HESI Health Assessment/Physical Assessment Practice Questions and Answers

The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation? An involuntary rhythmic, rapid, twitching of the eyeballs A dorsiflexion of the great toe with fanning of the other toes A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed A lack of normal sense of position when the client is unable to return extended fingers to a point of reference A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? Rhythmic respirations with periods of apnea Regular rapid and deep, sustained respirations Totally irregular respiration in rhythm and depth Irregular respirations with pauses at the end of inspiration and expiration Rhythmic respirations with periods of apnea A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? A defect in the cochlea A defect in cranial nerve VIII A physical obstruction to the transmission of sound waves A defect in the sensory fibers that lead to the cerebral cortex A physical obstruction to the transmission of sound waves While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? Lub-dub sounds Scratchy, leathery heart noise A blowing or swooshing noise Abrupt, high-pitched snapping noise A blowing or swooshing noise