Health Assessment HESI Exam Preparation Questions and Answers

A tuning fork would be used to assess cranial nerve VIII (the acoustic nerve). Cheyne-Stokes Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply. 1. Set the room temperature at a comfortable level. 2.Remove distracting objects from the interviewing area. 3.Place a chair for the client across from the nurse's desk. 4.Ensure comfortable seating at eye level for the client and nurse. 5.Provide seating for the client so that the client faces a strong light. 6.Ensure that the distance between the client and nurse is at least 7 ft (2.1 meters). 1, 2, 4 When preparing the physical environment for an interview, the nurse should set the room temperature at a comfortable level. The nurse should provide sufficient lighting for the client and nurse to see each other. The nurse should avoid having the client face a strong light because the client would have to squint into the full light. Distracting objects and equipment should be removed from the interview area. The nurse should arrange seating so that the nurse and client are seated comfortably at eye level, and the nurse avoids facing the client across a desk or table because this creates a barrier. The distance between the nurse and the client should be set by the nurse at 4 to 5 ft (1.2 to 1.5 meters). The emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion? 1.Poor hygiene 2.Difficulty walking 3.Fear of the parents 4.Bald spots on the scalp 2. Abuse is the nonaccidental physical injury or the nonaccidental act of omission of care by a parent or person responsible for a child. It includes neglect and physical, sexual, or emotional maltreatment. Sexual abuse can involve incest, molestation, exhibitionism, pornography, prostitution, or pedophilia. Many times the findings associated with sexual abuse may not be easily apparent in the child. The most likely assessment findings in sexual abuse include difficulty walking or sitting; torn, stained, or bloody underclothing; pain, swelling, or itching of the genitals; and bruises, bleeding, or lacerations in the genital or anal area.