Questions and Answers 100 Correct

Health Assessment HESI Practice Questions and Answers 100% Correct The registered nurse (RN) notifies the spouse of a client who was admitted to hospice with shallow respirations, of a change in the client's condition. Over the past hour, the client's respiratory pattern has changed to a Cheyne Stokes pattern. After receiving this information, the client's spouse begins vacuuming around the bed. Which stage of grief is the spouse displaying during the visit?

• Acceptance
• Denial
• Bargaining
• Depression - Correct Answer B. Denial

The spouse is exhibiting the first stage of denial (B) of Kubler-Ross's grief model by ignoring that the client's death is imminent (A, C, and D) are stages of grief that are not being displayed by the client's spouse during this observation.The registered nurse (RN) places an ice pack on a middle school student who comes to the school clinic complaining of a sprained ankle. Which therapeutic response should the RN anticipate?

• Reduced pain and minimized bruising.
• Lowering of body core temperature.
• Increased circulation around injury.
• Reabsorption of edema at injury. - Correct Answer A.

Cold applications produce a topical anesthetic effect to reduce pain as well as constrict blood vessels to minimize bruising (A). Local ice over an injured area will not lower the core temperature (B). The cold pack causes vasoconstriction which reduces circulation, not (C), to traumatized tissue and limits further edema around the injury (D), but not by reabsorption of edematous fluid.The registered nurse (RN) palpates a weak pedal pulse on the client'rs right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation (Select all that apply.)

• Diminished hair on legs.
• Bruising on extremities.
• Skin cool to touch.
• Capillary refill less than 3 seconds.
• Darkened skin on extremities. - Correct Answer A. Diminished hair on legs
• Skin cool to touch.

Diminished hair on the legs (A) and skin that is cool to the touch (C) are symptoms of decreased arterial blood flow. (B, D, and E) are not indicators for impaired circulation.Twenty four hours after a client returns from surgical gastric bypass, the registered nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister.Which assessment finding should the RN report as early signs of hypovolemic shock?

• Faint pedal pulses 1 / 3

• Decrease in blood pressure.
• Lethargy.
• Slow breathing. - Correct Answer C. Lethargy

Changes in the level of consciousness occur in the early stages of shock which decreases the perfusion to the brain which is manifested as lethargy (C). The respiratory rate increases, not (D). (A and B) are late signs of hypovolemic shock due to cardiac compensatory measures.The registered nurse (RN) is caring for a client who has taken atenolol for 2 years. The healthcare provider recently changed the medication to enalapril to manage the client's blood pressure. Which instruction should the RN provide the client regarding the new medication?

• Take the medication at bedtime.
• Report presence of increased bruising.
• Check pulse before taking medication.
• Rise slowly when getting out of bed or chair. - Correct Answer D. Rise slowly when

getting out of bed or chair.The client's new medication is an angiotensin-converting enzyme (ACE) inhibitor, which has the side effect of orthostatic hypotension. Instructing the client to rise from a chair or bed slowly (D) is indicated to avoid dizziness and falling. (A, B, and C) are not indicated when taking an ACE inhibitor.The registered nurse (RN) is assisting the healthcare provider (HCP) with the removal of a chest tube. Which intervention has the highest priority and should be anticipated by the RN after removal of the chest tube?

• Prepare the client for chest x-ray at the bedside.
• Review arterial blood gases after removal.
• Elevate the head of the bed to 45 degrees.
• Assist with disassembling the drainage system. - Correct Answer A. Prepare the

client for a chest x-ray at the bedside.A chest x-ray (A) should be performed immediately after the procedure to ensure lung expansion has been maintained after removal of the chest tube. (B) provides additional data after removal of the CT. (C) may assist the client to breathe easily, but the priority after chest tube removal is to ensure that the procedure was successful. The entire system, including the chest tube is discarded and not taken apart (D).A male client is admitted after falling from his bed. The healthcare provider (HCP) tells the family that he has an incomplete fracture of the humerus. The family asks the nurse what this means. Which type of fracture should the RN explain from these findings?

• Straight fracture line that is also a simple, closed fracture.
• Nondisplaced fracture line that wraps around the bone.
• A complete fracture that also punctures the skin.
• A fracture that bends or splinters part of the bone. - Correct Answer D. A fracture that

bends or splinters part of the bone. 2 / 3

An incomplete fracture (D) occurs through part of the thickness of bone. A linear (A) and a spiral fracture (B) describe the direction of the fracture line. An open fracture (C) is a compound fracture that breaks through the skin.The registered nurse (RN) is caring for a client with peptic ulcer disease (PUD). What assessment should the RN identify that is consistent with PUD? (Select all that apply)

• Hematemesis
• Gastric pain on an empty stomach
• Colic-like pain with fatty food ingestion
• Intolerance of spicy foods
• Diarrhea and stearrhea - Correct Answer A. Hematemesis
• Gastric pain on an empty stomach
• Intolerance of spicy foods

(A, B and D) correct. Manifestations of PUD include hematemesis (A), gastric pain (B), and spicy food intolerance. (C) is consistent with cholecystitis (D). (E) is not consistent with PUD.A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statement by the client conveys the client's understanding of the etiology of diverticula?

• Over use of laxatives for bowel regularity result in loss of peristaltic tone.
• Inflammation of the colon mucosa that cause growths that protrude into the lumen.
• Diverticulosis is the result of high fiber diet and sedentary life style.
• Chronic constipation causes weakening of colon wall which result in out-pouching

sacs. - Correct Answer D.A client who has chronic constipation (D) often strains to pass constipated stool which increases intestinal pressure that weakens the intestinal walls and causes out-pouching sacs, called diverticula which commonly occur in the signmoid. Regular use of laxatives (A) can result in the bowel's dependency on the laxative to stimulate intestinal motility, but constipation due to lack of fiver in diet, not (C), is a predisposing factor for formation of diverticula. Growths that protrude into the colon lumen are polyps (B), which are often pre-cancerous lesions.The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response?

• The client cannot understand the nurse.
• The client is uncomfortable with the nurse.
• The client is treating the nurse with respect.
• The client is purposefully disrespecting the nurse. - Correct Answer C.

In some Asian cultures, it is not appropriate to look a person of authority in the eyes, so the client is being respectful bu looking down while speaking with the nurse (C). (A, B, and D) does not reflect behaviors common to Asian culture.The registered nurse (RN) is caring for a client who developed oliguria and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the RN that the client is stabilizing?

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