Health Assessment- BSN 246 HESI REVIEW
50. A client is diagnoses w/ external otitis. Which finding would the nurse expect to note on assessment of the client?
A. a wider-than-normal ear canal
B.a peraly gray tympanic membrane
C.Redness and swelling in the ear canal
D.an excessive amount of serumen lodged in the ear canal: C. Redness and swelling in the ear canal
Rationale: external otitis is a painful condition caused when irritating or infective agents come into contact w/ the skin of the
external ear. Affected skin becomes red, swollen, and tender to touch or movement. Swelling of the ear canal narrows the canal
and can lead to temporary hearing loss from obstruction
51. A nursig student is performing a respiratory assessment on an adult client and is assessing for tactile fremitus. Which action
by the nursing student indicates a need for further teaching?
A. palpating over the lung apices in the supraclavicular area
B.Asking the client to repeat the work "99" during palpation
C.Palpating over the breast tissue to assess and compare vibrations from one side to the other
D.Comparing vibrations from one side to the other as the client repeats the word "99".: C. Palpating over the breast tissue
to assess and compare vibrations from one side to the other
Rationale:
When assessing for tactile fremitus (tactile vocal fremitus: the vibration of the chest wall that results from sound vibrations
created by speech or other vocal sound), the nurse would begin palpating over the lung apices in the supraclavicular area. The
nurse would compare vibrations from one side to the other as the client repeats the word "99"
52. The clinic nurse is preparing to assess the client's apical pulse. the nuse correctly palpates over which area?
A. Left midclavicular, 5th intercoastal space
B.Left lateral neck
C.Left anecuibital
D.Left popliteal fossa: A. Left midclavicular, 5th intercoastal space
Rationale:
the heart is locateed in the mediastinum. Its apex, or distal end, point tot he left and lies at the level of the ifth intercostal space. A
stethoscope needs to be placed in this area to pick up heart sounds most clearly.
53. the clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test
for the purpose of determining which status?
A. the client's ability to ambulate
,Health Assessment- BSN 246 HESI REVIEW
B.the intactness of the tympanic membrane
C.the intactness of the retinal structure of the eye
D the functional status of the vestibular apparatus in the inner ear.: D. the functional status of the vestibular apparatus in the
inner ear
Rationale: the Romberg test assesses the ability of the vestibular apparatus in the inner ear to help maintain standing balance. The
Romberg test also assesses intactness of the cerebellum and proprioception
54. A confrontation test is prescribed for a client seen in the eye and ear clinic. How would the nurse perform this test? Arrange
the actions in the order that they would be performed. All options must be used.
1. Asks the client to cover one eye
2. Examiner covers eye opposite to the eye covered by the client
3. Asks the client to report when object is first noted
4. Stands 2 to 3 ft (60 to 90 cm) in front of client and faces the client
5. The examiner brings in an object gradually from periphery: 4. Stands 2 to 3 ft (60 to 90 cm) in front of client and faces
the client
1. Asks the client to cover one eye
2. Examiner covers eye opposite to the eye covered by the client 5. the examiner brings in an object gradually from
periphery
3. asks the client to report when object is first noted.
Rationale:
the controntation test is a gross measure of peripheral vision. it compares the person's peripheral vision with the examiner's ,
whose vision is assumed to be normal. If the client does not see the object at the same time as the nurse, the peripheral field loss
is expected. the client need to be referred to an eye care specialist
55. The nurse in a health care clinic is preparing to test a client for accommodation. Initially, the nurse would ask the client to
take which action?
