HESI - Health Assessment V 1&2 Practice Flashcards

Practice flashcards based on HESI Health Assessment lecture notes covering physical assessment techniques, findings, and documentation for various body systems.

What thoracic assessment finding should the nurse expect in a client with chronic asthma and hyperinflation of the lungs?

Barrel chest

After hearing bowel sounds in the right upper quadrant, what should the nurse do next?

Note the character and frequency of bowel sounds

What is the appropriate action after documenting that placing a tongue blade on the back of the tongue caused the client to gag?

Document an intact gag reflex.

When teaching monthly breast self-assessment, which part of the breast is most important to assess closely for changes?

Upper outer quadrant.

For a postmenopausal woman with a waist measurement greater than $35\text{ inches}$, what health promotion message should be explained?

A waist circumference greater than $35\text{ inches}$ in women puts you at higher risk for type 2 diabetes and heart disease.

What change from a prior physical exam indicates potential osteoporosis in an older female client?

Height reduction of $1.5\text{ inches}$.

What is the best nurse response when a client pauses frequently and looks expectantly at the nurse during a health history interview?

Sit quietly to allow the client to respond comfortably.

Which action should the nurse take to prepare a client for a yearly physical examination of the abdomen?

Ask the client to urinate before beginning the examination.

What respiratory condition is indicated by a respiratory rate of $8\text{ breaths/minute}$?

Bradypnea.

How should a nurse assess for a pulse deficit?

Measure the apical pulse and compare it to the peripheral pulse.

What percussion sound is expected over the lower lobes of a client with bilateral lower lobe atelectasis?

Dull, thud-like.

Which technique should be used first when beginning a head-to-toe assessment at the head of the client?

Inspect the hair and skin.

What is the correct technique for palpating the abdominal aorta in a healthy young adult?

Deep palpation above and to the left of the umbilicus.

How many generations of family medical history should be documented for sufficient information about blood relatives?

At least 3 generations.

What finding represents normal internal rotation during a shoulder range of motion test?

Range of $90\text{ degrees}$ when the hands are placed at the small of the back.

How should a nurse begin the objective examination for a client with an itchy rash along the occipital hairline?

Inspect the scalp looking for nits.

How should a nurse document the finding where a client's extended leg rises off the table when the opposite knee is brought to the chest?

A flexion deformity referred to as a positive Thomas test.

What is the first question to ask a client with dark red, discrete, non-blanching lesions ranging from $1\text{ to }3\text{ mm}$?

Have you noticed any irregular bleeding?

What communication technique should be used for a client with hearing loss who is distressed by open-ended questions?

Face the client so they can see the mouth, check hearing aids, and reduce environmental noise.

What are the expected findings when examining a client with lymphedema after a mastectomy?

Swelling of the left arm and non-pitting edema.

In what position should a client be placed to begin the procedure for orthostatic vital signs?

Lying.

How should a nurse explain the finding of an irregularly enlarged uterus with firm, mobile, painless nodules in a postmenopausal client?

You have benign fibroid tumors, a common occurrence in women your age.

What statement by a client indicates a naturalistic belief in the cause of illness?

"My life is really out of balance."

Which hearing test is most reliable for a client with a history of prolonged occupational noise exposure?

Audiometry.

What is one specific assessment question included in the CAGE questionnaire?

Have you ever felt guilty about your drinking?

Which assessment is most helpful in determining the cause of reported hip pain?

Knee joint evaluation.

How does a nurse assess damage to the first cranial nerve after a head injury?

Occlude one nostril and have the client identify various odors.

What assessment finding suggests a client has contracted the mumps after exposure?

Swelling anterior to the ear lobe on one side of the face.

What actions allow a nurse to empathize with and understand a diverse population?

Be open to people who are different, have a curiosity about people, and become culturally competent.

Which two findings can a nurse determine specifically by palpating a client's skin?

Diaphoresis and scaling.

What is an appropriate question to test a client's remote memory?

What is your date of birth?

What is the Glasgow score for a client who opens eyes to sound ($3$), is confused during conversation ($4$), and localizes to pain ($5$)?

$$12$$

What is the range for the Glasgow Coma Scale score?

lowest possible is $3$ and the highest is $15$.

In a health history for lower abdominal pain and constipation, which information is of greatest concern?

Family history of colon cancer on the mother's side.

What skin finding is indicative of good hydration status after pinching and releasing the skin?

The skin immediately returns to normal position.

Which nursing assessment should be completed during the initial examination of a client exposed to meningitis?

Level of consciousness.

A nontender, solitary, round lobular mass that is solid, firm, and slides easily through breast tissue is consistent with what condition?

Fibroadenoma.

Which condition is characterized by severe pruritus, small papules, and burrows after exposure to a daycare outbreak?

Scabies.

What finding when asking a $96\text{-year-old}$ to smile requires further assessment of facial nerve function?

Only one side of the mouth moves when smiling.

How should a nurse document joint range of motion that is $15\%$ greater with passive ranging than active ranging?

Abnormal.

What should the registered nurse implement when using an interpreter for a client assessment?

Maintain eye contact with the client while listening to the translation.

