HESI RN EVOLVE Health Assessment Practice Exam QUESTIONS & ANSWERS 2022 LATEST UPDATE

HESI RN EVOLVE Health Assessment Practice Exam A client is reporting chest pain. What statement made by the client, helps the nurse to understand this client has a naturalistic belief in the cause of illness? a. "My life is really out of balance." b. "I knew I should have changed my diet." c. "I should have gone to church last week." Incorrect d. "I forgot to take my medicines last night." ANS; A The cause of disease may be viewed from three ways: biomedical, naturalistic, magicoreligious. People who conform to the naturalistic perspecive of disease causation, believe that the forces of nature must be kept in a natural balance or harmony. A nurse is working in a healthcare facility that serves a diverse population. What action(s) by the nurse will allow the nurse to empathize with and understand this population? (Select all that apply.) a. Be open to people who are different. b. Have a curiosity about people. c. Become culturally competent. d. Interact with each person in the same way. e. Request nurses take care of patients with the same ethnicity. f. Always request an interpreter for people from other countries. ANS: A,B,C As a health professional, the nurse is expected to listen to, empathize with, and understand people. To fulfill this role, nurses must first be open to people who are different from them, have a curiosity about people, and begin a journey to being culturally competent. Which statement is accurate about assessing the spleen? A. It must be enlarged at least three times normal size for it to be palpable. b. It is easily felt by reaching the left hand behind the 11th and 12thribs. c. It is normally felt by rolling the client on the right side and palpating. d. It is a firm mass palpated slightly left of midline in the upper abdomen. ANS: A Normally the spleen is not palpable at all and must be enlarged by three times its normal size to be felt. To search for it, the nurse must reach the left hand over the abdomen and behind the left side at the 11th and 12th ribs and lift up for support. The nurse should place the right hand obliquely on the left upper quadrant (with the fingers pointing toward the left axilla) and push the hand deeply down and under the left costal margin while asking the client to take a deep breath. Under normal circumstances, the nurse should feel nothing firm. What is the best place for the nurse to hear lower lobe lung sounds with a stethoscope? a. Posterior chest below the 3rd intercostalspace. b. Posterior-axillary line at the 4th intercostal space. c. Anterior chest at the level of the 4th intercostal space. d. Anterior-axillary line at the 5th intercostal space. ANS: B The posterior chest below the level of the 3rd intercostal spaces is occupied entirely by the lower lobes. This makes the posterior chest the best place for the nurse to hear lower lobe lung sounds with a stethoscope. The nurse is assessing a client who has a history of mitral stenosis. How should the nurse assess this client with a stethoscope to listen for this condition? a. Place the bell on the 5th intercostal space, left midclavicular line. b. Place the bell on the 2nd intercostal space, left midclavicular line. c. Put the diaphragm on the 5th intercostal space, left sternal border. d. Put the diaphragm on the 2nd intercostal space, left sternal border. ANS: A The best way to listen for low-pitch mitral heart sounds, such as a mitral stenosis murmur, is to place the bell of stethoscope onto the 5th intercostal space at the left midclavicular line. The nurse is assessing a client who has a history of aortic regurgitation. Where should the nurse place the stethoscope diaphragm to listen for this condition? a. 2nd intercostal space along the right sternal border. Correct b. 2nd intercostal space along the left sternal border. c. 3rd intercostal space on the right midclavicular line. d. 5th intercostal space on the left midclavicular line. ANS: A The best way to listen for high-pitch aortic heart sounds, such as an aortic regurgitation murmur, is to place the stethoscope diaphragm onto the 2nd intercostal space along the right sternal border. The client is experiencing severe pruritus and small papules and burrows on areas over one hand and the inner thighs. Which assessment data best explains the condition the client is experiencing? a. The client works in a daycare setting that has had a scabies outbreak. b. The client has been using a chemical stripping agent for home remodeling. c. The client has a family history of psoriasis in both parents and a sibling. d. The client routinely works with clay and paint as a hobby. ANS: A Scabies is a highly contagious condition that causes pruritus, small papules, vesicles and burrows in the skin as the scabies mite burrows into the superficial layer of the skin to lay her eggs. Scabies is often spread among children and others in close contact. A client comes to the clinic with a report of fever and a recent exposure to someone who was diagnosed with meningitis. Which nursing assessment should be completed during the initial examination of this client? a. Level of consciousness. b. Gait characteristics. c. Presence of trauma. d. Bladder control ability. ANS: A Initial