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HESI 1 - V1 and V2 REVIEW - Health Assessment 1 –
Copy.
The 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? - ANSWER-Note the character and frequency of
bowel sounds
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? - ANSWER-Barrel chest
During inspection of a 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? -
ANSWER-Document an intact gag reflex.
When 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? - ANSWER-
Upper outer quadrant.
The nurse is assessing a postmenopausal client who has a BMI of 32.
The 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? -
ANSWER-A waist circumference is greater than 35 inches in women
puts you at higher risk for type 2 diabetes and heart disease."
, 2|Page
The nurse performs a physical assessment on an older female client.
Which change from the prior exam may be an indication of
osteoporosis? - ANSWER-Height reduction of 1.5 inches.
While conducting an 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? -
ANSWER-Sit quietly to allow the client to respond comfortably.
A client is in the clinical for a yearly physical examination. Which
action should the nurse take when preparing to examine the client's
abdomen? - ANSWER-Ask the client to urinate before beginning the
examination.
Which respiratory condition should the nurse document after measuring
a respiratory rate of 8 breaths/minute? - ANSWER-Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit? -
ANSWER-Measure the apical pulse and compare it to the peripheral
pulse.
*A pulse deficit is a palpable difference between the apical pulse at the
point of maximal impulse and the radial pulse palpated at the wrist.
A client has been diagnosed with bilateral lower lobe atelectasis. What
percussion sound should the nurse expect to hear when percussing over
the client's lower lobes? - ANSWER-Dull, thud-like.
A 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? - ANSWER-Inspect the hair and skin.
HESI 1 - V1 and V2 REVIEW - Health Assessment 1 –
Copy.
The 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? - ANSWER-Note the character and frequency of
bowel sounds
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? - ANSWER-Barrel chest
During inspection of a 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? -
ANSWER-Document an intact gag reflex.
When 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? - ANSWER-
Upper outer quadrant.
The nurse is assessing a postmenopausal client who has a BMI of 32.
The 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? -
ANSWER-A waist circumference is greater than 35 inches in women
puts you at higher risk for type 2 diabetes and heart disease."
, 2|Page
The nurse performs a physical assessment on an older female client.
Which change from the prior exam may be an indication of
osteoporosis? - ANSWER-Height reduction of 1.5 inches.
While conducting an 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? -
ANSWER-Sit quietly to allow the client to respond comfortably.
A client is in the clinical for a yearly physical examination. Which
action should the nurse take when preparing to examine the client's
abdomen? - ANSWER-Ask the client to urinate before beginning the
examination.
Which respiratory condition should the nurse document after measuring
a respiratory rate of 8 breaths/minute? - ANSWER-Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit? -
ANSWER-Measure the apical pulse and compare it to the peripheral
pulse.
*A pulse deficit is a palpable difference between the apical pulse at the
point of maximal impulse and the radial pulse palpated at the wrist.
A client has been diagnosed with bilateral lower lobe atelectasis. What
percussion sound should the nurse expect to hear when percussing over
the client's lower lobes? - ANSWER-Dull, thud-like.
A 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? - ANSWER-Inspect the hair and skin.