What is the most important question for an underweight client during a health history?

Have you experienced sudden weight loss?

How should a nurse respond to a client who reports drinking two glasses of wine per night?

"What effect do you think your use of alcohol may have on you?"

Where should a nurse examine for peripheral edema in a client with heart failure?

Ankles.

For a fatigued client with pale lips, what additional data should the nurse collect?

Use of vitamin and iron supplements.

Where is the best place to hear lower lobe lung sounds with a stethoscope?

Posterior chest below the $3rd$ intercostal space.

What technique should be used to assess the posterior pharynx?

Press the tongue down one side at a time with a tongue depressor.

Which technique during a Mini-Mental State Examination (MMSE) helps decrease client anxiety?

Use simple sentences, reduce environmental detractors, and ask questions one at a time.

What findings besides a persistent cough should the nurse assess for in a client with bronchitis?

Phlegm production and wheezing.

How should a nurse assess a client for mitral stenosis using a stethoscope?

Place the bell on the $5th$ intercostal space, left midclavicular line.

What is a true statement regarding the palpability of the spleen?

It must be enlarged at least three times normal size for it to be palpable.

What is indicated if the eyes feel very firm and resist movement back into the orbit during palpation?

Abnormal finding.

Which tool is used to assess the neurological status of a client with traumatic brain injury?

Glasgow Coma Scale.

What technique helps determine evidence of hepatomegaly in a client with liver disease?

Use a bouncing motion to tap the middle finger placed within boundaries of the liver.

What is the best nursing response if an older client has not mentioned incontinence during a GU assessment?

Ask the client specifically about any leakage of urine.

How should a nurse interpret an Asian client's refusal to make eye contact during conversation?

The client is treating the nurse with respect.

What constitutes a negative Thomas test when the right knee is brought toward the chest?

The left leg remains on the table.

Where should the nurse place the stethoscope diaphragm to listen for aortic regurgitation?

$2nd$ intercostal space along the right sternal border.

Which finding regarding sudden hearing loss in one ear suggests a potentially serious medical condition?

There is no sign of associated infection.

Where should the nurse obtain information regarding the client's self-perception of health status?

Health history.

What condition is characterized by blurred vision and cloudy lenses?

Cataracts.

What condition does a fluorescent, yellow-green color under a Wood's lamp indicate?

Fungal infection.

What should a nurse look for when assessing dark skin for inflammation?

Change in consistency.

What lung auscultation sound is anticipated if a client reports pain when taking a deep breath?

Pleural friction rub.

What is the easiest method to obtain information about a client's nutritional intake?

24-hour dietary recall.

Besides a weak pedal pulse, what findings are consistent with diminished peripheral circulation?

Diminished hair on legs and skin cool to touch.

How should a nurse evaluate the spleen of a client who fell from a tree?

Percuss the splenic area as the client takes a deep breath.

How can a nurse facilitate accurate responses from an adolescent client accompanied by her mother?

Request that the mother leave the exam room.

If a client repeat three unrelated words as directed during a mental status exam, what is documented?

"Short-term memory is intact."

What technique is used when performing a Weber test?

Place a vibrating tuning fork midline on top of the head.

How does a nurse assess a client for scoliosis?

Observe the spine while the client is erect and bent forward.

What term describes a high-pitched scratchy heart sound heard during auscultation?

Friction rub.

If a client's pupils constrict and there is convergence of the axes during accommodation, how is this documented?

A normal finding.

Which cranial nerve is assessed using the Weber and Rinne tests?

VIII – vestibulocochlear.

Which structure should the nurse visualize using a tongue depressor in the mouth?

Pharynx.

What is a normal assessment finding when palpating a client's right kidney?

A round smooth mass that slides between the fingers.

What finding indicates acute urinary retention during bladder assessment?

Dull sound percussed over the bladder.

What is the term for irregularly shaped dark spots on the skin caused by aging and sun exposure?

Lentigines (liver spots).

How should a nurse evaluate for abnormal lumps during a well-woman breast exam?

With both arms at the client's side, lift one arm and palpate the axilla.

What is considered a normal thyroid finding in an adult client?

The gland is not palpable.

How should lower extremity edema be measured in a client with heart failure?

Measure bilateral ankle circumference with a nonstretchable tape measure.

If tophi are observed on a client's ear cartilage, what follow-up question should be asked?

Have you had sudden and severe pain in the toes or feet?

Physical appearance, posture, and ability to converse are documented as what type of data?

Objective.

What is a key indicator of a rotator cuff tear?

Inability to slowly lower the arm when abducted.

How should a nurse further assess a split in the second heart sound (S2)?

Listen to the sound while observing the client's respirations.

Which pain scale is appropriate for an older client following a surgical procedure?

Verbal descriptor scale.

What action should be taken if peristaltic movement is observed in the left lower quadrant?

Observe the direction of movement.

Where is the best location to place a stethoscope to hear normal lung sounds in the middle lung lobe?

$4th$ intercostal space, right midclavicular line.

How should an RN respond if a Muslim male client refuses a female nurse for breath sound assessment?

Request a male nurse or healthcare provider to perform the exam.