HESI V2 HEALTH ASSESSMENT
QUESTIONS & ELABORATED
COMPLETE SOLUTIONS ALREADY
GRADED A+
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 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 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 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? - CORRECT ANSWER *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 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 Correct answer is C. Since infections are
associated with abscesses and pus.
The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy.
While interviewing the client, which assessment technique should the nurse use when
asking about the client's use of illegal drugs and alcohol?
A. Obtain a drug using screen to verify legitimacy of client's stated history.
B. Allow the client to decline answering social questions.
C. Ask specifically about alcohol, marijuana, cocaine, her
D. Use the term illegal or illicit to describe street drug. - CORRECT ANSWER Correct
answer is C. When interviewing the patient, questions should be clear and specific.
The nurse applies pressure over an area of the lower abdomen where the client reports
pain. The client denies pain upon palpation, but reports pain when the pressure is
released. What action should the nurse implement?
A. Offer to administer a laxative prescribed for PRN use.
B. Obtain a prescription to catheterize the client's bladder.
C. Instruct the client in distraction and relation techniques.
D. Notify the healthcare provider of the rebound tenderness. - CORRECT ANSWER
Correct answer is D. As this could be a sign of appendicitis.
The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of
either venous or arterial insufficiency. Which assessment technique should the nurse
use to differentiate the pathophysiology causing the ulcer?
A. Measure the degree of join range of motion in the extremity.
B. Compare the skin turgor of the client's upper and lower leg.
C. Observe the specific location and appearance of the ulceration.
D. Note any change in the color of the ulcer when the leg is moved - CORRECT
ANSWER Correct answer is C. Location and appearance of the ulcer would give us the
type (venous vs arterial)
QUESTIONS & ELABORATED
COMPLETE SOLUTIONS ALREADY
GRADED A+
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 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 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 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? - CORRECT ANSWER *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 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 Correct answer is C. Since infections are
associated with abscesses and pus.
The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy.
While interviewing the client, which assessment technique should the nurse use when
asking about the client's use of illegal drugs and alcohol?
A. Obtain a drug using screen to verify legitimacy of client's stated history.
B. Allow the client to decline answering social questions.
C. Ask specifically about alcohol, marijuana, cocaine, her
D. Use the term illegal or illicit to describe street drug. - CORRECT ANSWER Correct
answer is C. When interviewing the patient, questions should be clear and specific.
The nurse applies pressure over an area of the lower abdomen where the client reports
pain. The client denies pain upon palpation, but reports pain when the pressure is
released. What action should the nurse implement?
A. Offer to administer a laxative prescribed for PRN use.
B. Obtain a prescription to catheterize the client's bladder.
C. Instruct the client in distraction and relation techniques.
D. Notify the healthcare provider of the rebound tenderness. - CORRECT ANSWER
Correct answer is D. As this could be a sign of appendicitis.
The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of
either venous or arterial insufficiency. Which assessment technique should the nurse
use to differentiate the pathophysiology causing the ulcer?
A. Measure the degree of join range of motion in the extremity.
B. Compare the skin turgor of the client's upper and lower leg.
C. Observe the specific location and appearance of the ulceration.
D. Note any change in the color of the ulcer when the leg is moved - CORRECT
ANSWER Correct answer is C. Location and appearance of the ulcer would give us the
type (venous vs arterial)
