HESI/Saunders Online Review for the NCLEX-PN
Examination (2 Year), 2nd Edition Module 4 Exam
2025 LATEST EXAM QUESTIONS AND VERIFIED
ANSWERS GRADED A+ ||Latest version
Inspection
Percussion
Palpating
Auscultation
Order of Assessment
2+ edema
A nurse performing a skin assessment of a client with heart failure notes that the client's
ankles are swollen. To assess the severity of the edema, the nurse presses the skin at
the ankle. Moderate pitting is present, but the indentation subsides rapidly. How would
the nurse document this finding?
Edema
is graded on a 4-point scale
Edema +1
indicates mild pitting with a slight indentation
Edema +2
is moderate pitting in which the indentation subsides rapidly
Edema +3
represents deep pitting in which the indentation remains for a short time and the ankle is
swollen
, Edema +4
denotes very deep pitting in which the indentation remains for a long time and the ankle
is very swollen.
Cranial nerve XI (spinal accessory nerve)
tested by asking the client to shrug the shoulders against the resistance of the nurse's
hand and to turn the head to each side as the nurse tries to resist the client's
movement.
Cranial nerve VII (the facial nerve)
is tested by asking the client to smile, frown, close the eyes tightly against the
resistance of the nurse, lift the eyebrows, show the teeth, and puff the cheeks.
Cranial nerve XII (the hypoglossal nerve)
is tested by inspecting the tongue as the client sticks out the tongue.
Snellen Eye Chart
Position the client in a well-lit spot 20 feet from the chart, with the chart at eye level, and
ask client to read the smallest line they can discern.
Near Vision
Use a hand-held vision screener (held about 14 inches from the eye) containing various
sizes of print or ask the client to read from a magazine.
Confrontation Test
The client covers one eye and looks straight ahead; the nurse, positioned 2 feet away
(60 centimeters), covers the eye opposite the client's covered eye.
The nurse advances a finger or other small object in from the periphery from several
directions; the client should see the object at the same time the nurse does.
Examination (2 Year), 2nd Edition Module 4 Exam
2025 LATEST EXAM QUESTIONS AND VERIFIED
ANSWERS GRADED A+ ||Latest version
Inspection
Percussion
Palpating
Auscultation
Order of Assessment
2+ edema
A nurse performing a skin assessment of a client with heart failure notes that the client's
ankles are swollen. To assess the severity of the edema, the nurse presses the skin at
the ankle. Moderate pitting is present, but the indentation subsides rapidly. How would
the nurse document this finding?
Edema
is graded on a 4-point scale
Edema +1
indicates mild pitting with a slight indentation
Edema +2
is moderate pitting in which the indentation subsides rapidly
Edema +3
represents deep pitting in which the indentation remains for a short time and the ankle is
swollen
, Edema +4
denotes very deep pitting in which the indentation remains for a long time and the ankle
is very swollen.
Cranial nerve XI (spinal accessory nerve)
tested by asking the client to shrug the shoulders against the resistance of the nurse's
hand and to turn the head to each side as the nurse tries to resist the client's
movement.
Cranial nerve VII (the facial nerve)
is tested by asking the client to smile, frown, close the eyes tightly against the
resistance of the nurse, lift the eyebrows, show the teeth, and puff the cheeks.
Cranial nerve XII (the hypoglossal nerve)
is tested by inspecting the tongue as the client sticks out the tongue.
Snellen Eye Chart
Position the client in a well-lit spot 20 feet from the chart, with the chart at eye level, and
ask client to read the smallest line they can discern.
Near Vision
Use a hand-held vision screener (held about 14 inches from the eye) containing various
sizes of print or ask the client to read from a magazine.
Confrontation Test
The client covers one eye and looks straight ahead; the nurse, positioned 2 feet away
(60 centimeters), covers the eye opposite the client's covered eye.
The nurse advances a finger or other small object in from the periphery from several
directions; the client should see the object at the same time the nurse does.
