2024 HESI HEALTH ASSESSMENT EXAM
VERSION COMPLETE EXAM QUESTIONS AND
CORRECT ANSWERS LATEST UPDATE
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Terms in this set (109)
,The nurse is setting up the Correct Answers: A, B, and D
physical environment for
an interview with a client Rationale:When preparing the physical environment
and plans to obtain for an interview, the nurse would set the room
subjective data regarding temperature at a comfortable level. The nurse would
the client's health. Which provide sufficient lighting for the client and nurse to
interventions are see each other. The nurse would avoid having the
appropriate? Select all client face a strong light because the client would
that apply. have to squint into the full light. Distracting objects
and equipment need to be removed from the
A.Set the room interview area. The nurse would arrange seating so
temperature at a that the nurse and client are seated comfortably at
comfortable level. eye level, and the nurse avoids facing the client
B.Remove distracting across a desk or table, because this creates a barrier.
objects from the The distance between the nurse and the client would
interviewing area. be set by the nurse at 4 to 5 feet (1.2 to 1.5 meters). If
C.Place a chair for the the nurse places the client any closer, the nurse will
client across from the be invading the client's private space and may create
nurse's desk. anxiety in the client. If the nurse places the client
D.Ensure comfortable farther away, the nurse may be seen as distant and
seating at eye level for the aloof by the client.
client and nurse.
E.Provide seating for the
so that the faces a strong
light.
F.Ensure that the distance
between the client and
the nurse is at least 7 feet.
,After performing an initial Correct Answer: A
abdominal assessment on
a client with nausea and Rationale:Although frequency and intensity of bowel
vomiting, the nurse would sounds vary, depending on the phase of digestion,
expect to note which normal bowel sounds are relatively high-pitched
finding? clicks or gurgles. Loud gurgles (borborygmi) indicate
hyperperistalsis and are commonly associated with
A. Waves of loud gurgles nausea and vomiting. A swishing or buzzing sound
auscultated in all four represents turbulent blood flow associated with a
quadrants. bruit. Bruits are not normal sounds. Bowel sounds are
B. Low-pitched swishing very high-pitched and loud (hyperresonance) when
auscultated in one or two the intestines are under tension, such as in intestinal
quadrants. obstruction. Therefore, options 2, 3, and 4 are
C. Relatively high-pitched incorrect.
clicks or gurgles
auscultated in one or two
quadrants.
D. Very high pitched, loud
rushes auscultated in
especially in one or two
quadrants.
, The nurse is performing a Correct Answer: C
neurological assessment
on a client and elicits a Rationale:In Romberg's test, the client is asked to
positive Romberg's sign. stand with the feet together and the arms at the sides,
The nurse makes this and to close the eyes and hold the position; normally
determination based on the client can maintain posture and balance. A
which observation? positive Romberg's sign is a vestibular neurological
sign that is found when a client exhibits a loss of
A. An involuntary rhythmic, balance when closing the eyes. This may occur with
rapid twitching of the cerebellar ataxia, loss of proprioception, and loss of
eyeballs. vestibular function. A lack of normal sense of position
B. A dorsiflexion of the coupled with an inability to return extended fingers to
ankle and great toe with a point of reference is a finding that indicates a
fanning of the other toes. problem with coordination. A positive gaze nystagmus
C. A significant sway when evaluation results in an involuntary rhythmic, rapid
the client stands erect twitching of the eyeballs. A positive Babinski's test
with feet together, arms at results in dorsiflexion of the ankle and great toe with
the side and the eyes fanning of the other toes; if this occurs in anyone
closed. older than 2 years, it indicates the presence of central
D. A lack of sense of nervous system disease.
position when the client is
unable to return extended
fingers to a point of
reference.
VERSION COMPLETE EXAM QUESTIONS AND
CORRECT ANSWERS LATEST UPDATE
Practice questions for this set
Learn
Studied 7 terms
Nice work, you're crushing it
Continue studying in Learn
Terms in this set (109)
,The nurse is setting up the Correct Answers: A, B, and D
physical environment for
an interview with a client Rationale:When preparing the physical environment
and plans to obtain for an interview, the nurse would set the room
subjective data regarding temperature at a comfortable level. The nurse would
the client's health. Which provide sufficient lighting for the client and nurse to
interventions are see each other. The nurse would avoid having the
appropriate? Select all client face a strong light because the client would
that apply. have to squint into the full light. Distracting objects
and equipment need to be removed from the
A.Set the room interview area. The nurse would arrange seating so
temperature at a that the nurse and client are seated comfortably at
comfortable level. eye level, and the nurse avoids facing the client
B.Remove distracting across a desk or table, because this creates a barrier.
objects from the The distance between the nurse and the client would
interviewing area. be set by the nurse at 4 to 5 feet (1.2 to 1.5 meters). If
C.Place a chair for the the nurse places the client any closer, the nurse will
client across from the be invading the client's private space and may create
nurse's desk. anxiety in the client. If the nurse places the client
D.Ensure comfortable farther away, the nurse may be seen as distant and
seating at eye level for the aloof by the client.
client and nurse.
E.Provide seating for the
so that the faces a strong
light.
F.Ensure that the distance
between the client and
the nurse is at least 7 feet.
,After performing an initial Correct Answer: A
abdominal assessment on
a client with nausea and Rationale:Although frequency and intensity of bowel
vomiting, the nurse would sounds vary, depending on the phase of digestion,
expect to note which normal bowel sounds are relatively high-pitched
finding? clicks or gurgles. Loud gurgles (borborygmi) indicate
hyperperistalsis and are commonly associated with
A. Waves of loud gurgles nausea and vomiting. A swishing or buzzing sound
auscultated in all four represents turbulent blood flow associated with a
quadrants. bruit. Bruits are not normal sounds. Bowel sounds are
B. Low-pitched swishing very high-pitched and loud (hyperresonance) when
auscultated in one or two the intestines are under tension, such as in intestinal
quadrants. obstruction. Therefore, options 2, 3, and 4 are
C. Relatively high-pitched incorrect.
clicks or gurgles
auscultated in one or two
quadrants.
D. Very high pitched, loud
rushes auscultated in
especially in one or two
quadrants.
, The nurse is performing a Correct Answer: C
neurological assessment
on a client and elicits a Rationale:In Romberg's test, the client is asked to
positive Romberg's sign. stand with the feet together and the arms at the sides,
The nurse makes this and to close the eyes and hold the position; normally
determination based on the client can maintain posture and balance. A
which observation? positive Romberg's sign is a vestibular neurological
sign that is found when a client exhibits a loss of
A. An involuntary rhythmic, balance when closing the eyes. This may occur with
rapid twitching of the cerebellar ataxia, loss of proprioception, and loss of
eyeballs. vestibular function. A lack of normal sense of position
B. A dorsiflexion of the coupled with an inability to return extended fingers to
ankle and great toe with a point of reference is a finding that indicates a
fanning of the other toes. problem with coordination. A positive gaze nystagmus
C. A significant sway when evaluation results in an involuntary rhythmic, rapid
the client stands erect twitching of the eyeballs. A positive Babinski's test
with feet together, arms at results in dorsiflexion of the ankle and great toe with
the side and the eyes fanning of the other toes; if this occurs in anyone
closed. older than 2 years, it indicates the presence of central
D. A lack of sense of nervous system disease.
position when the client is
unable to return extended
fingers to a point of
reference.
