NURS 320 HESI STUDY GUIDE EXAM
AND ALL ACCURATE ANSWERS.
Conductive hearing loss - Answer occurs from physical obstruction to the transmission of
sound waves.
Sensorineural hearing loss - Answer occurs from a result of pathological process in the inner
ear, a defect in CN VIII or defect of sensory fibers that lead to the cerebral cortex
Cheyne-Strokes respirations - Answer rhythmic respirations with periods of apnea, metabolic
dysfunction in the cerebral hemisphere or basal ganglia
Neurogenic hyperventilation - Answer regular, rapid, deep sustained respirations, dysfunction
in the low midbrain and middle pons
Ataxic respirations - Answer totally irregular in rhythm and depth, dysfunction in the medulla
Apneustic respirations - Answer irregular respirations with pauses at the end of
inspiration/expiration, dysfunction in the middle or caudal pons
Murmur - Answer abnormal hear sound, faint/loud blowing, swooshing sound with high, med,
low pitch
Lub-dub - Answer normal, represent S1S2
Pericardial friction rub - Answer scratchy, leathery heart sound
Click - Answer abrupt, high pitched snapping sound
6 cardinal positions of gaze - Answer assesses muscle weakness
Snellen eye chart - Answer Assesses visual acuity and CN II (optic). Assessed in 1 eye at a time,
and then in both eyes together with the client standing/sitting. Client stands 20 feet from the
, Testicular self examination (TSE) - Answer patient does exam on the same day each month,
standing after a shower/bath under warm water. Use both hands, with fingers under the
scrotum and thumbs on top, the client gently rolls the testicles feeling for any lumps
- Performed once a month, on the same day of each month.
Brudzinski's sign - Answer tested with client supine, nurse flexes clients head and should have
no pain. Positive sign indicates when the client flexes the hip and knee in response to neck
flexion and has pain in the vertebral column
Kernig's sign - Answer tests for meningeal irritation. Is positive when the client flexes the legs
at the hip and knee and complains of pain along the vertebral column when the leg is extended.
Decorticate posturing - Answer abnormal flexion
- client's upper arms are flexed and held tightly to the sides of the body and the legs are
extended and internally rotated.
Decerebrate posturing - Answer abnormal extension and occurs when the arms are fully
extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet
plantar flexed
Wheezes - Answer occur in asthma patients from the constriction of the bronchi. High pitched
sounds when air passes through an obstructed/narrow lumen
Stridor - Answer harsh sound noted with an upper airway obstruction, life threatening
Crackles - Answer produced by air passing over retained airway secretions or fluid, or the
sudden opening of collapsed airways
Diminished - Answer heard over lung tissue where poor oxygen exchange is occurring
Focused assessment - Answer focuses on a limited or short term problem, such as client's
complaint. Problem based, performed in a walk in clinic or emergency department
Complete assessment - Answer includes complete health history and physical examination and
AND ALL ACCURATE ANSWERS.
Conductive hearing loss - Answer occurs from physical obstruction to the transmission of
sound waves.
Sensorineural hearing loss - Answer occurs from a result of pathological process in the inner
ear, a defect in CN VIII or defect of sensory fibers that lead to the cerebral cortex
Cheyne-Strokes respirations - Answer rhythmic respirations with periods of apnea, metabolic
dysfunction in the cerebral hemisphere or basal ganglia
Neurogenic hyperventilation - Answer regular, rapid, deep sustained respirations, dysfunction
in the low midbrain and middle pons
Ataxic respirations - Answer totally irregular in rhythm and depth, dysfunction in the medulla
Apneustic respirations - Answer irregular respirations with pauses at the end of
inspiration/expiration, dysfunction in the middle or caudal pons
Murmur - Answer abnormal hear sound, faint/loud blowing, swooshing sound with high, med,
low pitch
Lub-dub - Answer normal, represent S1S2
Pericardial friction rub - Answer scratchy, leathery heart sound
Click - Answer abrupt, high pitched snapping sound
6 cardinal positions of gaze - Answer assesses muscle weakness
Snellen eye chart - Answer Assesses visual acuity and CN II (optic). Assessed in 1 eye at a time,
and then in both eyes together with the client standing/sitting. Client stands 20 feet from the
, Testicular self examination (TSE) - Answer patient does exam on the same day each month,
standing after a shower/bath under warm water. Use both hands, with fingers under the
scrotum and thumbs on top, the client gently rolls the testicles feeling for any lumps
- Performed once a month, on the same day of each month.
Brudzinski's sign - Answer tested with client supine, nurse flexes clients head and should have
no pain. Positive sign indicates when the client flexes the hip and knee in response to neck
flexion and has pain in the vertebral column
Kernig's sign - Answer tests for meningeal irritation. Is positive when the client flexes the legs
at the hip and knee and complains of pain along the vertebral column when the leg is extended.
Decorticate posturing - Answer abnormal flexion
- client's upper arms are flexed and held tightly to the sides of the body and the legs are
extended and internally rotated.
Decerebrate posturing - Answer abnormal extension and occurs when the arms are fully
extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet
plantar flexed
Wheezes - Answer occur in asthma patients from the constriction of the bronchi. High pitched
sounds when air passes through an obstructed/narrow lumen
Stridor - Answer harsh sound noted with an upper airway obstruction, life threatening
Crackles - Answer produced by air passing over retained airway secretions or fluid, or the
sudden opening of collapsed airways
Diminished - Answer heard over lung tissue where poor oxygen exchange is occurring
Focused assessment - Answer focuses on a limited or short term problem, such as client's
complaint. Problem based, performed in a walk in clinic or emergency department
Complete assessment - Answer includes complete health history and physical examination and