A focus on a close object
B.focus on a distant object
C.Close 1 eye and read letters on a chart
D.Raise 1 finger when the sound is heard: B. Focus on a distant object
Rationale: the nurse tests for accomodation by initially asking the client to focus on a distant object. This process dilates the
pupils. The client is then asked to shift gaze to a near object, such as a finger held about 3in. from the nose. A normal response
includes pupillary constrictin and convergence of the axes of the eyes
, Health Assessment- BSN 246 HESI REVIEW
56. A group of postmenopausal women are learning to do breast self-examination (BSE) in a teaching session at the clinic. The
clinic nurse would teach the group which point about the procedure
A. do the exam on the same day every month
B.Do the exam 7 days after the start of the menstrual cycle.
C.Examine the left breast withthe left hand and vice versa
D.Us the tips of the fingers to increase the liklelihood of feeling lumps. A: A. do the exam on the same day every month
Rationale: women who are postmenopausal are taught to do BSE on the same day every month. Before menopause, women
would do the procedure 7 days after the start of the menstrual cycle, when the breasts are least tender. Each breast is examined
w/ the opposite hand. the pads of the fingers, not the fingertips would be used for palpation.
The client may use a circular, up and down, or wedge method of assessment. Consistency of use of the same method is more
important than the actual method used.
57. The nurse is examining a dark-skinned client for the presence of petechiae (pinpoint non-blanching spots that measure < 2
mm in size). The nurse will best observe these lesions in which body area?
A. Sclerae
B.Oral mucosa
C.Sole of the foot
D.Palm of the hand: B. Oral Mucosa
In a dark-skinned client, petechiae are best observed in the conjuctivae and oral mucosa.
-Jaundice would be best noted in the sclerae of the eye. -Cynaosis would be best noted in teh palms of the hand and soles of the
feet.
58. The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How would the nurse best determine the
presence of erythema.
A. Assess for drainage from the wound
B.Assess for redness around the wound edge
C.Palpate for swelling aound the wound edges
D.Palpate for increased skin temperature around the wound edges.: D. Palpate for increased skin temp around the wound
edges
Rationale:
Erythema is a form of macula characterized by diffuse redness of the skin. In a dark-skinned client, erythema is best determined by
palpating for increased skin temperature.
Redness around the wound edfes may be difficult to note in the dark-skinned client.
50. A client is diagnoses w/ external otitis. Which finding would the nurse expect to note on assessment of the client?
A. a wider-than-normal ear canal
B.a peraly gray tympanic membrane
C.Redness and swelling in the ear canal
D.an excessive amount of serumen lodged in the ear canal: C. Redness and swelling in the ear canal
Rationale: external otitis is a painful condition caused when irritating or infective agents come into contact w/ the skin of the
external ear. Affected skin becomes red, swollen, and tender to touch or movement. Swelling of the ear canal narrows the canal
and can lead to temporary hearing loss from obstruction
51. A nursig student is performing a respiratory assessment on an adult client and is assessing for tactile fremitus. Which action
by the nursing student indicates a need for further teaching?
A. palpating over the lung apices in the supraclavicular area
B.Asking the client to repeat the work "99" during palpation
C.Palpating over the breast tissue to assess and compare vibrations from one side to the other
D.Comparing vibrations from one side to the other as the client repeats the word "99".: C. Palpating over the breast tissue
to assess and compare vibrations from one side to the other
Rationale:
When assessing for tactile fremitus (tactile vocal fremitus: the vibration of the chest wall that results from sound vibrations
created by speech or other vocal sound), the nurse would begin palpating over the lung apices in the supraclavicular area. The
nurse would compare vibrations from one side to the other as the client repeats the word "99"
52. The clinic nurse is preparing to assess the client's apical pulse. the nuse correctly palpates over which area?
A. Left midclavicular, 5th intercoastal space
B.Left lateral neck
C.Left anecuibital
D.Left popliteal fossa: A. Left midclavicular, 5th intercoastal space
Rationale:
the heart is locateed in the mediastinum. Its apex, or distal end, point tot he left and lies at the level of the ifth intercostal space. A
stethoscope needs to be placed in this area to pick up heart sounds most clearly.
53. the clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test
for the purpose of determining which status?
