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HESI Prep 2 Health Assessment with correct Answers The nurse is performing a vision examination. Which of these charts is most widely used for vision examinations? A) Snellen B) Shetllen C) Smoollen D) Schwellon - ✔A) Snellen The nurse hears bilateral louder, longer, and lower tones when percussing over the lungs of a 4 - year old child. What should the nurse do next? a) Palpate over the area for increased pain and tenderness. b) Ask the child to take shallow breaths and percuss over the area again. c) Refer the child immediately because of an increased amount of air in the lungs. d) Consider this a normal finding for a child this age and proceed with the examination. - ✔d) Consider this a normal finding for a child this age and proceed with the examination. A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After putting a call in to the physician and placing the patient on oxygen, which of these is the best action for the nurse to take when assessing the patient further? a) Count the patient's respirations. b) Percuss the thorax bilaterally, noting any differences in percussion tones. c) Call for a chest x-ray and wait for the results before beginning an assessment. d) Inspect the thorax for any new masses and bleeding associated with respirations. - ✔b) Percuss the thorax bilaterally, noting any differences in percussion tones. The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use?
a) The slope of the earpieces should point posteriorly (toward the occiput). b) The stethoscope does not magnify sound but does block out extraneous room noise. c) The fit and quality of the stethoscope are not as important as its ability to magnify sound. d) The ideal tubing length should be 22 inches to dampen distortion of sound. - ✔b) The stethoscope does not magnify sound but does block out extraneous room noise. The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? a) The diaphragm is used to listen for high-pitched sounds. b) The diaphragm is used to listen for low-pitched sounds. c) The diaphragm should be held lightly against the person's skin to block out low-pitched sounds. d) The diaphragm should be held lightly against the person's skin to listen for extra heart sounds and murmurs. - ✔a) The diaphragm is used to listen for high-pitched sounds. Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should: a) Warm the end piece of the stethoscope by placing it in warm water b) Leave the gown on so that the patient does not get chilled during the examination c) Make sure that the bell side of the stethoscope is turned to the "on" position d) Check the temperature of the room and offer blankets to the patient if he or she feels cold - ✔d) Check the temperature of the room and offer blankets to the patient if he or she feels cold The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a) Palpation b) Inspection c) Percussion d) Auscultation - ✔a) Palpation
c) The nurse follows the same examination sequence regardless of the patient's age or condition. d) The nurse organizes the assessment so that the patient does not change positions too often. - ✔d) The nurse organizes the assessment so that the patient does not change positions too often. A man is at the clinic for a physical examination. He states that he is "very anxious" about the physical examination. What steps can the nurse take to make him more comfortable? a) Appear unhurried and confident when examining him. b) Stay in the room when he undresses in case he needs assistance. c) Ask him to change into an examining gown and take off his undergarments. d) Defer measuring vital signs until the end of the examination, which allows him time to become comfortable. - ✔a) Appear unhurried and confident when examining him. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? a) There is no need to wash one's hands after removing gloves, as long as the gloves are still intact. b) Wash hands before and after every physical patient encounter. c) Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another. d) Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases. - ✔b) Wash hands before and after every physical patient encounter. The nurse is examining a patient's lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation?
a) Wash hands and contact the physician. b) Continue to examine the ulceration and then wash hands. c) Wash hands, put on gloves, and continue with the examination of the ulceration. d) Wash hands, proceed with rest of the physical examination, and then continue with the examination of the leg ulceration. - ✔c) Wash hands, put on gloves, and continue with the examination of the ulceration. During the examination, it is often appropriate to offer some brief teaching about the patient's body or the examiner's findings. Which of these statements by the nurse is most appropriate? a) "Your atrial dysrhythmias are under control." b) "You have pitting edema and mild varicosities." c) "Your pulse is 80 beats per minute. This is within the normal range." d) "I'm using my stethoscope to listen for any crackles, wheezes, or rubs." - ✔c) "Your pulse is 80 beats per minute. This is within the normal range." The nurse keeps in mind that the most important reason to share information and offer brief teaching while performing the physical examination is to help: a) The examiner feel more comfortable and gain control of the situation b) Build rapport and increase the patient's confidence in the examiner c) The patient understand his or her disease process and treatment modalities d) The patient identify questions about his or her disease and potential areas of patient education - ✔b) Build rapport and increase the patient's confidence in the examiner The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination? a) When the infant is sleeping b) At the end of the examination c) Before auscultation of the thorax d) Halfway through the examination - ✔b) At the end of the examination
