HESI V2 health assessment
A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I have lung cancer
or something," and wants to get checked out since, "I can't seem to get rid of this body-wracking dry
cough that has been hanging around for the last six weeks." Which computer documentation of this
client's concerns should the nurse enter?
A. Presents with a hacking non-productive cough of 6 weeks duration.
B. Describe having a "body-wracking dry cough" of 6 weeks duration.
C. Expresses concern of "lung cancer" symptoms for last 6 weeks.
D. Young adult male presents with fears that he has "lung cancer" - (correct Answer) - Correct answer is
B, as assessment process includes chief complaint which is how the patient describe why he is here in
the hospital or clinic and can't include diagnosis.
A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right
hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response.
Which interpretation of this finding is accurate?
A. A normal reflex response.
B. Absent or sluggish response consistent with a lower motor neuron lesion.
C. Flaccid paralysis.
D. Hyperactive response consistent with an upper motor neuron disorder. - (correct Answer) - Correct
answer is D, brisk 4+ response is correlated with hyperactive response.
The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating
the spleen?
A. Pain notes when palpating McBurney's point.
B. Tip of spleen palpable when client is asked to forcefully exhale.
C. Rebound tenderness with compression over right upper quadrant. D. Firm mass palpated at bottom of
left rib cage. - (correct Answer) - Correct answer is D. McBurney's point is related to appendicitis and not
spleen.
In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the stethoscope at
which location? - (correct Answer) - *under mandible towards lymph nodes. transverse to trachea
A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for
pneumonia without hospitalization. Which technique should the nurse implement to assess for
adventitious lung sounds?
A. Use the bell of the stethoscope to listen to the lung fields over lower lobes. B. Have the client lay flat
, while listening to the anterior surface of the chest.
C. Press the stethoscope's diaphragm firmly on the skin over each lung field.
D. Shave all chest hair that may distort sounds heard through the diaphragm. - (correct Answer) - Correct
answer is C. The nurse should listen to all lungs fields during assessment and move from side to side
during auscultation.
A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a muffled voice.
Which complication should the nurse suspect?
A. Foreign body obstruction.
B. Laryngeal polyps.
C. Peritonsillar abscess.
D. Nasal polyps - (correct Answer) - Correct answer is C. Since infections are associated with abscesses
and pus.
The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While
interviewing the client, which assessment technique should the nurse use when asking about the client's
use of illegal drugs and alcohol?
A. Obtain a drug using screen to verify legitimacy of client's stated history.
B. Allow the client to decline answering social questions.
C. Ask specifically about alcohol, marijuana, cocaine, her
D. Use the term illegal or illicit to describe street drug. - (correct Answer) - Correct answer is C. When
interviewing the patient, questions should be clear and specific.
The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client
denies pain upon palpation, but reports pain when the pressure is released. What action should the
nurse implement?
A. Offer to administer a laxative prescribed for PRN use.
B. Obtain a prescription to catheterize the client's bladder.
C. Instruct the client in distraction and relation techniques.
D. Notify the healthcare provider of the rebound tenderness. - (correct Answer) - Correct answer is D. As
this could be a sign of appendicitis.
The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or
arterial insufficiency. Which assessment technique should the nurse use to differentiate the
pathophysiology causing the ulcer?
A. Measure the degree of join range of motion in the extremity.
A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I have lung cancer
or something," and wants to get checked out since, "I can't seem to get rid of this body-wracking dry
cough that has been hanging around for the last six weeks." Which computer documentation of this
client's concerns should the nurse enter?
A. Presents with a hacking non-productive cough of 6 weeks duration.
B. Describe having a "body-wracking dry cough" of 6 weeks duration.
C. Expresses concern of "lung cancer" symptoms for last 6 weeks.
D. Young adult male presents with fears that he has "lung cancer" - (correct Answer) - Correct answer is
B, as assessment process includes chief complaint which is how the patient describe why he is here in
the hospital or clinic and can't include diagnosis.
A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right
hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response.
Which interpretation of this finding is accurate?
A. A normal reflex response.
B. Absent or sluggish response consistent with a lower motor neuron lesion.
C. Flaccid paralysis.
D. Hyperactive response consistent with an upper motor neuron disorder. - (correct Answer) - Correct
answer is D, brisk 4+ response is correlated with hyperactive response.
The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating
the spleen?
A. Pain notes when palpating McBurney's point.
B. Tip of spleen palpable when client is asked to forcefully exhale.
C. Rebound tenderness with compression over right upper quadrant. D. Firm mass palpated at bottom of
left rib cage. - (correct Answer) - Correct answer is D. McBurney's point is related to appendicitis and not
spleen.
In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the stethoscope at
which location? - (correct Answer) - *under mandible towards lymph nodes. transverse to trachea
A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for
pneumonia without hospitalization. Which technique should the nurse implement to assess for
adventitious lung sounds?
A. Use the bell of the stethoscope to listen to the lung fields over lower lobes. B. Have the client lay flat
, while listening to the anterior surface of the chest.
C. Press the stethoscope's diaphragm firmly on the skin over each lung field.
D. Shave all chest hair that may distort sounds heard through the diaphragm. - (correct Answer) - Correct
answer is C. The nurse should listen to all lungs fields during assessment and move from side to side
during auscultation.
A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a muffled voice.
Which complication should the nurse suspect?
A. Foreign body obstruction.
B. Laryngeal polyps.
C. Peritonsillar abscess.
D. Nasal polyps - (correct Answer) - Correct answer is C. Since infections are associated with abscesses
and pus.
The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While
interviewing the client, which assessment technique should the nurse use when asking about the client's
use of illegal drugs and alcohol?
A. Obtain a drug using screen to verify legitimacy of client's stated history.
B. Allow the client to decline answering social questions.
C. Ask specifically about alcohol, marijuana, cocaine, her
D. Use the term illegal or illicit to describe street drug. - (correct Answer) - Correct answer is C. When
interviewing the patient, questions should be clear and specific.
The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client
denies pain upon palpation, but reports pain when the pressure is released. What action should the
nurse implement?
A. Offer to administer a laxative prescribed for PRN use.
B. Obtain a prescription to catheterize the client's bladder.
C. Instruct the client in distraction and relation techniques.
D. Notify the healthcare provider of the rebound tenderness. - (correct Answer) - Correct answer is D. As
this could be a sign of appendicitis.
The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or
arterial insufficiency. Which assessment technique should the nurse use to differentiate the
pathophysiology causing the ulcer?
A. Measure the degree of join range of motion in the extremity.
