Download Physical Assessment Prep: Practice Questions & Review and more Exams Nursing in PDF only on Docsity!
University of Pennsylvania Master the 2025 HESI
Physical Assessment with 120 Exam – High-Yield
Practice Questions and Comprehensive Review
Guide
What is the purpose of having the patient clench his teeth and smile? A. It tests two-point discrimination. B. It tests CN VII and lets you observe tooth occlusion. C. It tests the abdominal reflexes. D. It tests CN III, IV and VI. - - correct ans- - B. It tests CN VII and lets you observe tooth occlusion Having the patient clench the teeth and smile tests CN VII and lets you observe tooth occlusion. In proper occlusion, the upper and lower molars interdigitate, and the premolars and canines interdigitate. Touching the skin with one or two sterile needles to determine the distance at which the patient can no longer distinguish two points is how two-point discrimination is tested. Stroking each abdominal quadrant tests the abdominal reflexes. Cranial nerves III, IV, and VI are tested by checking extraocular movements. Why is it important to have equipment and supplies organized before the exam? A. It makes you look smarter to the patient. B. It avoids interruptions and delays. C. In case you are out of a supply, you can skip that part of the exam. D. It lets you focus on the testing instead of the patient's response. - - correct ans- - B. It avoids interruptions and delays
Having equipment ready and supplies organized before the exam avoids interruptions and delays. Whether the patient thinks you are smart is not the focus of the exam. Skipping part of the exam is not a valid response to missing equipment; it is your responsibility to be prepared. You must always focus on the patient's response in case it is abnormal; that is why you are performing the exam! Which of the following is part of monitoring and care? A. Explain that no additional screening will ever be needed. B. Stay in the room while the patient is returning to street clothes. C. Keep the patient's glasses until they are back in street clothes. D. Ask the patient if she/he has any questions or concerns about the exam. - - correct ans- - D. Ask the patient if she/he has any questions or concerns about the exam. It is vital to allow the patient to ask any questions! Additional screenings may be needed, based on the findings of the exam. Explaining which screenings are needed is part of monitoring and care. Provide privacy for the patient while she/he returns to street clothes. It is appropriate to return corrective lenses to the patient promptly at the conclusion of the exam. When preparing to measure the height and weight of a newly admitted patient, why would the nurse ask about the patient's ability to stand? A. To determine if a wheelchair should be requested B. To determine if the patient is steady enough to stand without assistance C. To determine if a bed scale must be obtained to measure the patient's weight D. To establish how much help the patient will need with personal care - - correct ans- - B. To determine if the patient is steady enough to stand without assistance Before measuring height and weight, the nurse asks about the patient's ability to stand in order to determine if the patient is steady enough to stand without assistance while
To ensure accurate measurement of a patient's daily weight, the patient should be weighed at the same time of day, wearing the same clothes, and he or she should be asked to void first. The patient need not need list all food and drink consumed since the last time he or she was weighed. The nurse need not weigh the patient with two different scales in order to compare the weights. As the nurse is conducting an admission interview, the patient states, "I've lost 30 pounds over the last 4 months." Which question might the nurse ask to determine if the weight loss was intentional or unintentional? A. "Is your health care provider aware of this weight loss?" B. "Has your weight fluctuated like this before?" C. "Have you been following a specific diet?" D. "Is it easy for you to lose weight?" - - correct ans- - C. "Have you been following a specific diet?" Asking if the patient has been following a specific diet will help determine if the patient's weight loss was intentional or unintentional because it asks the patient to offer a possible explanation for the weight loss. Whether the patient has reported the weight loss to a health care provider is irrelevant. Asking if the patient's weight has fluctuated before or if it's easy for the patient to lose weight will not help determine if the patient's weight loss was intentional or unintentional. It merely asks about the patient's history of weight loss. For which patient would the nurse instruct nursing assistive personnel (NAP) to weigh a patient with a bed scale? A. Patient with an ostomy device B. Patient with chronic renal failure who receives hemodialysis three times a week C. Patient who is using a walker after knee replacement surgery D. Patient who has heart failure and a consequent inability to bear weight - - correct ans- - D. Patient who has heart failure and a consequent inability to bear weight
A bed scale would be needed for a patient with heart failure and a consequent inability to bear weight. The patient is unable to stand without assistance and most likely would not be able to tolerate sitting for a chair weight. A bed scale would not be needed for the patient with an ostomy device. There is no reason why this patient cannot stand on a scale. A bed scale would not be needed for a patient with chronic renal failure who receives hemodialysis. If the patient is weak, a chair scale can be used. A bed scale would not be needed for a patient who is using a walker after knee replacement surgery. If the patient is unable to stand without assistance, a chair scale can be used. Which of the following is not included in a head-to-toe assessment? A. Near vision test B. Testing the spinal reflexes C. Exercise stress test D. Balance tests - - correct ans- - C. Exercise stress test An exercise stress test is not included in a head-to-toe assessment. Near vision is tested with the Rosenbaum card. Spinal reflexes and balance are tested as part of the neurologic system assessment. When continuing to assess the abdominal area, the nurse hears a swishing sound. In what area would this sound be heard? Femoral artery. This area would produce a swishing sound that occurs during systole. Epigastric area. The midline areas would not produce this sound. Umbilical area. The umbilical area would not produce this sound.
