HESI Health Assessment Practice Quiz

HESI Health Assessment Practice Quiz 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? - ANS Fibroadenoma. (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.) Paget disease. Plugged mammary duct. Mastitis. Which tool should the nurse use when assessing the neurological status of a client with traumatic brain injury? - ANS Braden Scale. Cranial nerve examination. Glasgow Coma Scale. (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). Numerical pain scale. 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? - ANS 1.)Push gently using fingers of both hands to determine the boundaries of the liver. 2.)Use a bouncing motion to tap the middle finger placed within boundaries of the liver. (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.) 3.)Tap the liver's boundaries lightly with a percussion hammer to produce a sound. 4.)Cup hands and clap with alternating contact with the skin over regions of the liver. 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? - ANS Postural alignment. Knee joint evaluation. (A client with hip pain usually experiences radiation of pain to the groin or knee. Although the hip is difficult to palpate, the knee is readily accessible. A client with hip pain should be assessed for knee joint mobility, structural abnormalities, and fluid accumulation.) Deep tendon reflexes. Cranial nerve testing. 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.) - ANS Bruising on extremities Darkened skin on extremities Capillary refill less than 3 seconds Diminished hair on legs(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.) Skin cool to touch (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.) 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? - ANS Removal of gallbladder 5 years ago. Family history of hypertension on father's side. Administration of rubeola vaccine at age 7. Family history of colon cancer on mother's side.(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? - ANS Vital signs. Genetic predisposition. Health history. (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.) Informed consent. Which findings can the nurse determine by palpating a client's skin? (Select all that apply.) - ANS Scaling. (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.) Pallor. Diaphoresis. (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.) Pruritus. Jaundice. 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? - ANS The hearing loss involves high frequencies. There is no sign of associated infection. (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 works in a busy office setting. The client has no prior history of hearing loss. During the initial assessment, the nurse notes that a client has blurred vision with cloudy lenses. Which condition should the nurse document? - ANS Cataracts. (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.) Pink eye. Corneal abrasion. Glaucoma. What is the best place for the nurse to hear lower lobe lung sounds with a stethoscope? - ANS Anterior chest at the level of the 4th intercostal space. Anterior-axillary line at the 5th intercostal space. Posterior-axillary line at the 4th intercostal space. Posterior chest below the 3rd intercostalspace. (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.) 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? - ANS The client's teeth have a yellowed appearance. The client smiles broadly but appears anxious. Only one side of the mouth moves when smiling. (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.) The client asks the nurse to repeat the directions. 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? - ANS Gait characteristics. Presence of trauma. Level of consciousness. 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.) Bladder control ability. 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? - ANS 1.)Place the bell on the 2nd intercostal space, left midclavicular line. 2.)Put the diaphragm on the 2nd intercostal space, left sternal border. 3.)Place the bell on the 5th intercostal space, left midclavicular line. (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.) 4.)Put the diaphragm on the 5th intercostal space, left sternal border. 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? - ANS The skin remains tented. The skin slowly falls back into place. The skin appears blanched and returns to pink. The skin immediately returns to normal position. (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.) 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.) - ANS 1.)Reduce environmental detractors during the examination. 2.)Allow family to answer for the client to decrease frustration. 3.)Move to another question if the client seems confused. 4.)Ask questions one at a time to decrease confusion. 5.)Use simple sentences during the examination. 1, 4, and 5 Communication techniques for clients with cognitive impairments should be simple, withoutenvironmental distractions, and direct. 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? - ANS 3rd intercostal space on the right midclavicular line. 2nd intercostal space along the right sternal border. (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.) 5th intercostal space on the left midclavicular line. 2nd intercostal space along the left sternal border. Which statement is accurate about assessing the spleen? - ANS 1.)It is normally felt by rolling the client on the right side and palpating. 2.)It is a firm mass palpated slightly left of midline in the upper abdomen. 3.)It is easily felt by reaching the left hand behind the 11th and 12th ribs. 4.)It must be enlarged at least three times normal size for it to be palpable. (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.) 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? - ANS 1.)This is a sign of uterine cancer and I will report this to the healthcare provider. 2.)You have benign fibroid tumors, a common occurrence in women your age. (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.) 4.)This is a very common finding in pregnancy and it will go away.. 5.)This is a sign of endometriosis, so we will need to biopsy the lesions. 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? - ANS 1.)"You alcohol intake should be reduced by 8 ounces daily." 2.)"The amount of alcohol you are drinking concerns me." 3.)"What effect do you think your use of alcohol may have on you?" (The client's perception of his alcohol use determines whether or not his pattern of alcohol consumption is a problem for him.) 4.)"Does your use of alcohol concern any of your family members?"