symptoms of meningitis include headache, fatigue, stiff neck, and changes in level of consciousness. It is necessary to determine if the client is demonstrating signs of meningitis before planning immediate care. Aclient reports feeling increasingly fatigued for several months, and the nurse observes that the client's lips are pale. Which additional data should the nurse collect based on this presentation? A. Current alcohol and tobacco use. B. A 24-hour dietary recall. C. Use of vitamin and iron supplements. Correct D. Daily pattern of oral hygiene practices. ANS: C Increasing fatigue and pale lips could indicate anemia. The nurse should determine if the client is taking vitamin or iron supplements to manage anemia. The nurse is assessing a client who has experienced a sudden onset of hearing loss in the right ear. Which finding should alert the nurse to a potentially serious medical condition that requires further evaluation? a. The client works in a busy office setting. b. There is no sign of associated infection. c. The client has no prior history of hearing loss. d. The hearing loss involves high frequencies. ANS: B Sudden hearing loss is sometimes associated with an upper respiratory infection or ear infection. Sudden hearing loss without the presence of an infection can be an indication of a more serious condition that requires further evaluation. The client reports to the nurse a recent exposure to the mumps. Which assessment finding suggests the client has contracted the mumps? A. Enlargement centered along the anterior lower neck region. B. Swelling anterior to the ear lobe on one side of the face. C. Generalized rounded shape of the face. D. Paralysis on one side of the face. ANS: B The parotid salivary gland is not normally palpable, but the mumps infection may cause swelling and tenderness of these glands. The swelling of the parotid glands can be either unilateral or bilateral in appearance. When a client reports recent exposure to mumps, the nurse should check for parotid tenderness by palpating in a line from the outer corner of the eye to the lobule of the ear. A client states that she had a mastectomy of her left breast last year and now experiences lymphedema. What should the nurse expect to find when examining the client? A. Swelling of the left arm and non-pitting edema. B. Bilateral swelling of the arms with weakened pulses. C. Complaints of pain when taking the blood pressure on the affected side. D. Metastasis of cancer due to cancer being in the lymph nodes ANS: A Lymphedema is caused by lymphatic system blockage occurring after breast and lymph node surgery. A client with lymphedema typically presents with unilateral swelling, non-pitting edema, and tight fitting jewelry. Treatment is required toprevent a chronic progressive condition. Upgrade to remove ads Only $3.99/month What is the best nursing response to an older client who has not mentioned incontinence during a genitourinary assessment? A. Ask the client specifically about any leakage of urine. B. Document that the client reports having no incontinence. C. Have the client cough and then check for urine leakage. D. Determine if the client has ever had urinary tract surgery. ANS: A Incontinence is a manageable condition, but many clients do not report incontinence due to embarrassment. The nurse needs to ask the client directly about urine leakage to avoid missing this information. A client is in the clinic for a routine health examination. The nurse notices the client appears underweight. Which question is most important for the nurse to ask when completing the health history of this client? A. What types of food do you like or dislike? B. Have you experienced sudden weight loss? C. Do you use dietary supplements every day? D. Can you recall the last 24 hours of food intake? ANS: B A client who is underweight may have an underlying illness, for example, weight loss without any change in dietary and/or physical activity could be an indicator of the presence of cancer or a metabolic syndrome such as Grave's disease. It is important to determine if the weight loss has been sudden, gradual, and/or intentional because this information will guide the remaining dietary history. A client is in the clinic and is reporting lower abdominal pain and constipation. Which information is of greatest concern to the nurse when obtaining the health history from this client? A. Administration of rubeola vaccine at age 7. B. Removal of gallbladder 5 years ago. C. Family history of colon cancer on mother's side. D. Family history of hypertension on father's side. ANS: C Abdominal pain and constipation can be signs of colon cancer, and some forms of colon cancer can be hereditary. A family history of colon cancer is of significant concern, and the nurse should report this information to the healthcare provider. Which information should the nurse obtain to identify the client's self-perception of health status? A. Vital signs. B. Health history. C. Informed consent. D. Genetic predisposition. ANS: B A health history is a collection of subjective data. Obtaining a detailed health history is a good way for the nurse to assess the client's perception of current health status. During the initial assessment, the nurse notes that a client has blurred