Health Assessment Hesi Practice Exam
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A nurse conducting a physical assessment is observing the client's balance and performing tests
to determine the client's sense of equilibrium. Which cranial nerve is the nurse assessing?
1. Cranial nerve II
2. Cranial nerve IX
3. Cranial nerve VII
4. Cranial nerve VIII - Answer✔4. Cranial nerve VIII
Cranial nerve VIII is the acoustic nerve. Hearing tests are performed to assess the cochlear
portion of this nerve. Tests to assess equilibrium, such as observation of the client's balance
when the client is walking or standing, involve the vestibular portion.
A nurse performing a neurological assessment of a client who has sustained a stroke (brain
attack) is preparing to check for stereognosis. Which action should the nurse take to perform
this assessment?
1. Placing an object in the client's hand and asking the client to identify it
2. Tracing a number on the client's hand and asking the client to identify it
3. Moving the client's finger up and down and asking the client which way it is being moved
4. Making two simultaneous pinpricks on the skin and asking the client to distinguish them -
Answer✔1. Placing an object in the client's hand and asking the client to identify it
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Stereognosis is the client's ability to recognize objects placed in his or her hand.
A nurse performing an abdominal assessment of a client is preparing to auscultate for bowel
sounds. In which part of the abdomen should the nurse place the stethoscope first?
1. Left upper quadrant
2. Left lower quadrant
3. Right upper quadrant
4. Right lower quadrant - Answer✔4. Right lower quadrant
To auscultate for bowel sounds, the nurse places the diaphragm endpiece of the stethoscope
lightly against the skin, then begins to auscultate in the right lower abdominal quadrant, in the
area of the ileocecal valve, because bowel sounds are always present there normally.
A nurse performing a physical assessment of a client is checking the client's mouth and throat.
As part of the assessment, the nurse plans to assess the function of cranial nerve XII. What
should the nurse ask the client to do as a means of assessing this nerve?
1. Frown
2. Show the teeth
3. Stick out the tongue
4. Say "ah" as the tongue is depressed with a tongue blade - Answer✔3. Stick out the tongue
To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse asks the client to
stick out the tongue. The nurse then notes the forward thrust in the midline as the client
protrudes the tongue. The nurse also asks the client to verbalize certain words and then listen
for clear, distinct speech.
Discontinuous high-pitched crackling sounds heard during inspiration that do not clear with
coughing - Answer✔Fine Crackles
Loud, low-pitched bubbling and gurgling sounds heard on inspiration (may be present on
expiration); may decrease with coughing or suctioning but reappear - Answer✔Coarse Crackles
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High-pitched, continuous musical sounds heard during inspiration or expiration -
Answer✔Wheezing
Loud, low-pitched, coarse rumbling sounds heard during inspiration or expiration; may be
cleared by coughing - Answer✔Rhonchi
Dry, grating quality sounds heard best during inspiration; does not clear with coughing -
Answer✔Pleural Friction Rub
Moderately pitched; heard over the major bronchi - Answer✔Bronchovesicular sounds
Low-pitched rustling; heard over the peripheral lung fields - Answer✔Vesicular sounds
High-pitched, with a harsh, hollow, tubular quality heard over the trachea and larynx -
Answer✔Bronchial sounds
A nurse preparing to perform a respiratory assessment of an adult client is reading the client's
medical record. The nurse sees that the health care provider noted resonance on percussion of
the client's posterior chest. What interpretation does the nurse make of this finding?
1. The client has normal, healthy lungs.
2. The client may have a pneumothorax.
3. The client most likely has a lung tumor.
4. An excessive amount of air is present in the lungs. - Answer✔1. The client has normal,
healthy lungs.
Resonance on percussion predominates in healthy adult lung tissue.
When too much air is present such as in the case of emphysema where it is trapped in the
alveoli and pneumothorax where it is trapped in the pleural space leading to lung collapse. -
Answer✔Hyperresonance
Indicates an abnormal density in the lungs, such as that noted in pneumonia, pleural effusion,
or atelectasis or in the presence of a tumor. - Answer✔Dull note on percussion of the lungs
A nurse performing a breast examination is preparing to palpate the client's breasts. Into which
position should the nurse assist the client to perform palpation?
1. A standing position, with the client holding both arms above her head
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2. A standing position, with the client holding her hands firmly on her hips
3. A supine position, with the arm on the side being examined positioned across the chest
4. A supine position, with the arm on the side being examined positioned behind the head and
a small pillow placed under the shoulder on the same side - Answer✔4. A supine position, with
the arm on the side being examined positioned behind the head and a small pillow placed
under the shoulder on the same side
To palpate the breasts, the nurse assists the client into a supine position and positions the
client's arm on the side being examined behind the head. A small pillow is placed under the
shoulder on the same side. The nurse uses the pads of the first three fingers to gently compress
the breast tissue against the chest wall and notes tissue consistency. Palpation is performed
systematically, with care taken to ensure that the entire breast and tail are palpated.
A nurse performing a neck assessment of a client is testing the status of cranial nerve XI. What
does the nurse ask the client to do to enable assessment of this nerve?
1. Smile
2. Lift the eyebrows
3. Stick out the tongue
4. Shrug the shoulders against resistance - Answer✔4. Shrug the shoulders against resistance
Cranial nerve XI (spinal accessory nerve) is 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.
Increased lumbar curvature - Answer✔Lordosis (Swayback)
Exaggeration of the posterior curvature of the thoracic spine - Answer✔Kyphosis (hunchback)
Lateral spinal curvature - Answer✔Scoliosis
A nurse performing a musculoskeletal assessment is inspecting the posterior aspect of the
client's posture as the client stands. After noting an exaggeration of the posterior curvature of
the client's thoracic spine, how does the nurse interpret this finding?
1. Lordosis
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