HESI:l NURl 101/l NUR101l (Latestl 2025/l
2026l Update)l Healthl Assessmentl Examl Prep|l Questionsl &l Answers|l Gradel A|l 100%l Correctl (Verifiedl Solutions)-l Fortis
Q:l Duringl cardiacl auscultation,l thel nursel hearsl al splitl inl thel secondl heartl soundl whenl listeningl tol thel secondl leftl intercostall spacel ofl al malel client.l Tol assessl thisl soundl morel fully,l whatl actionl shouldl thel nursel implement?
Inchl thel stethoscopel downl thel leftl sidel ofl thel client'sl sternum.Askl thel clientl tol coughl andl thenl listenl atl thel sitel again.Instructl clientl tol holdl hisl breathl sol thel soundl isl clearer.Listenl tol thel soundl whilel observingl thel client'sl respirations.
Answer:l
Listenl tol thel soundl whilel observingl thel client'sl respirations.
Al splitl S2l isl heardl onlyl inl thel pulmonicl valvel areal (secondl leftl interspace).l Listeningl whilel observingl respirationsl allowsl thel examinerl tol determinel thel typel ofl S2l splitl thatl isl occurring.l Otherl actionsl arel notl usefull inl auscultatingl al splitl S2.
Q:l Al clientl hasl comel tol thel clinicl forl al routinel healthl assessment.l Whatl isl thel bestl assessmentl questionl forl thel nursel tol askl al clientl afterl observingl tophil onl thel client'sl earl cartilage?
Havel youl hadl suddenl andl severel painl inl thel toesl orl feet?Dol youl havel al familyl historyl ofl osteoporosis?Havel youl everl hadl painl alongl thel sidel ofl yourl leg?Dol youl havel al historyl ofl rheumatoidl arthritisl orl bursitis?
Answer:l
Havel youl hadl suddenl andl severel painl inl thel toesl orl feet?
Tophil (plurall forml ofl tophus)l arel depositsl ofl uricl acidl crystalsl foundl inl thel skin,l cartilage,l andl orl onl thel surfacel ofl joints.l Tophil arel seenl inl thel advancedl stagesl ofl gout,l al conditionl inl whichl uricl acidl crystalsl havel depositedl intol thel joints,l particularly,l 1 / 4
thel toes.l Goutl willl oftenl presentl clinicallyl asl suddenl andl severel painl inl thel toesl orl lowerl extremities.l Thel nursel shouldl askl aboutl al historyl ofl suddenl andl severel painl inl thel toesl orl lowerl extremitiesl afterl observingl tophil onl thel earl cartilage.
Q:l Thel nursel isl requestingl thel clientl tol performl al Rombergl Testl tol assessl neurologicall status.l Duringl thel test,l thel nursel notesl thatl thel clientl swaysl slightly.l Whichl isl thel nurse'sl nextl action?
Documentl thel normall finding.Havel thel clientl widenl thel basel ofl thel feet.Askl thel clientl tol walkl tol thel doorl andl back.Askl thel clientl ifl therel isl anyl dizziness.
Answer:l
Documentl thel normall finding.
Tol performl al Rombergl Test,l thel clientl isl askedl tol standl upl withl feetl togetherl andl armsl atl thel sides.l Oncel inl al stablel position,l thel clientl isl askedl tol closel theirl eyesl andl holdl thel positionl forl aboutl 20l seconds.l Normallyl al personl canl maintainl posturel andl balancel evenl withl thel visuall orientingl informationl blocked,l althoughl slightl swayingl mayl occur.
Q:l Anl olderl clientl pushesl thel nurse'sl handl awayl whenl palpationl isl initiatedl duringl physicall assessment.l Whichl additionall objectivel signl aidsl thel nursel inl assessingl forl abdominall tenderness?
Takesl deepl breathsl whenl palpationl isl performed.Reboundl tenderness.Closesl eyesl duringl palpationl ofl thel abdomen.Smilesl whenl askedl ifl painl isl illicitedl withl palpation.
Answer:l
Reboundl tenderness.
Anl objectivel signl thatl canl aidl inl determiningl abdominall tendernessl isl thel assessmentl ofl reboundl tendernessl whenl thel personl reportsl abdominall painl orl whenl youl elicitl tendernessl duringl palpation.