A Decreased bone formation reduces height in most older adults, which may cause shortening of the vertebrae and thinning of the vertebral disks. B Decreased bone formation reduces height in most older adults and is not due to arthritis. C This is appropriate advice, but is not related the patient's height. D This is an expected occurrence and does not warrant concern. In collecting a history from an older adult, which information does the nurse consider least essential for a patient of this age? a. Past health history b. Genogram c. Functional abilities d. Mental health - - correct ans- - ANS: B Feedback A Past health history is important to document the patient's chronic illnesses. B A genogram is not routinely used to document the family history for an older adult. The health status and cause of death of the patient's parents and siblings lose value as the patient ages. C Assessing functional abilities provides data about how well the patient performs activities of daily living. D Mental health data are essential to collect about all patients regardless of age. In assessing the mood of older adult patients, a nurse documents which finding as abnormal? a. Sadness and grief after returning from the funeral of a long-time friend b. Depression that interferes with the ability to perform activities of daily living c. Frustration about rearranging the day's schedule to attend a grandson's birthday party d. Crying about the unexpected death of a pet that had been with the family 12 years - - correct ans- - ANS: B
Feedback A Emotional experiences of sadness, grief, response to loss, and temporary "blue" moods are normal responses in older adults. B Persistent depression that interferes significantly with the ability to function is not an expected finding. C This is a normal response for any adult. D Emotional experiences of sadness, grief, response to loss, and temporary "blue" moods are normal responses in older adults. When assessing the pain level of an older adult, a nurse considers which factor? a. Neural transmission of pain is increased as a part of the aging process. b. Older adult patients are not reliable in their descriptions of pain and how it affects them. c. Physiologic indicators of pain that are unique to older adults are tachycardia and hypotension. d. The older adult may believe that pain is a factor of aging and not worth mentioning. - - correct ans- - ANS: D Feedback A Neural transmission is the same for older and younger adults. B Becoming older does not diminish one's ability to describe pain. C The physiologic indicators are the same for older and younger adults. D Some older adults may perceive pain as an expected aspect of aging that they must endure. A nurse is assessing the pain of an 86-year-old man who had hip surgery recently. The patient has been slightly confused since his surgery, but he responds to simple questions. What is the best way to assess this patient's pain? a. Ask him to rate his pain on a scale of 0 to 10. b. Ask him to rate his pain using a list of descriptive adjectives.
