbowel rsound ractivity rin rthe rrecord. r r
B. Encourage rincreased rconsumption rof rfiber rin rthe rdiet. r r
C. Observe rthe rnext rbowel rmovement rfor rsigns rof rbleeding. r r
D. Report rthe rhyperactivity rto rthe rhealthcare rprovider. r- rCorrect ranswer ris rA. rNormal
rBowel rsound rconsist rof rclicks rand rgurgles rand r5-30 rper rminute. rAn roccasional
rborborygmus r(Loud rprolonged rgurgle) rmay rbe rhear. r
