HESI Health Assessment Exam 2 Questions & Answers
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Objective. - AnswerDuring the interview portio of the health assessment, a nurse notes
the person's posture, physical appearance, and ability to converse. How should the
nurse document these findings?
.A round smooth mass that slides between the fingers - AnswerAs a part of a routine
health assessment, the nurse assesses the kidneys as part of the abdominal
assessment. Which assessment finding should the nurse conclude is normal when
palpating the client's right kidney?
.Upper outer quadrant. - AnswerWhen teaching a client how to perform a monthly
breast self-assessment, the nurse should tell the client that it is most important to
assess which part of the breast more closely for changes?
.Gland is not palpable - AnswerThe nurse is completing a physical exam on an adult
client. Which thyroid finding is considered normal?
.4th intercostal space, right midclavicular line. Correct - AnswerThe nurse is assessing a
client's middle lung lobe. What is the best location for the nurse to place a stethoscope
diaphragm to hear normal lung sounds in this lobe?
.Document a normal finding. - AnswerWhile performing a head-to-toe assessment, the
nurse assesses the client's pupillary accommodation. During the second portion of the
test, the nurse notes that the client's pupils constrict and there is convergence of the
axes of the eyes. What action should the nurse implement next?
.A consensual response in the opposite eye. - AnswerThe nurse is performing a head-
to-toe assessment on a client. The nurse is assessing the client's pupillary light reflex by
first darkening the room and asking the person to gaze into the distance. Then, the
nurse advances a light toward one eye from the client's side. What would the nurse
expect to see at this time?
.Inspect the scalp looking for nits - AnswerA client presents with a rash along the
occipital area of the hairline and reports intense itching. How should the nurse begin the
objective part of the examination?
.Have you had sudden and severe pain in the toes or feet? - AnswerA client has come
to the clinic for a routine health assessment. What is the best assessment question for
the nurse to ask a client after observing tophi on the client's ear cartilage?
.Measure bilateral ankle circumference with a non-stretchable tape measure. -
AnswerHow should the nurse assess for lower extremity edema in a client who has
been diagnosed with heart failure?
, .Seek the assistance of a healthcare team member who speaks the client's preferred
language. - AnswerThe nurse is conducting an interview with a client who speaks
limited English. What action should the nurse implement?
.Ask whether the client has been in a foreign country recently. - AnswerA client reports
a recent onset of nausea and vomiting. What subjective information is important for the
nurse to ascertain?
.Document at least 3 generations of the client's family medical history. Correct -
AnswerThe nurse is conducting a family history as part of the assessment interview.
Which action should the nurse take to ensure that sufficient information about the
client's blood relatives is obtained?
.Verbal descriptor scale. - AnswerAn older client has just returned to the room following
a surgical procedure. Which pain scale should the nurse use when assessing the
client's pain level?
.Dull sound percussed over bladder. - AnswerA client reports lower abdominal pain and
a feeling of pressure in the bladder. Which assessment finding indicates acute urinary
retention?
.Nocturia. - AnswerWhich term should the nurse use to document the condition of a
client who reports waking up frequently during the night to urinate?
.Measure the apical pulse and compare it to the peripheral pulse. - AnswerWhich
procedure should the nurse use to assess for a pulse deficit?
.Ask the client to urinate before beginning the examination. - AnswerA client is in the
clinical for a yearly physical examination. Which action should the nurse take when
preparing to examine the client's abdomen?
.Friction rub. - AnswerWhich term should the nurse use to document in the client's
medical record for a high-pitched scratchy sound during auscultation of the heart?
.Use abdominal muscles to sit up. - AnswerThe nurse is assessing for the presence of a
hernia. Which action should the nurse ask the client to perform while lying supine?
.Note the character and frequency of bowel sounds. - AnswerThe nurse is assessing
bowel sounds for a hospitalized client. The nurse has heard bowel sounds in the right
upper quadrant. What action should the nurse take next?
.Inspect the hair and skin. - AnswerA client is being assessed upon admission to the
medical-surgical unit. The nurse is preparing to complete a head-to-toe assessment and
will begin at the head of the client. Which technique should the nurse use to begin the
assessment?