vision with cloudy lenses. Which condition should the nurse document? A. Pink eye. B. Cataracts. C. Glaucoma. D. Corneal abrasion. ANS: B The nurse should be sure to identify signs of visual impairment so that safety precautions may be implemented when necessary. Signs of cataracts include cloudy lenses and blurred vision. While palpating a client's breasts, the nurse detects a nontender, solitary, round lobular mass that is solid and firm and slides easily through the breast tissue . The findings of this breast exam are consistent with which condition? A. Mastitis. B. Paget disease. C. Fibroadenoma. D. Plugged mammary duct. ANS: C Fibroadenoma are benign tumors that are nontender masses that are round and lobular and when palpated move easily through breast tissue and feel solid and firm. They are diagnosed by palpation, ultrasound, and needle biopsy. They are usually not surgically removed unless they enlarged to greater than 5 cm in size. Which part of the body should the nurse examine when assessing for peripheral edema in a client with heart failure? A. Face. B. Ankles. C. Knees. D. Jugular veins. ANS: B Edema is caused by fluid accumulating in the interstitial spaces. Dependent extremities such as the feet and ankles are more prone to peripheral edema caused by conditions such as heart failure, so the nurse should assess the ankles for dependent edema. Which condition is indicated by a fluorescent, yellow-green color when the nurse uses a Wood's lamp toexamine a client's skin lesions? A. Fungal infection. B. Bacterial infection. C. Allergic reaction. D. Skin cancer. ANS: B A Wood's lamp produces a black-light effect to examine skin lesion color and to detect fungal skin infections. A fluorescent,yellow-green or blue-green color indicates a fungal infection. The nurse is performing a routine physical examination on an adult client. When gathering a health history, which question is included in the CAGE questionnaire? A. When did you have your last alcoholic drink? B. How does alcohol usually affect you? C. What is your favorite alcoholic drink? D. Have you ever felt guilty about your drinking? ANS: D The CAGE questionnaire can be used to screen clients for excessive or uncontrolled drinking. CAGE is the acronym for Cut down, Annoyed, Guilty, and Eye-opener. To assess for possible alcohol abuse, the nurse should ask if the client has ever felt guilty about drinking. A client has just returned from the recovery room and asks to get out of bed to go to the bathroom. The nurse decides to obtain orthostatic vital signs first. How will the nurse position the client to begin this procedure? A. Lying. B. Sitting. C. Leaning. D. Standing ANS: A When obtaining orthostatic vital signs, the nurse takes serial measurements of pulse and blood pressure. The order of positions for obtaining orthostaticvital signs is lying, sitting, and then standing. Upgrade to remove ads Only $3.99/month The nurse is assessing a client for a hip flexion contracture. Which finding indicates a negative Thomas test when the client's right knee is brought toward the chest? A. The left leg internally rotates. B. The left leg rises off of the table. C. The left leg remains on the table. Correct D. The left leg externally rotates. ANS: C The Thomas test is performed by having the client bring one knee toward the chest while the other leg remains extended on the table. A positive Thomas test is elicited when the extended leg rises off the table, when the opposite leg's knee is brought up to the client's chest, indicating hip flexor contracture. If the extended leg (the left leg, in this example) remains on the table, the test is negative. An adult client is in the clinic for a regular physical examination. The nurse is assessing the client's hydration status by pinching then releasing the client's skin. Which finding is indicative of good hydration status? A. The skin remains tented. B. The skin appears blanched and returns to pink. C. The skin slowly falls back into place. D. The skin immediately returns to normal position. ANS: D Skin turgor refers to elasticity and isassessed by gently pinching and then releasing the skin on the forearm, back of the hand, or under the clavicle. If skin turgor is normal, the skin will return to normal position immediately when released. Poor skin turgor is indicative of dehydration and is determined when the tented skin does not return or slowly returns back to place. The nurse is performing a thoracic assessment on a client with chronic asthma and hyperinflation of the lungs. Which finding should be expected for this client? A. Kyphosis. B. Barrel chest. C. Pectus Excavatum. D. Pectus Carinatum. ANS: C A barrel chest is associated with chronic asthma and hyperinflation of the lungs. The nurse can expect to note an increased anteroposterior chest diameter and ribs that are horizontal instead of having a normal downward slope. The nurse performs a series of cranial nerve tests on a client with a head injury. Which test should the nurse use to assess damage to the first cranial nerve? A. Ask the client to count down from 100 by 7s for as long as possible. B. Occlude one nostril and have the client identify various odors. C. Have the client follow the tip of a moving penlight with the eyes. D. Tell the client