a) Asking questions enhances the child's autonomy. b) Asking the child for permission helps to develop a sense of trust. c) This is an appropriate statement because children at this age like to have choices. d) Children at this age like to say "No." The examiner should not offer a choice when there is none - ✔d) Children at this age like to say "No." The examiner should not offer a choice when there is none A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action? a) The nurse should plan to perform a complete mental status examination. b) The nurse should refer him to a psychometrician. c) The nurse should plan to integrate the mental status examination into the history and physical examination. d) The nurse should reassure his wife that memory loss after a physical shock is normal and will subside soon. - ✔a) The nurse should plan to perform a complete mental status examination. The nurse is conducting a patient interview. Which statement made by the patient should the nurse explore more fully during the interview? The patient states that he: a) "Sleeps like a baby" b) Has no health problems c) "Never did too good in school" d) Currently is not taking any medication - ✔c) "Never did too good in school"
A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient's speech is dysarthric and that she is lethargic. The nurse's best approach regarding this examination is to: a) Plan to defer the rest of the mental status examination b) Skip the language portion of the examination and go on to assess mood and affect c) Do an in-depth speech evaluation and defer the mental status examination to another time d) Go ahead and assess for suicidal thoughts because dysarthria is often accompanied by severe depression - ✔a) Plan to defer the rest of the mental status examination A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes: a) She probably doesn't have any problems at all. b) She is just trying to shock people and her dress should be ignored. c) She has manic syndrome because of her abnormal dress and grooming. d) That more information should be gathered to decide whether her dress is appropriate. - ✔d) That more information should be gathered to decide whether her dress is appropriate. A patient has been in the intensive care unit for 10 days. He has just been moved to the medicalsurgical unit, and the admitting nurse is planning to perform a mental status examination on him. During the tests of cognitive function the nurse would expect that he: a) May display some disruption in thought content b) Will state, "I am so relieved to be out of intensive care" c) Will be oriented to place and person but may not be certain of the date d) May show evidence of some clouding of his level of consciousness - ✔c) Will be oriented to place and person but may not be certain of the date During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question?
A patient tells the nurse that he is allergic to penicillin. What would be the nurse's best response tothis information? a) "Are you allergic to any other drugs?" b) "How often have you received penicillin?" c) "I'll write your allergy on your chart so you won't receive any penicillin." d) "Please describe what happens to you when you take penicillin." - ✔d) "Please describe what happens to you when you take penicillin." The nurse is taking a family history. Important diseases or problems to ask the patient about specifically include: a) Emphysema b) Head trauma c) Mental illness d) Fractured bones - ✔c) Mental illness The review of systems provides the nurse with: a) Physical findings related to each system b) Information regarding health promotion practices c) An opportunity to teach the patient medical terms d) Information necessary for the nurse to diagnose the patient's medical problem - ✔d) Information necessary for the nurse to diagnose the patient's medical problem Which of these statements represents subjective data the nurse obtained from the patient regarding the patient's skin? a) Skin appears dry. b) No obvious lesions. c) Denies color change. d) Lesion noted lateral aspect right arm. - ✔c) Denies color change.
In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? a) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors. b) Note-taking allows the patient to continue at his or her own pace as the nurse records what is said. c) Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. d) Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort. - ✔a) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors. The nurse asks, "I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here." This question is found at the _____ phase of the interview process. a) Summary b) Closing c) Body d) Opening or introduction - ✔d) Opening or introduction A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening with this patient? a) "Hello, Nancy, my name is Mrs. C." b) "Hello, Mrs. H., my name is Mrs. C. It sure is cold today!" c) "Mrs. H., my name is Mrs. C. How are you?" d) "Mrs. H., my name is Mrs. C. I'll need to ask you a few questions about what happened." - ✔d) "Mrs. H., my name is Mrs. C. I'll need to ask you a few questions about what happened."
Illness is seen as a part of life's rhythmic course and as an outward sign of disharmony within. This statement most accurately reflects the views about illness from the _____ theory. a) Naturalistic b) Biomedical c) Reductionist d) Magicoreligious - ✔a) Naturalistic An imaginary line connecting the highest point on each iliac crest would cross the _____ vertebra. a) First sacral b) Fourth lumbar c) Seventh cervical d) Twelfth thoracic - ✔b) Fourth lumbar The nurse is explaining to a patient that there are "shock absorbers" in his back to cushion the spine and to help it move. The nurse is referring to his: a) Vertebral column b) Nucleus pulposus c) Vertebral foramen d) Intervertebral disks - ✔d) Intervertebral disks During an interview the patient states, "I can feel this bump on the top of both of my shoulders—it doesn't hurt but I am curious about what it might be." The nurse should tell the patient: a) "That is your subacromial bursa." b) "That is your acromion process." c) "That is your glenohumeral joint."
