HEALTH ASSESSMENT HESI EXAM ALREADY GRADED A 100% SCORED

1) 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.

2) 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.

3) 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.

4) 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.

5) 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

6) 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

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7) The nurse is preparing to use an otoscope for an examination. Which statement is true

regarding the otoscope?

a) The otoscope is often used to direct light onto the sinuses.

b) The otoscope uses a short, broad speculum to help visualize the ear.

c) The otoscope is used to examine the structures of the internal ear.

d) The otoscope directs light into the ear canal and onto the tympanic membrane.

8) An examiner is using an ophthalmoscope to examine a patient’s eyes. The patient has

astigmatism and is nearsighted. The use of which of these techniques would indicate that the

examination is being performed correctly?

a) Using the large full circle of light when assessing pupils that are not dilated

b) Rotating the lens selector dial to the black numbers to compensate for astigmatism

c) Using the grid on the lens aperture dial to visualize the external structures of the eye

d) Rotating the lens selector dial to bring the object into focus

9) The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:

a) Auscultate over the area with a fetoscope

b) Use a goniometer to measure the pulsations

c) Use a Doppler device to check for pulsations over the area

d) Check for the presence of pulsations with a stethoscope

10) The nurse is preparing to perform a physical assessment. The correct action by the nurse is

reflected by which statement?

a) The nurse performs the examination from the left side of the bed.

b) The nurse examines tender or painful areas first to help relieve the patient’s anxiety.

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.

11) 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.

12) 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.