to walk heel to toe in a straight line for nine steps. ANS: B Cranial nerve I is the olfactory nerve. When testing this nerve, the nurse should occlude one nostril and have the client identify smells such as alcohol, coffee grounds, or cloves, then repeat this test with the opposite nostril. Assessing the client's sense of smell can help detect damage to the olfactory nerve.Jarvis, 2016., Physical Examination and Health Assessment, 7th ed., chapter 23, p 353 Which tool should the nurse use when assessing the neurological status of a client with traumatic brain injury? A. Glasgow Coma Scale. B. Braden Scale. C. Numerical pain scale. D. Cranial nerve examination. ANS: A The Glasgow Coma Scale is the best method for assessing the neurological status and level of consciousness following a traumatic brain injury. The Glasgow Coma Scale assesses eye opening, motor responses, and verbal responses and has a scale of 3 to 15 (15 is awake, alert, and oriented).Jarvis, 2016., Physical Examination and Health Assessment, 7th ed., chapter 23, p. 672 A client with dark skin is reporting a painful and itching area on the lower left leg. What should the nurse look for when assessing this client's skin for inflammation? A. Change in consistenc B. Change in turgor. C. Redness. D. Pallor ANS: A Inflammation in a dark-skinned client appears as a change in consistency. Further findings that indicate inflammation are changes in texture and excessive warmth. While assessing level of consciousness, the nurse finds that a client localizes to pain, is confused during conversation, and opens the eyes to sound. How should the nurse document the Glasgow score of this client? 12. 10. 9. 7. ANS: A The Glasgow Coma Scale is used to establish baseline data based on eye opening, motor response, and verbal response. The lowest possible score is 3 and thehighest is 15. This client's Glasgow Coma Scale (GCS) score is 12: Opening eyes to sound is a score of 3, localizing to pain is a 5, and confusion during a conversation is a 4 (3 + 5 + 4 = 12). Which question should the nurse ask in order to test a client's remote memory? A. What is your date of birth? B. Who is your current healthcare provider? C. What medications are you taking? D. How did you arrive at the hospital today? ANS: A Cognition is typically evaluated in a rapid and focused manner and includes the assessment of memory. Remote memory, or long-term memory, can be tested by asking the client's date of birth. A client reports pain when taking a deep breath. Which lung auscultation sound should the nurse anticipate hearing? A. Pleural friction rub. B. Rhonchus. C. Coarse crackles. D. Wheezing. ANS: A A client reports pain when taking a deep breath. Which lung auscultation sound should the nurse anticipate hearing? Pleural friction rub. Correct Rhonchus. Coarse crackles. Wheezing. The nurse is examining the hip joint of a client who reports hip pain. Which other assessment is most helpful in determining the cause of the client's pain? A. Knee joint evaluation. B. Cranial nerve testing. C. Postural alignment. D. Deep tendon reflexes. ANS: A The nurse is examining the hip joint of a client who reports hip pain. Which other assessment is most helpful in determining the cause of the client's pain? Knee joint evaluation. Correct Cranial nerve testing. Postural alignment. Incorrect Deep tendon reflexes. Upgrade to remove ads Only $3.99/month A postmenopausal female client is undergoing a routine physical examination. She has reported nothing out of the ordinary. When performing the examination of the genitourinary system, the nurse finds an irregularly enlarged uterus with firm, mobile, painless nodules in the uterine wall. How should the nurse explain this finding to the client? A. You have benign fibroid tumors, a common occurrence in women your age. Correct B. This is a sign of uterine cancer and I will report this to the healthcare provider. C. This is a sign of endometriosis, so we will need to biopsy the lesions. Incorrect D. This is a very common finding in pregnancy and it will go away.. ANS: A With myomas (uterine fibroids), subjective findings are varied depending on the size and location of the lesions. Often there are no symptoms. Symptoms that may occur include vague discomfort, bloating, heaviness, pelvic pressure, dyspareunia, urinary frequency, backache, or excessive uterine bleeding and anemia if myoma disturbs endometrium. Objective findings: uterus irregularly enlarged, firm, mobile, and nodular with hard, painless nodules in the uterine wall. These benign tumors are common; by age 50 years 70% of White women and greater than 80% of Black women will have at least one.Jarvis (2016). Physical Examination and Health Assessment, 7th ed., p. 764. The nurse is assessing the posterior pharynx during a physical examination. Which technique should the nurse use? A. Press the tongue down one side at a time with a tongue depressor. B. Ask the client to open the mouth and say "ah." C. Listen for hoarseness after asking the client to speak. D. Palpate the neck and ask the client to swallow. ANS: A When assessing the posterior pharynx, a tongue depressor should be used to press down one side of the tongue at a time to avoid stimulating the gag reflex. A nurse is completing a nutritional