HESI- HEALTH ASSESSMENT EXAM QUESTIONS AND
ANSWERS GRADED A+ 100% VERIFIED.
1. The nurse is setting up the physical environment for an interview with a
client and plans to obtain subjective data regarding the client's health. Which
interventions are appropriate? Select all that apply.
A. Set the room temperature at a comfortable level.
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, B. Remove distracting objects from the interviewing area.
C. Place a chair for the client across from the nurse's desk.
D. Ensure comfortable seating at eye level for the 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.: Correct Answers: A, B, and D
Rationale:When preparing the physical environment for an interview, the nurse
would set the room temperature at a comfortable level. The nurse would provide
sufficient lighting for the client and nurse to see each other. The nurse would avoid
having the client face a strong light because the client would have to squint into the
full light. Distracting objects and equipment need to be removed from the interview
area. The nurse would arrange seating so that the nurse and client are seated
comfortably at eye level, and the nurse avoids facing the client across a desk or
table, because this creates a barrier. The distance between the nurse and the client
would be set by the nurse at 4 to 5 feet (1.2 to 1.5 meters). If the nurse places the
client any closer, the nurse will be invading the client's private space and may create
anxiety in the client. If the nurse places the client farther away, the nurse may be
seen as distant and aloof by the client.
2. After performing an initial abdominal assessment on a client with nausea
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, and vomiting, the nurse would expect to note which finding?
A. Waves of loud gurgles auscultated in all four quadrants.
B. Low-pitched swishing auscultated in one or two quadrants.
C. Relatively high-pitched clicks or gurgles auscultated in one or two quad-
rants.
D. Very high pitched, loud rushes auscultated in especially in one or two
quadrants.: Correct Answer: A
Rationale:Although frequency and intensity of bowel sounds vary, depending on the
phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles.
Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly associated
with nausea and vomiting. A swishing or buzzing sound represents turbulent blood
flow associated with a bruit. Bruits are not normal sounds. Bowel sounds are very
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, high-pitched and loud (hyperresonance) when the intestines are under tension, such
as in intestinal obstruction. Therefore, options 2, 3, and 4 are incorrect.
3. The nurse is performing a neurological assessment on a client and elicits a
positive Romberg's sign. The nurse makes this determination based on which
observation?
A. An involuntary rhythmic, rapid twitching of the eyeballs.
B. A dorsiflexion of the ankle and great toe with fanning of the other toes.
C. A significant sway when the client stands erect with feet together, arms at
the side and the eyes closed.
D. A lack of sense of position when the client is unable to return extended
fingers to a point of reference.: Correct Answer: C
Rationale:In Romberg's test, the client is asked to stand with the feet together and
the arms at the sides, and to close the eyes and hold the position; normally the
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ANSWERS GRADED A+ 100% VERIFIED.
1. The nurse is setting up the physical environment for an interview with a
client and plans to obtain subjective data regarding the client's health. Which
interventions are appropriate? Select all that apply.
A. Set the room temperature at a comfortable level.
mailto:https://www.stuvia.com/user/techgrades
, B. Remove distracting objects from the interviewing area.
C. Place a chair for the client across from the nurse's desk.
D. Ensure comfortable seating at eye level for the 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.: Correct Answers: A, B, and D
Rationale:When preparing the physical environment for an interview, the nurse
would set the room temperature at a comfortable level. The nurse would provide
sufficient lighting for the client and nurse to see each other. The nurse would avoid
having the client face a strong light because the client would have to squint into the
full light. Distracting objects and equipment need to be removed from the interview
area. The nurse would arrange seating so that the nurse and client are seated
comfortably at eye level, and the nurse avoids facing the client across a desk or
table, because this creates a barrier. The distance between the nurse and the client
would be set by the nurse at 4 to 5 feet (1.2 to 1.5 meters). If the nurse places the
client any closer, the nurse will be invading the client's private space and may create
anxiety in the client. If the nurse places the client farther away, the nurse may be
seen as distant and aloof by the client.
2. After performing an initial abdominal assessment on a client with nausea
mailto:https://www.stuvia.com/user/techgrades
, and vomiting, the nurse would expect to note which finding?
A. Waves of loud gurgles auscultated in all four quadrants.
B. Low-pitched swishing auscultated in one or two quadrants.
C. Relatively high-pitched clicks or gurgles auscultated in one or two quad-
rants.
D. Very high pitched, loud rushes auscultated in especially in one or two
quadrants.: Correct Answer: A
Rationale:Although frequency and intensity of bowel sounds vary, depending on the
phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles.
Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly associated
with nausea and vomiting. A swishing or buzzing sound represents turbulent blood
flow associated with a bruit. Bruits are not normal sounds. Bowel sounds are very
mailto:https://www.stuvia.com/user/techgrades
, high-pitched and loud (hyperresonance) when the intestines are under tension, such
as in intestinal obstruction. Therefore, options 2, 3, and 4 are incorrect.
3. The nurse is performing a neurological assessment on a client and elicits a
positive Romberg's sign. The nurse makes this determination based on which
observation?
A. An involuntary rhythmic, rapid twitching of the eyeballs.
B. A dorsiflexion of the ankle and great toe with fanning of the other toes.
C. A significant sway when the client stands erect with feet together, arms at
the side and the eyes closed.
D. A lack of sense of position when the client is unable to return extended
fingers to a point of reference.: Correct Answer: C
Rationale:In Romberg's test, the client is asked to stand with the feet together and
the arms at the sides, and to close the eyes and hold the position; normally the
mailto:https://www.stuvia.com/user/techgrades