d) "That is the greater tubercle of your humerus." - ✔b) "That is your acromion process." The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)? a) Flexion and extension b) Supination and pronation c) Circumduction d) Inversion and eversion - ✔a) Flexion and extension A patient is visiting the clinic for an evaluation of a swollen, painful knuckle. The nurse notices that the knuckle above his ring on the left hand is swollen and that he is unable to remove his wedding ring. This joint is called the _____ joint. a) Interphalangeal b) Tarsometatarsal c) Metacarpophalangeal d) Tibiotalar - ✔c) Metacarpophalangeal The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? a) Dullness b) Tympany c) Resonance d) Hyperresonance - ✔a) Dullness Which structure is located in the left lower quadrant of the abdomen? a) Liver
In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 and slightly irregular; split S2. Which of these findings can be explained by expected hemodynamic changes related to age? a) Increase in resting heart rate b) Increase in systolic blood pressure c) Decrease in diastolic blood pressure d) Increase in diastolic blood pressure - ✔b) Increase in systolic blood pressure A 45-year-old man is in the clinic for a routine physical. During the history the patient states that he's been having difficulty sleeping. "I'll be sleeping great and then I wake up and feel like I can't get my breath." The nurse's best response to this would be: a) "When was your last electrocardiogram?" b) "It's probably because it's been so hot at night." c) "Do you have any history of problems with your heart?" d) "Have you had a recent sinus infection or upper respiratory infection?" - ✔c) "Do you have any history of problems with your heart?"
- In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history? a) Family history, hypertension, stress, age b) Personality type, high cholesterol, diabetes, smoking c) Smoking, hypertension, obesity, diabetes, high cholesterol d) Alcohol consumption, obesity, diabetes, stress, high cholesterol - ✔c) Smoking, hypertension, obesity, diabetes, high cholesterol The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short amount of time, hungry again. What other information would the nurse want to have?
a) The infant's sleeping position b) Sibling history of eating disorders c) Amount of background noise when eating d) Presence of dyspnea or diaphoresis when sucking - ✔d) Presence of dyspnea or diaphoresis when sucking In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would: a) Palpate the artery in the upper one third of the neck b) Listen with the bell of the stethoscope to assess for bruits c) Palpate both arteries simultaneously to compare amplitude d) Instruct patient to take slow deep breaths during auscultation - ✔b) Listen with the bell of the stethoscope to assess for bruits The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? a) "Tactile fremitus is caused by moisture in the alveoli." b) "Tactile fremitus indicates that there is air in the subcutaneous tissues." c) "Tactile fremitus is caused by sounds generated from the larynx." d) "Tactile fremitus reflects the blood flow through the pulmonary arteries." - ✔c) "Tactile fremitus is caused by sounds generated from the larynx." The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ____ comparison. a) Side-to-side b) Top-to-bottom c) Posterior-to-anterior d) Interspace-by-interspace - ✔a) Side-to-side
D) physical deformity. - ✔B) mobility. After the health history has been obtained, and before beginning the physical examination, the nurse should ask the patient to first: A) empty the bladder. B) completely disrobe. C) lie on the examination table. D) walk around the room. - ✔A) empty the bladder. During a complete health assessment, how would the nurse test the patient's hearing? A) By observing how the patient participates in normal conversation B) Using the whispered voice test C) Using the Weber and Rinne tests D) Testing with an audiometer - ✔B) Using the whispered voice test A patient states, "Whenever I open my mouth real wide, I feel this popping sensation in front of my ears." To further examine this, the nurse would: A) place the stethoscope over the temporomandibular joint and listen for bruits. B) place the hands over his ears and ask him to open his mouth "really wide." C) place one hand on his forehead and the other on his jaw and ask him to try to open his mouth. D) place a finger on his temporomandibular joint and ask him to open and close his mouth. - ✔D) place a finger on his temporomandibular joint and ask him to open and close his mouth. The nurse has just completed an examination of a patient's extraocular muscles. When documenting the findings, the nurse should document the assessment of which cranial nerves?
A) II, III, VI
B) II, IV, V
C) III, IV, V
D) III, IV, VI -
✔D) III, IV, VI
A patient's uvula rises midline when she says "ahh" and she has a positive gag reflex. The nurse has just tested which cranial nerves? A) IX, X B) IX, XII C) X, XII D) XI, XII - ✔A) IX, X During an examination, the nurse notices that a patient is unable to stick out his tongue. Which cranial nerve is involved with successful performance of this action? A) I B) V C) XI D) XII - ✔D) XII A patient is unable to shrug her shoulders against the nurse's resistant hands. What cranial nerve is involved with successful shoulder shrugging? A) VII B) IX C) XI D) XII - ✔C) XI
