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HESI 1 - V1 AND V2 REVIEW - HEALTH
ASSESSMENT 1 | COMPREHENSIVE Q&A FOR
GUARANTEED SUCCESS
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? - correct-answer-12.
The Glasgow Coma Scale is used to establish baseline data based on eye opening,
motor response, and verbal response. The lowest possible score is 3 and the
highest is 15. This client's Glasgow Coma Scale (GCS) score is 12: Opening eyes to
sound is a score of 3, localizing to pain is a 5, and confusion during a conversation
is a 4 (3 + 5 + 4 = 12).
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? - correct-answer-Family history of colon cancer on
mother's side.
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? - correct-answer-The skin
immediately returns to normal position.
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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? - correct-answer-Level
of consciousness.
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? - correct-
answer-Fibroadenoma.
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? - correct-answer-The client works in a
daycare setting that has had a scabies outbreak.
When assessing facial nerve function of a 96-year-old, the nurse asks the client to
smile in an exaggerated manner. Which finding is most important for the nurse to
further asses? - correct-answer-Only one side of the mouth moves when smiling.
When performing range of motion exercises on the joints of an older adult client,
the nurse notes that joint range is greater with passive ranging than with active
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ranging. A goniometer indicates that this difference is as much as 15% in some
joints. How should this finding be documented? - correct-answer-Abnormal.
Which action should the registered nurse (RN) implement to complete an
assessment for a client while using an interpreter? - correct-answer-Maintain eye
contact with the client while listening to the translation.
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? - correct-answer-Have you
experienced sudden weight loss?
A male executive is seen in the primary care clinic for a physical examination.
While obtaining the client's health history, the nurse inquires about his drug and
alcohol use. The executive denies drug use, but reports that he has "two glasses of
wine" per night. Which response is best for the nurse to provide? - correct-
answer-"What effect do you think your use of alcohol may have on you?"
Which part of the body should the nurse examine when assessing for peripheral
edema in a client with heart failure? - correct-answer-Ankles.
HESI 1 - V1 AND V2 REVIEW - HEALTH
ASSESSMENT 1 | COMPREHENSIVE Q&A FOR
GUARANTEED SUCCESS
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? - correct-answer-12.
The Glasgow Coma Scale is used to establish baseline data based on eye opening,
motor response, and verbal response. The lowest possible score is 3 and the
highest is 15. This client's Glasgow Coma Scale (GCS) score is 12: Opening eyes to
sound is a score of 3, localizing to pain is a 5, and confusion during a conversation
is a 4 (3 + 5 + 4 = 12).
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? - correct-answer-Family history of colon cancer on
mother's side.
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? - correct-answer-The skin
immediately returns to normal position.
,2|Page
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? - correct-answer-Level
of consciousness.
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? - correct-
answer-Fibroadenoma.
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? - correct-answer-The client works in a
daycare setting that has had a scabies outbreak.
When assessing facial nerve function of a 96-year-old, the nurse asks the client to
smile in an exaggerated manner. Which finding is most important for the nurse to
further asses? - correct-answer-Only one side of the mouth moves when smiling.
When performing range of motion exercises on the joints of an older adult client,
the nurse notes that joint range is greater with passive ranging than with active
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ranging. A goniometer indicates that this difference is as much as 15% in some
joints. How should this finding be documented? - correct-answer-Abnormal.
Which action should the registered nurse (RN) implement to complete an
assessment for a client while using an interpreter? - correct-answer-Maintain eye
contact with the client while listening to the translation.
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? - correct-answer-Have you
experienced sudden weight loss?
A male executive is seen in the primary care clinic for a physical examination.
While obtaining the client's health history, the nurse inquires about his drug and
alcohol use. The executive denies drug use, but reports that he has "two glasses of
wine" per night. Which response is best for the nurse to provide? - correct-
answer-"What effect do you think your use of alcohol may have on you?"
Which part of the body should the nurse examine when assessing for peripheral
edema in a client with heart failure? - correct-answer-Ankles.
