BSN 246 HESI Health Assessment V1/ACTUAL
EXAM – NIGHTINGALE COLLEGE
Save
Terms in this set (197)
The nurse is performing a Barrel chest
thoracic assessment on a
client with chronic asthma
and hyperinflation of the
lungs. Which finding
should be expected for
this client?
The nurse is assessing Note the character and frequency of bowel sounds
bowel sounds for a
hospitalized client. The
nurse has heard bowel
sounds in the right upper
quadrant. What action
should the nurse take
next?
,During inspection of a Document an intact gag reflex.
client's mouth and
pharynx, the nurse places
a tongue blade on the
back of the tongue which
causes the client to gag.
After removing the tongue
blade, what action should
the nurse take?
When teaching a client Upper outer quadrant.
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?
The nurse is assessing a A waist circumference is greater than 35 inches in
postmenopausal client women puts you at higher risk for type 2 diabetes and
who has a BMI of 32. The heart disease."
client has a chest
measurement of 42 inches,
waist measurement of 45
inches, and hip
measurement of 50 inches.
What important message
should the nurse explain
to the client to promote
health promotion?
The nurse performs a Height reduction of 1.5 inches.
physical assessment on an
older female client. Which
change from the prior
exam may be an indication
of osteoporosis?
,While conducting an Sit quietly to allow the client to respond comfortably.
interview to obtain a
health history, the nurse
notices that the client
pauses frequently and
looks at the nurse
expectantly. Which
response is best for the
nurse to provide?
A client is in the clinical for Ask the client to urinate before beginning the
a yearly physical examination.
examination. Which action
should the nurse take
when preparing to
examine the client's
abdomen?
Which respiratory Bradypnea.
condition should the nurse
document after measuring
a respiratory rate of 8
breaths/minute?
Measure the apical pulse and compare it to the
peripheral pulse.
Which procedure should
the nurse use to assessfor
*A pulse deficit is a palpable difference between the
a pulse deficit?
apical pulse at the point of maximal impulse and the
radial pulse palpated at the wrist.
A client has been Dull, thud-like.
diagnosed with bilateral
lower lobe atelectasis.
What percussion sound
should the nurse expect
to hear when percussing
over the client's lower
lobes?
, A client is being assessed Inspect the hair and skin.
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?
The nurse is assessing a Deep palpation above and to the left of the umbilicus.
healthy young adult
during an annual physical
examination. Which
assessment technique
should the nurse
implement when palpating
the abdominal aorta?
The nurse is conducting a Document at least 3 generations of the client's family
family history as part of medical history.
the assessment interview.
Which action should the
nurse take to ensure that
sufficient information
about the client's blood
relatives is obtained?
The nurse is testing the Range of 90 degrees when the hands are placed at
client's shoulders for the small of the back.
range of motion. What
should the nurse
document to record
normal internal rotation?
EXAM – NIGHTINGALE COLLEGE
Save
Terms in this set (197)
The nurse is performing a Barrel chest
thoracic assessment on a
client with chronic asthma
and hyperinflation of the
lungs. Which finding
should be expected for
this client?
The nurse is assessing Note the character and frequency of bowel sounds
bowel sounds for a
hospitalized client. The
nurse has heard bowel
sounds in the right upper
quadrant. What action
should the nurse take
next?
,During inspection of a Document an intact gag reflex.
client's mouth and
pharynx, the nurse places
a tongue blade on the
back of the tongue which
causes the client to gag.
After removing the tongue
blade, what action should
the nurse take?
When teaching a client Upper outer quadrant.
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?
The nurse is assessing a A waist circumference is greater than 35 inches in
postmenopausal client women puts you at higher risk for type 2 diabetes and
who has a BMI of 32. The heart disease."
client has a chest
measurement of 42 inches,
waist measurement of 45
inches, and hip
measurement of 50 inches.
What important message
should the nurse explain
to the client to promote
health promotion?
The nurse performs a Height reduction of 1.5 inches.
physical assessment on an
older female client. Which
change from the prior
exam may be an indication
of osteoporosis?
,While conducting an Sit quietly to allow the client to respond comfortably.
interview to obtain a
health history, the nurse
notices that the client
pauses frequently and
looks at the nurse
expectantly. Which
response is best for the
nurse to provide?
A client is in the clinical for Ask the client to urinate before beginning the
a yearly physical examination.
examination. Which action
should the nurse take
when preparing to
examine the client's
abdomen?
Which respiratory Bradypnea.
condition should the nurse
document after measuring
a respiratory rate of 8
breaths/minute?
Measure the apical pulse and compare it to the
peripheral pulse.
Which procedure should
the nurse use to assessfor
*A pulse deficit is a palpable difference between the
a pulse deficit?
apical pulse at the point of maximal impulse and the
radial pulse palpated at the wrist.
A client has been Dull, thud-like.
diagnosed with bilateral
lower lobe atelectasis.
What percussion sound
should the nurse expect
to hear when percussing
over the client's lower
lobes?
, A client is being assessed Inspect the hair and skin.
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?
The nurse is assessing a Deep palpation above and to the left of the umbilicus.
healthy young adult
during an annual physical
examination. Which
assessment technique
should the nurse
implement when palpating
the abdominal aorta?
The nurse is conducting a Document at least 3 generations of the client's family
family history as part of medical history.
the assessment interview.
Which action should the
nurse take to ensure that
sufficient information
about the client's blood
relatives is obtained?
The nurse is testing the Range of 90 degrees when the hands are placed at
client's shoulders for the small of the back.
range of motion. What
should the nurse
document to record
normal internal rotation?
