Health Assessment HESI Practice Correct Answer

The nurse hears bilateral louder, longer, and lower tones when percussing over the lungs of a 4-year old child. What should the nurse do next? a) Palpate over the area for increased pain and tenderness. b) Ask the child to take shallow breaths and percuss over the area again. c) Refer the child immediately because of an increased amount of air in the lungs. d) Consider this a normal finding for a child this age and proceed with the examination. d) Consider this a normal finding for a child this age and proceed with the examination. A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After putting a call in to the physician and placing the patient on oxygen, which of these is the best action for the nurse to take when assessing the patient further? a) Count the patient's respirations. b) Percuss the thorax bilaterally, noting any differences in percussion tones. c) Call for a chest x-ray and wait for the results before beginning an assessment. d) Inspect the thorax for any new masses and bleeding associated with respirations. ... When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? a) There is no need to wash one's hands after removing gloves, as long as the gloves are still b) Wash hands before and after every physical patient encounter. c) Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another. d) Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases. b) b) Wash hands before and after every physical patient encounter. The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? a) The slope of the earpieces should point posteriorly (toward the occiput). b) The stethoscope does not magnify sound but does block out extraneous room noise. c) The fit and quality of the stethoscope are not as important as its ability to magnify sound. d) The ideal tubing length should be 22 inches to dampen distortion of sound. ... The nurse is conducting a patient interview. Which statement made by the patient should the nurse explore more fully during the interview? The patient states that he: a) "Sleeps like a baby" b) Has no health problems c) "Never did too good in school" d) Currently is not taking any medication c) "Never did too good in school" The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? a) The diaphragm is used to listen for high-pitched sounds. b) The diaphragm is used to listen for low-pitched sounds. c) The diaphragm should be held lightly against the person's skin to block out low-pitched sounds. d) The diaphragm should be held lightly against the person's skin to listen for extra heart sounds and murmurs. ... A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient's speech is dysarthric and that she is lethargic. The nurse's best approach regarding this examination is to: a) Plan to defer the rest of the mental status examination b) Skip the language portion of the examination and go on to assess mood and affect c) Do an in-depth speech evaluation and defer the mental status examination to another time d) Go ahead and assess for suicidal thoughts because dysarthria is often accompanied by severe depression b) Skip the language portion of the examination and