A. the client's ability to ambulate
,Health Assessment- BSN 246 HESI REVIEW
B.the intactness of the tympanic membrane
C.the intactness of the retinal structure of the eye
D the functional status of the vestibular apparatus in the inner ear.: D. the functional status of the vestibular apparatus in the
inner ear
Rationale: the Romberg test assesses the ability of the vestibular apparatus in the inner ear to help maintain standing balance. The
Romberg test also assesses intactness of the cerebellum and proprioception
54. A confrontation test is prescribed for a client seen in the eye and ear clinic. How would the nurse perform this test? Arrange
the actions in the order that they would be performed. All options must be used.
1. Asks the client to cover one eye
2. Examiner covers eye opposite to the eye covered by the client
3. Asks the client to report when object is first noted
4. Stands 2 to 3 ft (60 to 90 cm) in front of client and faces the client
5. The examiner brings in an object gradually from periphery: 4. Stands 2 to 3 ft (60 to 90 cm) in front of client and faces
the client
1. Asks the client to cover one eye
2. Examiner covers eye opposite to the eye covered by the client 5. the examiner brings in an object gradually from
periphery
3. asks the client to report when object is first noted.
Rationale:
the controntation test is a gross measure of peripheral vision. it compares the person's peripheral vision with the examiner's ,
whose vision is assumed to be normal. If the client does not see the object at the same time as the nurse, the peripheral field loss
is expected. the client need to be referred to an eye care specialist
55. The nurse in a health care clinic is preparing to test a client for accommodation. Initially, the nurse would ask the client to
take which action?
A focus on a close object
B.focus on a distant object
C.Close 1 eye and read letters on a chart
D.Raise 1 finger when the sound is heard: B. Focus on a distant object
Rationale: the nurse tests for accomodation by initially asking the client to focus on a distant object. This process dilates the
pupils. The client is then asked to shift gaze to a near object, such as a finger held about 3in. from the nose. A normal response
includes pupillary constrictin and convergence of the axes of the eyes
, Health Assessment- BSN 246 HESI REVIEW
56. A group of postmenopausal women are learning to do breast self-examination (BSE) in a teaching session at the clinic. The
clinic nurse would teach the group which point about the procedure
A. do the exam on the same day every month
B.Do the exam 7 days after the start of the menstrual cycle.
C.Examine the left breast withthe left hand and vice versa
D.Us the tips of the fingers to increase the liklelihood of feeling lumps. A: A. do the exam on the same day every month
Rationale: women who are postmenopausal are taught to do BSE on the same day every month. Before menopause, women
would do the procedure 7 days after the start of the menstrual cycle, when the breasts are least tender. Each breast is examined
w/ the opposite hand. the pads of the fingers, not the fingertips would be used for palpation.
The client may use a circular, up and down, or wedge method of assessment. Consistency of use of the same method is more
important than the actual method used.
57. The nurse is examining a dark-skinned client for the presence of petechiae (pinpoint non-blanching spots that measure < 2
mm in size). The nurse will best observe these lesions in which body area?
A. Sclerae
B.Oral mucosa
C.Sole of the foot
D.Palm of the hand: B. Oral Mucosa
In a dark-skinned client, petechiae are best observed in the conjuctivae and oral mucosa.
-Jaundice would be best noted in the sclerae of the eye. -Cynaosis would be best noted in teh palms of the hand and soles of the
feet.
58. The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How would the nurse best determine the
presence of erythema.
A. Assess for drainage from the wound
B.Assess for redness around the wound edge
C.Palpate for swelling aound the wound edges
D.Palpate for increased skin temperature around the wound edges.: D. Palpate for increased skin temp around the wound
edges
Rationale:
Erythema is a form of macula characterized by diffuse redness of the skin. In a dark-skinned client, erythema is best determined by
palpating for increased skin temperature.
Redness around the wound edfes may be difficult to note in the dark-skinned client.
