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Health Assessment Remediation - HESI

Mometrix
Get Quizlet's official HESI A2 - 1 term, 1 practice question, 1 full practice test
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Terms in this set (10)

In assessing the flexion of a client's neck, which action should the nurse instruct the client to perform?

Tilt the chin toward the ceiling.

Move the chin toward each shoulder.

Press the chin against the chest.

Direct one ear toward the shoulder.
Move the chin toward each shoulder.

Rationale
Flexion, or bending, of the neck is best assessed by asking the client to press the chin against the chest.
During a physical exam, the nurse observes the external genitalia of an older adult female. The nurse notes that the client's pubic hair is thin and sparse. What follow-up action should the nurse take in response to this finding?


Review the client's metabolic profile.

Conduct a nutritional assessment.

Document the finding in the medical record.

Determine if the client uses estrogen cream.
Conduct a nutritional assessment.

Rationale
Changes in estrogen production following menopause result in many physical changes, including a reduction and thinning of pubic hair in the older adult woman. The nurse should document this normal finding in the client's medical record.
During a routine assessment, the nurse plans to assess a client for vertigo. Which assessment technique should the nurse use?


Listen for changes in speech patterns.

Measure blood pressure while standing.

Assess orientation to person, place, and time.

Ask about sensations of spinning around.
Ask about sensations of spinning around.

Rationale
Vertigo is a subjective feeling of rotational spinning, which is assessed by asking the client about any sensations of spinning.
The nurse listens for a client's heart sounds by firmly pressing the diaphragm of the stethoscope against the client's chest. After hearing normal heart sounds, the nurse wants to listen for extra heart sounds. What action should the nurse take first?

Rotate the endpiece of the stethoscope.

Release the amount of pressure used to hold the stethoscope.

Re-adjust the earpieces of the stethoscope.

Continue to hold the stethoscope firmly in place with one hand.
Rotate the endpiece of the stethoscope.

Rationale
The diaphragm of the stethoscope is best for hearing high pitched sounds, including normal heart and lung sounds. To best listen for extra heart sounds, the nurse should first turn the endpiece of the stethoscope so that the bell of the stethoscope can be used to hear these low-pitched sounds.
The nurse inspects a client's mouth and throat. Which finding warrants the most immediate action by the nurse?


Dorsal surface of the tongue is rough with a white coating.

Tonsils are observable and covered with a white membrane.

Ventral surface of the tongue appears smooth and glistening.

Teeth are yellowed and crooked with debris collected in the gaps.
Tonsils are observable and covered with a white membrane.

Rationale
A white membrane covering the tonsils may be an indication of a disease process such as infectious mononucleosis and requires immediate follow-up action by the nurse.
The nurse assesses the skin of an older adult client. Which finding warrants the most immediate follow-up by the nurse?


Multiple cherry angiomas on the trunk.

Bruises of several different colors.

Thin, flakey appearance of the skin.

Several small, round symmetric moles.
Multiple cherry angiomas on the trunk.

Rationale
Bruises of several colors indicate brusing that occurred at different times. This warrants the most immediate assessment to determine fall risk or possible elder abuse.
During assessment of the thorax and lungs, which technique should the nurse use to assess the client's AP diameter?

Inspection.

Percussion.

Palpation.

Auscultation.
Inspection

Rationale
The nurse uses inspection to observe and compare the antero-posterior (AP) diameter with the transverse diameter of the chest.
The nurse learns in report that a client has developed ascites. Which action best confirms the presence of ascites?


Check for an abdominal fluid wave.

Palpate for lower flank edema.

Measure the abdominal girth.

Assess skin color for jaundice.
Check for an abdominal fluid wave.

Rationale
To best confirm the presence of ascites, fluid accumulation in the abdomen, the nurse should palpate for the presence of an abdominal fluid wave.
During the health history, a client describes a symptom to the nurse. Which information about the symptom is best obtained by use of a numeric scale?


Radiation.

Quality.

Timing.

Severity.
Severity.

Rationale
The severity of a symptom, which is a subjective description of how "bad" the symptom feels to the client, can be rated by a scale such as a numeric or picture scale, allowing for more consistent, ongoing evaluation of improvement or worsening of the symptom's severity. Pain i
The nurse plans to assess function of a client's Cranial Nerve XI, the Spinal Accessory nerve. The nurse instructs the client to shrug both shoulders. What action should the nurse take while the client shrugs the shoulders?

Apply pressure on both shoulders.

Observe accessory muscle movement.

Visually compare shoulder movement.

Listen for crepitation in the joint.
Apply pressure on both shoulders.

Rationale
The nurse assesses Spinal Accessory nerve function by applying pressure while the client shrugs the shoulders. The nurse should check for symmetrical strength as the client shrugs the shoulders against the resistance applied.
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