HESI V2 health assessment 2025
Study online at https://quizlet.com/_hlzc4d
A 29 year old male client informs the
nurse that he came to the clinic to see
if, "Maybe I have lung cancer or some-
thing," 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."
Correct answer is B, as assessment
Which computer documentation of this
process includes chief complaint which
client's concerns should the nurse en-
is how the patient describe why he is
ter?
here in the hospital or clinic and can't
A. Presents with a hacking non-produc-
include diagnosis.
tive 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"
A 75-year-old client with a recent history
of a cerebrovascular accident (CVA) pre-
sents 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 ac-
Correct answer is D, brisk 4+ response is
curate?
correlated with hyperactive response.
A. A normal reflex response.
B. Absent or sluggish response consis-
tent with a lower motor neuron lesion.
C. Flaccid paralysis.
D. Hyperactive response consistent with
an upper motor neuron disorder.
The nurse examines a client's abdomen.
Which finding indicates an abnormal re-
sponse when palpating the spleen?
Correct answer is D. McBurney's point is
A. Pain notes when palpating McBur-
related to appendicitis and not spleen.
ney's point.
B. Tip of spleen palpable when client is
asked to forcefully exhale.
, HESI V2 health assessment 2025
Study online at https://quizlet.com/_hlzc4d
C. Rebound tenderness with compres-
sion over right upper quadrant. D. Firm
mass palpated at bottom of left rib cage.
In auscultating for the presence of a
*under mandible towards lymph nodes.
carotid artery bruit, the nurse places the
transverse to trachea
bell of the stethoscope at which location?
A male client arrives at the clinic for
follow-up health assessment after re-
cent antibiotic treatment for pneumonia
without hospitalization. Which technique
should the nurse implement to assess for
adventitious lung sounds? Correct answer is C. The nurse should
A. Use the bell of the stethoscope to listen to all lungs fields during assess-
listen to the lung fields over lower lobes. ment and move from side to side during
B. Have the client lay flat while listening auscultation.
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.
A client with streptococcus pharyngitis
reports high fever, difficulty swallowing
and a muffled voice. Which complication
should the nurse suspect? Correct answer is C. Since infections are
A. Foreign body obstruction. associated with abscesses and pus.
B. Laryngeal polyps.
C. Peritonsillar abscess.
D. Nasal polyps
The nurse is obtaining a health history for
a client prior to a scheduled cholecystec-
tomy. While interviewing the client, which
assessment technique should the nurse
Correct answer is C. When interviewing
use when asking about the client's use
the patient, questions should be clear
of illegal drugs and alcohol?
and specific.
A. Obtain a drug using screen to verify
legitimacy of client's stated history.
B. Allow the client to decline answering
social questions.
, HESI V2 health assessment 2025
Study online at https://quizlet.com/_hlzc4d
C. Ask specifically about alcohol, mari-
juana, cocaine, her
D. Use the term illegal or illicit to describe
street drug.
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 pre- Correct answer is D. As this could be a
scribed for PRN use. sign of appendicitis.
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.
The nurse is assessing an ulcer on a
client's lower extremity, which is likely the
result of either venous or arterial insuf-
ficiency. Which assessment technique
should the nurse use to differentiate the
pathophysiology causing the ulcer?
Correct answer is C. Location and ap-
A. Measure the degree of join range of
pearance of the ulcer would give us the
motion in the extremity.
type (venous vs arterial)
B. Compare the skin turgor of the client's
upper and lower leg.
C. Observe the specific location and ap-
pearance of the ulceration.
D. Note any change in the color of the
ulcer when the leg is moved
The nurse is conducting a physical as-
sessment of a young adult. Which infor-
Correct answer is D. Hair, nail, and skin
mation provides the best indication of the
are the most important reflection of nutri-
individual's nutritional status?
tional status.
A. Status of current appetite.
B. A 24-hour diet history.
Study online at https://quizlet.com/_hlzc4d
A 29 year old male client informs the
nurse that he came to the clinic to see
if, "Maybe I have lung cancer or some-
thing," 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."
Correct answer is B, as assessment
Which computer documentation of this
process includes chief complaint which
client's concerns should the nurse en-
is how the patient describe why he is
ter?
here in the hospital or clinic and can't
A. Presents with a hacking non-produc-
include diagnosis.
tive 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"
A 75-year-old client with a recent history
of a cerebrovascular accident (CVA) pre-
sents 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 ac-
Correct answer is D, brisk 4+ response is
curate?
correlated with hyperactive response.
A. A normal reflex response.
B. Absent or sluggish response consis-
tent with a lower motor neuron lesion.
C. Flaccid paralysis.
D. Hyperactive response consistent with
an upper motor neuron disorder.
The nurse examines a client's abdomen.
Which finding indicates an abnormal re-
sponse when palpating the spleen?
Correct answer is D. McBurney's point is
A. Pain notes when palpating McBur-
related to appendicitis and not spleen.
ney's point.
B. Tip of spleen palpable when client is
asked to forcefully exhale.
, HESI V2 health assessment 2025
Study online at https://quizlet.com/_hlzc4d
C. Rebound tenderness with compres-
sion over right upper quadrant. D. Firm
mass palpated at bottom of left rib cage.
In auscultating for the presence of a
*under mandible towards lymph nodes.
carotid artery bruit, the nurse places the
transverse to trachea
bell of the stethoscope at which location?
A male client arrives at the clinic for
follow-up health assessment after re-
cent antibiotic treatment for pneumonia
without hospitalization. Which technique
should the nurse implement to assess for
adventitious lung sounds? Correct answer is C. The nurse should
A. Use the bell of the stethoscope to listen to all lungs fields during assess-
listen to the lung fields over lower lobes. ment and move from side to side during
B. Have the client lay flat while listening auscultation.
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.
A client with streptococcus pharyngitis
reports high fever, difficulty swallowing
and a muffled voice. Which complication
should the nurse suspect? Correct answer is C. Since infections are
A. Foreign body obstruction. associated with abscesses and pus.
B. Laryngeal polyps.
C. Peritonsillar abscess.
D. Nasal polyps
The nurse is obtaining a health history for
a client prior to a scheduled cholecystec-
tomy. While interviewing the client, which
assessment technique should the nurse
Correct answer is C. When interviewing
use when asking about the client's use
the patient, questions should be clear
of illegal drugs and alcohol?
and specific.
A. Obtain a drug using screen to verify
legitimacy of client's stated history.
B. Allow the client to decline answering
social questions.
, HESI V2 health assessment 2025
Study online at https://quizlet.com/_hlzc4d
C. Ask specifically about alcohol, mari-
juana, cocaine, her
D. Use the term illegal or illicit to describe
street drug.
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 pre- Correct answer is D. As this could be a
scribed for PRN use. sign of appendicitis.
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.
The nurse is assessing an ulcer on a
client's lower extremity, which is likely the
result of either venous or arterial insuf-
ficiency. Which assessment technique
should the nurse use to differentiate the
pathophysiology causing the ulcer?
Correct answer is C. Location and ap-
A. Measure the degree of join range of
pearance of the ulcer would give us the
motion in the extremity.
type (venous vs arterial)
B. Compare the skin turgor of the client's
upper and lower leg.
C. Observe the specific location and ap-
pearance of the ulceration.
D. Note any change in the color of the
ulcer when the leg is moved
The nurse is conducting a physical as-
sessment of a young adult. Which infor-
Correct answer is D. Hair, nail, and skin
mation provides the best indication of the
are the most important reflection of nutri-
individual's nutritional status?
tional status.
A. Status of current appetite.
B. A 24-hour diet history.