2024||Verified Answers || A+ Guaranteed!!
Objective. - AnswerDuring the interview portio of the health assessment, a nurse notes
the person's posture, physical appearance, and ability to converse. How should the
nurse document these findings?
.A round smooth mass that slides between the fingers - AnswerAs a part of a routine
health assessment, the nurse assesses the kidneys as part of the abdominal
assessment. Which assessment finding should the nurse conclude is normal when
palpating the client's right kidney?
.Upper outer quadrant. - AnswerWhen teaching a client how to perform a monthly
breast self-assessment, the nurse should tell the client that it is most important to
assess which part of the breast more closely for changes?
.Gland is not palpable - AnswerThe nurse is completing a physical exam on an adult
client. Which thyroid finding is considered normal?
.4th intercostal space, right midclavicular line. Correct - AnswerThe nurse is assessing a
client's middle lung lobe. What is the best location for the nurse to place a stethoscope
diaphragm to hear normal lung sounds in this lobe?
.Document a normal finding. - AnswerWhile performing a head-to-toe assessment, the
nurse assesses the client's pupillary accommodation. During the second portion of the
test, the nurse notes that the client's pupils constrict and there is convergence of the
axes of the eyes. What action should the nurse implement next?
.A consensual response in the opposite eye. - AnswerThe nurse is performing a head-
to-toe assessment on a client. The nurse is assessing the client's pupillary light reflex by
first darkening the room and asking the person to gaze into the distance. Then, the
nurse advances a light toward one eye from the client's side. What would the nurse
expect to see at this time?
.Inspect the scalp looking for nits - AnswerA client presents with a rash along the
occipital area of the hairline and reports intense itching. How should the nurse begin the
objective part of the examination?
.Have you had sudden and severe pain in the toes or feet? - AnswerA client has come
to the clinic for a routine health assessment. What is the best assessment question for
the nurse to ask a client after observing tophi on the client's ear cartilage?
.Measure bilateral ankle circumference with a non-stretchable tape measure. -
AnswerHow should the nurse assess for lower extremity edema in a client who has
been diagnosed with heart failure?
, .Seek the assistance of a healthcare team member who speaks the client's preferred
language. - AnswerThe nurse is conducting an interview with a client who speaks
limited English. What action should the nurse implement?
.Ask whether the client has been in a foreign country recently. - AnswerA client reports
a recent onset of nausea and vomiting. What subjective information is important for the
nurse to ascertain?
.Document at least 3 generations of the client's family medical history. Correct -
AnswerThe nurse is conducting a family history as part of the assessment interview.
Which action should the nurse take to ensure that sufficient information about the
client's blood relatives is obtained?
.Verbal descriptor scale. - AnswerAn older client has just returned to the room following
a surgical procedure. Which pain scale should the nurse use when assessing the
client's pain level?
.Dull sound percussed over bladder. - AnswerA client reports lower abdominal pain and
a feeling of pressure in the bladder. Which assessment finding indicates acute urinary
retention?
.Nocturia. - AnswerWhich term should the nurse use to document the condition of a
client who reports waking up frequently during the night to urinate?
.Measure the apical pulse and compare it to the peripheral pulse. - AnswerWhich
procedure should the nurse use to assess for a pulse deficit?
.Ask the client to urinate before beginning the examination. - AnswerA client is in the
clinical for a yearly physical examination. Which action should the nurse take when
preparing to examine the client's abdomen?
.Friction rub. - AnswerWhich term should the nurse use to document in the client's
medical record for a high-pitched scratchy sound during auscultation of the heart?
.Use abdominal muscles to sit up. - AnswerThe nurse is assessing for the presence of a
hernia. Which action should the nurse ask the client to perform while lying supine?
.Note the character and frequency of bowel sounds. - AnswerThe nurse is assessing
bowel sounds for a hospitalized client. The nurse has heard bowel sounds in the right
upper quadrant. What action should the nurse take next?
.Inspect the hair and skin. - AnswerA client is being assessed upon admission to the
medical-surgical unit. The nurse is preparing to complete a head-to-toe assessment and
will begin at the head of the client. Which technique should the nurse use to begin the
assessment?