Which finding indicates to a nurse that a neonate has a cephalhematoma? a. Well-defined edematous area over one cranial bone b. Molding of the cranium that causes generalized cerebral edema c. Diffuse edema over two or more cranial bones d. Anterior fontanelle that is deeply depressed - - correct ans- - ANS: A Feedback A This is a subperiosteal hematoma under the scalp that occurs secondary to birth trauma. The area, which appears as a soft, well-defined swelling over the cranial bone, generally is reabsorbed within the first month of life. B Molding is secondary to the head passing through the birth canal and generally lasts less than a week. C Cephalhematoma occurs over one cranial bone rather than several, and is well- defined rather than diffuse. D Anterior fontanelles are soft but not depressed. What finding does a nurse look for when assessing the skin of an older adult with solar lentigo? a. Yellowish, thin papules with a central depression b. Pigmented, raised, wartlike lesions on the face or trunk c. Small, soft, pigmented tags of skin on the face and neck d. Irregular, flat, deeply pigmented macules on sun-exposed areas - - correct ans- - ANS: D Feedback A Yellowish, thin papules with a central depression is a description of sebaceous hyperplasia. B Pigmented, raised, wart-like lesions on the face or trunk is a description of seborrheic keratosis. C Small, soft, pigmented tags of skin on the face and neck is a description of acrochordon (skin tags).
D Irregular, flat, deeply pigmented macules on sun-exposed areas is a description of solar lentigo. In assessing the nails of an older adult, which finding does a nurse expect to find? a. Transverse ridges b. Thick, brittle, and yellow nails c. Thin, brittle nails d. Lateral edges turned upward - - correct ans- - ANS: B Feedback A These changes occur when the patient has had nail trauma. B Thick, brittle, and yellow nails are expected changes in the nails of older adults. C These changes occur when the patient has anemia. D This change, called spoon nail, occurs when the patient has anemia. What is the best color for nurses to select when designing educational materials for older adults? a. Blue b. Yellow c. Violet d. Green - - correct ans- - ANS: B Feedback A Color perception of blue, violet, and green may be impaired for older adults. B Color perception of blue, violet, and green may be impaired for older adults. C Color perception of blue, violet, and green may be impaired for older adults. D Color perception of blue, violet, and green may be impaired for older adults.
A 75-year-old man reports he stopped playing cards with his friends because their voices sounded mumbled. How does the nurse explain the cause of this change? a. Sudden low-frequency hearing loss b. Accumulation of earwax in the outer ear c. Damage to the middle ear from ear infections d. Gradual high-frequency hearing loss - - correct ans- - ANS: D Feedback A This does not describe presbycusis and is not an expected change with aging. B This does not describe presbycusis and is not an expected change with aging. C This does not describe presbycusis and is not an expected change with aging. D This is a description of presbycusis, a sensorineural hearing loss, and an expected change with aging. Which finding on cardiovascular assessment of an older adult patient warrants further evaluation? a. Occasional ectopic beats heard on auscultation of the heart b. Murmur heard over the mitral valve c. Systolic pressure of 156 in the right arm and 188 in the left arm d. Persistent S4 sound in a patient with a history of decreased ventricular function - - correct ans- - ANS: C Feedback A Occasional ectopic beats are common and may or may not be significant. B Sclerosis of the mitral and aortic valves may cause murmurs. C These systolic pressures are above normal and require further evaluation. D The S4 heart sound is common in older adults and may be associated with decreased left ventricular compliance.
An older adult patient reports being able to see her granddaughter play basketball out of the sides of her eyes, but not in the center of her eyes. Based on this information, what vision disorder does the nurse suspect? a. Presbyopia b. Macular degeneration c. Pseudoptosis d. Entropion - - correct ans- - ANS: B Feedback A Presbyopia is a decrease in near vision that usually occurs after age 40 and is treated with corrective lenses. B Gradual loss of central vision may be caused by macular degeneration due to changes in the retina. C Pseudoptosis is a relaxed upper eyelid. D Entropion is a disorder of the eyelid, in which the lower lid turns inward. The nurse examining the breasts of an older adult woman recognizes which finding as normal? a. Firm and rounded breasts of equal size and shape b. Relatively large size and number of mammary ducts c. Loose elasticity and puckering of the suspensory ligaments d. Flattened breasts with a slightly granular texture on palpation - - correct ans- - ANS: D Feedback A The breasts in postmenopausal women may appear flattened. B This is not a finding in older women. C The suspensory ligaments in older woman are relaxed, but not puckering. D The breasts in postmenopausal women may appear flattened and elongated or pendulous secondary to a relaxation of the suspensory ligaments.
