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Hesi Pratice

Question	Answer
A college student sees the nurse because she has missed her last two menstrual periods. Which assessment is most important for the nurse to obtain?	Body Weight, Hirsutism, Thyroid Enlargement
Which question by the nurse is likely to elicit the most information regarding a client's use of medications to treat a chronic cough?	What medications have you taken for your cough?
Heart sounds are loudest for S1 at the:	Apex of the heart
An older adult client comes to the healthcare provider's office for a routine follow-up exam for high blood pressure, osteoarthritis, constipation, and chronic sinusitis. Which is most important for the nurse to address?	Obtain a medication history including prescription and non-pre scription drugs
To assess a client's ability to think abstractly, which question is likely to provide the best information?	What does, "the early bird catches the worm," mean?
The nurse observes that a client who is intoxicated has an ataxic gait. Which finding does the nurse expect to be positive upon further assessment?	Romberg sign
In assessing an adult client, the nurse calculates the Body Mass Index (BMI) as 14 kg/m2. Which nursing problem should be in cluded in this client's plan of care?	Imbalanced nutrition, less than body requirements
While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles lasting about 3 seconds and occurring every 5 to 10 seconds in all quadrants. How should the nurse document this finding?	Normal bowel sounds
During a skin assessment, the school nurse observes several round, flat, pinpoint, red spots. How should the nurse document this finding?	Petechiae
A 16-year-old client with a history of chronic ear infections has dense white patches on the tympanic membranes. What should the nurse do next?	Record the findings in the client's record
A nurse uses a tuning fork to assess for which condition?	Hearing loss
During a health assessment, the nurse determines which technique to evaluate the ability to reside in an assisted living facility:	Instruct the client to demonstrate activities of daily living
Which assessments should the nurse conduct for a focused neurological assessment in the stroke unit?	Glasgow Coma Scale 2. Muscle Tone Pupil Size Level of Consciousness
During range of motion, the nurse notes crepitation in the left knee. What is most likely related?	Degenerative disease
To confirm a report that a client is stuporous, which assessment should the nurse perform?	Determine the response to stimuli
For a client with gallstones, which action should the nurse perform to confirm jaundice?	Examine the client's sclera for icterus
How can smoking affect a client's sleep?	Difficulty falling asleep with more frequent arousals
The nurse documents Heberden's nodes during an assessment. Which finding should be documented?	distal interphalangeal joint nodules that deviate
A client reports that a mole has changed from brown to black and enlarged in size. What is the nurse's priority action?	Advise the client to see a healthcare provider for immediate evaluation
During percussion, what indicates hepatomegaly?	A dull percussion tone outside the costal margins
Which history finding may explain erectile dysfunction in a male client?	History of type 2 diabetes mellitus
A client with audible wheezing, decreased tactile fremitus, and prolonged expirations has trouble breathing. What condition is likely?	Asthma exacerbation
When a nurse observes scleral jaundice in a client, which finding during percussion confirms hepatomegaly?	A dull percussion tone outside the costal margins
Which phrase supports the conclusion of orthopnea?	"I sleep on three pillows at night."
While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the explanation for failure to locate the gallbladder by palpation?	The gallbladder is normal
The nurse is assessing a client's abdomen and identifies a cen trally localized distension that is pulsating. This finding should direct the nurse to consider which pathology?	Aneurysm
The nurse learns the client's father was diagnosed with schizophrenia in his 20s, same age as client hesitates to discuss the topic. Which approach is best for the nurse to use to interview the client about mental health concerns?	Begin with questions that are less sensitive in nature
Performing oral inspection of a client with dark pigmented skin, the nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?	Document this finding in the medical record
The left foot plantar reflex of an adult client, the nurse observes an extension of the great toe and fanning of other toes. Which interpretation of this finding is accurate?	Pyramidal tract disease
The nurse is doing a health assessment of a client who smoked 3 packs of cigarettes every day for the last 20 years before quitting 2 years ago. How should the nurse document the client's pack years? Enter the numerical value only.	60
adult female was brought to the ED., by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?	Peri-umbilical pain localizing to right lower quadrant
When assessing an older adult client, which finding is most indicative of dehydration?	Tenting noted in subclavicular area
The school nurse is interviewing a 13-year-old girl who wants to go home from school because of back pain. Which question should the nurse ask the adolescent first?	What were you doing when you first noticed the problem?
