HESI HEALTH ASSESMENT V2 HEALTH ASSESSMENT ACTUAL EXAM 2 DIFFERENT VERSIONS 2023/2024

HESI HEALTH ASSESMENT V2 HEALTH ASSESSMENT ACTUAL EXAM 2 DIFFERENT VERSIONS 2023/2024. 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. B. Compare the skin turgor of the client's upper and lower leg. C. Observe the specific location and appearance of the ulceration. D. Note any change in the color of the ulcer when the leg is moved Correct answer is C. Location and appearance of the ulcer would give us the type (venous vs arterial) The nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual's nutritional status? A. Status of current appetite. B. A 24-hour diet history. C. History of a recent weight loss. D. Condition of hair, nails, and skin. Correct answer is D. Hair, nail, and skin are the most important reflection of nutritional status. The nurse is assessing a healthy adult male during an annual physical examination. The nurse auscultates the client's abdomen and hears gurgling sound every ten seconds. What action should the nurse take in response to this finding? A. Document this normal bowel sound activity in the record. B. Encourage increased consumption of fiber in the diet. C. Observe the next bowel movement for signs of bleeding. D. Report the hyperactivity to the healthcare provider. Correct answer is A. Normal Bowel sound consist of clicks and gurgles and 5-30 per minute. An occasional borborygmus (Loud prolonged gurgle) may be hear.