Which techniques does a nurse use routinely to collect data when assessing a patient's anterior thorax? Select all that apply. a. Palpation of the thorax for fremitus b. Inspection of the skin for color, intactness, lesions, and scars c. Auscultation of breath sounds bilaterally d. Auscultation of heart sounds for rate, rhythm, frequency, and S1 and S e. Palpation the anterior chest wall for thoracic expansion f. Inspection of respiratory movement for symmetry and ease of respiration - - correct ans- - ANS: B, C, D, F Correct: These techniques are performed in a routine head-to-toe assessment of the anterior thorax. Incorrect: Palpation of the thorax for fremitus and palpation of the anterior chest wall for thoracic expansion are not performed unless indicated. What risk factors for falls does a nurse teach a group of older adults? Select all that apply. a. Being a woman b. Taking more than six medications c. Having hypertension d. Having cataracts e. Muscle strength 3/5 bilaterally f. Incontinence - - correct ans- - ANS: B, D, E, F Correct: Adverse effects of medications can contribute to falls. Cataracts impair vision, which is a risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine or stool increases risk for falls. Incorrect: Men have a higher risk for falls than women. Hypertension itself does not contribute to falls. Dizziness does contribute to falls. Which data do nurses document under the category of past health history? a. Chronic diseases
b. Immunizations received c. Allergies to medications or food d. Causes of death of the patient's parents - - correct ans- - ANS: B Feedback A Chronic diseases are documented under the present health status category. B Immunizations are documented under the past health history category. C Allergies to medications or food are documented under the present health status category. D Causes of death of parents are documented under the family history category. A patient reports she has shortness of breath and peripheral edema. Under which category does the nurse document these data? a. Review of systems b. Present health status c. Past health history d. Functional ability - - correct ans- - ANS: A Feedback A In the review systems part of the history, the nurse asks patients whether they have had symptoms from specific body systems. Patients either deny or admit to having the symptoms. B The present health status category contains data on chronic diseases, medications, and allergies. C The past health history category contains data on childhood diseases, surgeries and hospitalizations, and immunizations. D The functional ability category contains data on patient's activities, including maintaining a home and working full-time.
- When does the health assessment begin?
a. Fever b. Atelectasis c. Pressure ulcer d. Thrombophlebitis - - correct ans- - ANS: C Feedback A Fever is a common occurrence in ill patients that may indicate inflammation or infection. B Atelectasis is collapse of alveoli that may occur due to the patient's hypoventilation, such as after surgery. C Pressure ulcer is termed a never event because it refers to preventable, medical errors that should never occur. D Thrombophlebitis is inflammation of veins that may occur due to immobility. What data do nurses document under the category general survey? a. Mental health b. Functional ability c. Diet and nutrition d. Orientation - - correct ans- - ANS: D Feedback A Mental health is described under the heading of personal and psychosocial history. B Functional ability data are collected during the history. C Diet and nutrition data are collected during the history. D The general survey is the beginning of the examination when the nurse is collecting data about the patient. When performing a neurologic assessment of a male patient, a nurse discovers that shouting and shaking are necessary to arouse the patient enough to assess his neurologic status. After the patient answers questions about who he is and squeezes
the nurse's hand as requested, he returns to "sleep." How does the nurse document this patient's level of consciousness? a. Lethargic b. Obtunded c. Stuporous d. Semicomatose - - correct ans- - ANS: B Feedback A Lethargic patients can be aroused by saying their names and touching them. B Obtunded patients require shouting and vigorous shaking to arouse them; they carry out requests while awake, but return to "sleep" when stimuli stops. C Stuporous patients require painful stimuli to respond and the response usually is a withdrawal from the source of pain. D Semicomatose patients require painful stimuli and respond with abnormal flexion or extension.
- What data do nurses collect when assessing a patient's wound? Select all that apply. a. Skin turgor b. Width, length, and depth c. Presence of pulsations d. Wound color e. Presence of edema f. Drainage color - - correct ans- - ANS: B, D, E, F Correct: These data are collected when assessing a wound. Incorrect: Skin turgor is assessed in intact skin rather than wounds. Presence of pulsations is not indicated when assessing a wound. Which data do nurses document under the category of personal and psychosocial health history? Select all that apply. a. Allergies to medications or food