assessment with a client. What is the easiest method for the nurse to use to get information about the client's nutritional intake? A. 24-hour dietary recall B. Food diary. C. Intake and output record. D. Lab information (albumin, pre-albumin). ANS: A Nutritional history, which includes the client's recall of food and fluid intake during a 24-hour period, is an important factor in determining a client's nutritional status. The nurse should include the client's dietary recall when performing a nutritional screening. The nurse is preparing to assess the hearing of a client with a history of prolonged exposure to occupational noise. Which hearing test provides the most reliable assessment of hearing status? A. Audiometry. B. Whispered voice. C. Weber. D. Rinne. ANS: A Prolonged exposure to loud occupational noise can cause sensorineural hearing loss by damaging the cochlear hair cells. Audiometry is the most reliable method of testing the acuity of auditory sensory perception. The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply.) A. Diminished hair on legs B. Bruising on extremities C. Skin cool to touch D. Capillary refill less than 3 seconds E. Darkened skin on extremities ANS: A, C Diminished hair on the legs and skin that is cool to touch are symptoms of decreased arterial blood flow. The other options are not indicators for impaired peripheral circulation. Which findings can the nurse determine by palpating a client's skin? (Select all that apply.) A. Pruritus. B. Diaphoresis. C. Pallor. D. Jaundice. E. Scaling. ANS: B, E Palpation, or touch, can provide information about skin texture, including the presence of scaling and skin moisture, including diaphoresis, or perspiration. Pruritus, or itching, is a subjective finding reported by the client, and pallor and jaundice describe skin color, assessed through observation. The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response? A. The client cannot understand the nurse. B. The client is uncomfortable with the nurse. C. The client is treating the nurse with respect. D. The client is purposefully disrespecting the nurse. ANS: C In some Asian cultures, it is not appropriate to look a person of authority in the eye, so the client is being respectful by looking down while speaking with the nurse. The nurse is interviewing a client who reports having a persistent, productive cough during the winter caused by bronchitis. Which additional finding should the nurse assess for bronchitis? A. Phlegm production and wheezing. B. Smoking history. C. Hemoptysis. D. Night sweats. ANS: A A chronic, seasonal cough related to bronchitis is likely accompanied withphlegm production and wheezing. Although smoking can contribute to a chronic cough, the typical seasonal cough is an inflammatory reaction to seasonal changes. A registered nurse (RN) is performing a mini-mental state examination (MMSE) for a client who is being admitted to an assisted living community. Which communication techniques should the RN implement to decrease anxiety in the client? (Select all that apply.) A. Use simple sentences during the examination. B. Move to another question if the client seems confused. C. Reduce environmental detractors during the examination. D. Allow family to answer for the client to decrease frustration. E. Ask questions one at a time to decrease confusion. ANS: A, C, E Communication techniques for clients with cognitive impairments should be simple, withoutenvironmental distractions, and direct` A client with progressive hearing loss appears distressed when the registered nurse (RN) asks openended questions about the client's health history. Which forms of communication should the RN use? A. Face the client so the client can see the RN's mouth. B. Increase one's speech volume when interacting with the client. C. Repeat information to the client if misunderstood. D. Check if the client's hearing aides are working properly. E. Reduce environmental noise surrounding the client. ANS: A, D, E A client with hearing loss can develop the ability to read "lips," so facing the client during conversation allows visualization of the lips and directs the sound towards the client. Inspection of the hearing aide device's functionality is a vital step in communication. Hearing aides magnify all surrounding noise, so it is imperative to reduce outside environmental noise during the interview process. Speaking clearly with enunciation and in a regular tone is easier for a client to understand than increasing the volume of speech. If a client shows signs of confusion, rephrasing the question, instead of repeating, should be done to decrease client anxiety and facilitate understanding. Upgrade to remove ads Only $3.99/month Which action should the registered nurse (RN) implement to complete an assessment for a client while using an interpreter? A. Ask closed-ended questions with the assistance of the interpreter. B. Maintain eye contact with the client while listening to the translation. C. Instruct interpreter to answer questions from interpreter's point of view. D. Protect the client's privacy by asking a limited number of questions. ANS: B When completing an assessment, the RN should maintain eye contact with the client to gather additional information from the client's nonverbal