HESI Assessment questions with complete solution

Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness? A. Percussion B. Palpation C. Inspection D. Auscultation - ANSWER-C. Inspection Nurse notes an enlarged, visible lymph node on the client's neck. What action should the nurse take next? A. Record this normal finding in the assessment record. B. Auscultate the lymph node for the presence of a bruit. C. Cover the inflamed area and notify the healthcare provider. D. Ask the client about any localized tenderness at the site. - ANSWER-D. Ask the client about any localized tenderness at the site. The nurse is interviewing a male client who is admitted for chest pain. With each question, the client answers in broken English that is mixed with French phrases and looks to his wife. Frequently his wife anxiously speaks up and contradicts each of the client's responses. What should the nurse do? A. Attempt to calm the spouse before progressing with the health history B. Alternate questions between the two and gather as much data as possible C. Ask the spouse to leave the room during the interview D. Request an interpreter to communicate focused questions - ANSWER-D. Request an interpreter to communicate focused questions The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. What question should the nurse ask firs