HESI Health Assessment 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? - "My life is really out of balance." 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.) - Be open to people who are different Have a curiosity about people. Become culturally competent. Which statement is accurate about assessing the spleen? - It must be enlarged at least three times normal size for it to be palpable. What is the best place for the nurse to hear lower lobe lung sounds with a stethoscope? - Posterior chest below the 3rd intercostalspace. 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? - Place the bell on the 5th intercostal space, 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? - 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? - The client works in a daycare setting that has had a scabies outbreak. 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? - Level of consciousness. A client 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? - Use of vitamin and iron supplements. 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? - There is no sign of associated infection. The client reports to the nurse a recent exposure to the mumps. Which assessment finding suggests the client has contracted the mumps? - Swelling anterior to the ear lobe on one side of the face. 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? - Swelling of the left arm and non-pitting edema. What is the best nursing response to an older client who has not mentioned incontinence during a genitourinary assessment? - Ask the client specifically about any leakage of urine. 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? - Have you experienced sudden weight loss? 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? - Family history of colon cancer on mother's side. Correct Which information should the nurse obtain to identify the client's self-perception of health status? - Health history. During the initial assessment, the nurse notes that a client has blurred vision with cloudy lenses. Which condition should the nurse document? - Cataracts 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? - Fibroadenoma. Which part of the body should the nurse examine when assessing for peripheral edema in a client with heart failure? - Ankles. Which condition is indicated by a fluorescent, yellow-green color when the nurse uses a Wood's lamp toexamine a client's skin lesions? - 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? - Have you ever felt guilty about your 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? - Lying 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? - The left leg remains on the table. 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? - The skin immediately returns to normal position. 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? - barrel chest 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? - Occlude one nostril and have the client identify various odors. Which tool should the nurse use when assessing the neurological status of a client with traumatic brain injury? - Glasgow Coma Scale 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? - Change in consistency 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