cues. The nurse is completing a physical assessment of a client who feel from a tree. The client's abdomen is soft with hyperactive bowel sounds in all four quadrants. Which assessment technique should the nurse implement when evaluating the client's spleen? A. Elevate head of bed 30 degrees to percuss the spleen. B. Palpate the splenic borders before percussing. C. Percuss the splenic area as the client takes a deep breath. D. Place client in a Trendelenburg position to isolate the spleen. Incorrect ANS: C If the spleen is enlarged due to an infection or trauma, tympany changes are noted with dullness upon inspiration. The nurse is assessing a client with liver disease who is jaundice and exhibits scleral edema. During the health assessment, the nurse should implement which technique to determine evidence of hepatomegaly? A. Tap the liver's boundaries lightly with a percussion hammer to produce a sound. B. Push gently using fingers of both hands to determine the boundaries of the liver. C. Use a bouncing motion to tap the middle finger placed within boundaries of the liver. D. Cup hands and clap with alternating contact with the skin over regions of the liver. ANS: C Percussion is a tapping techniques done with short, sharp strokes to assess underlying structures, such as the liver which is solid and should have a dull sound. When percussing the liver for abnormal sounds, the middle finder of dominant hand is used to tap with a bouncing motion on the opposite middle finder that is placed within the boundaries of the liver, which if diseased is no longer dense and does not reveal a dull sound. When assessing facial nerve function of a 96-year-old, the nurse asks the client to smile in an exaggerated manner. Which finding is most important for the nurse to further asses? A. Only one side of the mouth moves when smiling. B. The client's teeth have a yellowed appearance. C. The client smiles broadly but appears anxious. D. The client asks the nurse to repeat the directions. ANS: A The facial nerve innervates the muscles of facial expression. Asymmetry in facial movement may indicate damage to the facial nerve and requires further assessment by the nurse. A male executive is seen in the primary care clinic for a physical examination. While obtaining the client's health history, the nurse inquires about his drug and alcohol use. The executive denies drug use, but reports that he has "two glasses of wine" per night. Which response is best for the nurse to provide? A. "You alcohol intake should be reduced by 8 ounces daily." B. "Does your use of alcohol concern any of your family members?" C. "What effect do you think your use of alcohol may have on you?" D. "The amount of alcohol you are drinking concerns me." ANS: A The client's perception of his alcohol use determines whether or not his pattern of alcohol consumption is a problem for him. When performing range of motion exercises on the joints of an older adult client, the nurse notes that joint range is greater with passive ranging than with active ranging. A goniometer indicates that this difference is as much as 15% in some joints. How should this finding be documented? A. Normal. B. Expected in older adults. C. Minor deviation. D. Abnormal. ANS: A This finding is abnormal and may be indicative of generalized muscle weakness or a joint disorder. During an external examination of the eyes, the nurse gently palpates the eyes while the client's eyelids are closed. The eyes are both very firm and resist movement back into the orbit. How should the nurse document this finding? A. Abnormal finding. B. Expected finding. C. Normal variation. D. Sign of aging. ANS: C This is an abnormal finding that may be indicative of glaucoma, hyperthyroidism, or a retroorbital tumor. The nurse enters an examination room to conduct a routine health assessment on an adolescent female client, who is accompanied by her mother. Which action by the nurse is likely to facilitate accurate responses to personal and social history questions? A. Include the mother in the interviewing process. B. Request that the mother leave the exam room. C. Allow the client to broach discussion of any sensitive topics. D. Use highly structured and directed questions to explore sensitive topics. ANS: B The teen needs to be able to explore sensitive issues in a private and confidential setting, so the parent should be asked to leave the room. The personal and social history contains many areas of special sensitivity to adolescents including such issues as drug and alcohol use and sexual activity. The teen should provide the personal and socia history, not the parent. While performing a mental status exam (MSE), the nurse asks a client to remember three unrelated words and repeat them later. The client was able to repeat the words as directed. Which computer documentation is accurate? A. "Exhibits an above average intelligence." B. "Reflects no apparent lapses in concentration." C. "Demonstrates appropriate judgment in everyday scenario." D. "Short-term memory is intact." ANS: D The nurse can determine that the client's short-term memory is functional. The situation as described depicts the expected outcome of a mental status exam in that the client is able to remember and repeat the words as directed.