- / 4
Q:l Anl olderl clientl hasl justl returnedl tol thel rooml followingl al surgicall procedure.l Whichl painl scalel shouldl thel nursel usel whenl assessingl thel client'sl painl level?
Verball descriptorl scale.Wong-Bakerl scale.Numericl ratingl scale.Facesl painl scale-revised.
Answer:l
Verball descriptorl scale.
Thel descriptorl scalel usesl wordsl ratherl thanl numbersl orl picturesl tol describel pain.l Thisl methodl ofl reportingl painl isl lessl confusingl andl lessl abstractl forl olderl adults.l Thel choicesl providedl forl ratingl thel intensityl ofl painl includel thel following:l nol pain,l mildl pain,l moderatel pain,l andl severel pain.
Q:l Thel nursel usesl thel mini-mentall statel examinationl (MMSE)l whenl assessingl al clientl forl admissionl tol anl assistedl livingl facility.l Whichl findingl isl thel nursel assessingl whenl requestingl thel clientl tol countl backwardl byl 7s?
Recalll ofl information.Orientationl tol surroundings.Attentionl tol details.Abilityl tol followl complexl commands.
Answer:l
Attentionl tol details.
Whenl conductingl thel MMSEl andl havingl thel clientl countl backwardl byl 7s.l Thisl evaluatesl theirl abilityl tol dol simplel calculationsl andl isl specificl tol thel client'sl attentionl tol detaill andl stayingl focusedl andl notl gettingl distractedl byl externall stimuli.
Q:l Thel nursel isl completingl al physicall examl onl anl adultl client.l Whichl thyroidl findingl isl consideredl normal?
Glandl isl usuallyl notl visiblel onl inspection.Glandl isl solidl bilaterally.Bruitsl arel detectedl bilaterally.Nodalsl arel palpated.
- / 4
Answer:l
Glandl isl usuallyl notl visiblel onl inspection.
Inl al normall healthyl adult,l thyroidl glandsl arel usuallyl notl visiblel onl inspection.
Q:l Duringl al client'sl routinel well-womanl physicall exam,l thel nursel examinesl thel breasts.l Whichl assessmentl techniquel shouldl thel nursel implementl tol evaluatel forl anyl abnormall lumps?
Palpatel eachl breastl simultaneouslyl notingl anyl differences.Inspectl thel areolarl area'sl color,l shape,l andl thel nipplesl forl galactorrhea.Checkl forl breastl symmetryl whilel thel client'sl handsl arel abovel thel head.Withl bothl armsl atl client'sl side,l liftl onel arml andl palpatel thel axilla.
Answer:l
Withl bothl armsl atl client'sl side,l liftl onel arml andl palpatel thel axilla.
Lymphl nodesl orl massesl shouldl notl normallyl bel palpatedl inl thel axilla.l Thel bestl wayl tol assessl thel axillal isl tol havel thel clientl relaxl herl armsl atl herl sidel sol thatl thel musclesl arel relaxed.l Typically,l breastsl arel notl exactlyl thel samel sizel orl shape,l andl assessingl symmetryl willl notl uncoverl smalll lumps.
Q:l Thel nursel isl assessingl al clientl whol reportsl havingl shoulderl pain.l Whichl signl isl thel bestl indicatorl ofl al rotatorl cuffl tear?
Inabilityl tol adductl thel arml froml thel body.Inabilityl tol slowlyl lowerl thel arml whenl abducted.Inabilityl tol externallyl rotatel thel arm.Inabilityl tol internallyl rotatel thel arm.
Answer:l
Inabilityl tol slowlyl lowerl thel arml whenl abducted.
Rotatorl cuffl damagel canl bel assessedl withl thel Dropl Arml test,l inl whichl thel affectedl arml isl passivelyl abductedl atl 90l degreesl andl thel clientl isl unablel tol keepl thel arml elevatedl orl slowlyl andl smoothlyl lowerl thel arml froml thisl positionl withoutl movingl thel shoulderl forwardl tol havel thel otherl musclesl compensatel forl thel tornl rotatorl cuffl muscle.
- / 4