The nurse is preparing a seminar on Testicular Self-Examination, TSE. Which instructions should be included in the content for this seminar?	Examine the testicles during bathing
client with rectal bleeding. nurse observes dried, dark red blood on the surface of a purple, shiny tissue mass that extrudes from the anal opening. When documenting in the client's EMR, which findings should the nurse center	Dried dark red blood on swollen external hemorrhoids
The assessment on an older adult client calculates a balance score of 12 and a gait score of 8. Which do these results indicate?	Increased risk for falling
Drag from word choices to complete the sentence. Heart sounds are loudest for S1 at the	Heart sounds are loudest for S1 at the apex and S2 is loudest at the base.
A client states, I am legally blind, which assessment technique should a nurse use to obtain subjective data to support the client's statement? Observe the client's optic disc through a nostalmoscope	Assess the client's ability to read a Snellen chart from a distance of 20 feet.
Use a client's laboratory results for a client admitted with gastrointestinal GI bleeding who has no visible hemorrhoids on inspection of the anal area. Which laboratory test indicates that the client's bleeding is not yet resolved?	Somatic RIT changes from 36% to 32%.
begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings.	Atrophy, Kyphosis
Which instruction should the nurse give the client who has a lung abscess?	Repeat vocalizing the letter E while the thorax is auscultated.
The lower legs of a client with diabetes mellitus are shiny and with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?	Palpate the client's dorsalis pedis pulses.
Passing heart sounds of a client with rheumatic valvular heart dis ease, where should the nurse place the stethoscope to auscultate the triguspid valve?	Left 4th intercostal space next to left sternal border.
The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?	Use a standard pain assessment questionnaire and scale.
has nailed clubbing. Which additional information is consistent with this finding?	Oxygen saturation of 85%.
Obtained during a skin assessment, should the school nurse report to the healthcare provider.	Red, swollen, painful nodule located on upper back on a school-aged boy
Skin and nail exam on an older adult female client. The nurse notes that she has longitudinal ridges on her fingernails. What does this finding indicate?	expected Variation
When assessing an older adult client with a history of cardiovascular disease, dyspnea, and peripheral edema, which method is best for the nurse to use to assess the client's pulse rate?	Auscultate the apical pulse at the point of maximal impulse
Slight crackling throughout lung fields. Right breath sounds louder than left. Blowing, hollow sounds above sternum. Faint whistling over both lung bases.	Blowing, hollow sounds above sternum.
a health history for a client being admitted for new-onset seizures. Which action should the nurse implement to accurately record the health history findings?	Enter the information in the electronic medical record at the client's bedside
The assessment on an older adult client and calculates a balance score of 12 and a gait score of 8. Which do these results indicate?	Increased risk for falling.
Fix a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?	Listen to the heart sounds using the bell of a stethoscope.
Ask the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size, which is the priority nursing action.	Advise the client to see his health care provider for immediate evaluation
NGN The client is a 35-year-old male with no history of any medical conditions is in the clinic for an annual physical	Reach under a gown to listen and take care that no clothing rubs on the stethoscope Ensure the room is as quiet as possible Keep the examination room warm, and warm the stethoscope. Wet the chest hair before auscultating
NGN 46-year-old male who comes to the emergency department having difficulty breathing, which has worsened over the last 24 hours.	Condition: Pleural Effusion Actions: Assess for tactile fremitus. Inspect the chest for lag on the affected side. Parameters: Respiratory Rate and Pulse Cyanosis
NGN History and Physical 57-year-old client presents with joint pain and stiffness in their hands.	Findings Indicative of Rheumatoid Arthritis (RA): Symmetrical involvement, Joint swelling, Pain increases with motion, Fatigue and fever, Small joints of the hand Findings Not Applicable to RA: Heberden's nodes, Morning stiffness quickly resolves
Passing heart sounds of a client with rheumatic valvular heart dis ease, where should the nurse place the stethoscope to auscultate the triguspid valve?	Left 4th intercostal space next to left sternal border.
The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?	Use a standard pain assessment questionnaire and scale.
has nailed clubbing. Which additional information is consistent with this finding?	Oxygen saturation of 85%.
Obtained during a skin assessment, should the school nurse report to the healthcare provider.	Red, swollen, painful nodule located on upper back on a school-aged boy.

Created by: kyleenightin

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