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HESI RN HEALTH ASSESSMENT

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Total Questions : 85

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Question 1:

The nurse inspects the client's fingernails. Which differentiating characteristics are observed in this assessment finding?

A. Longitudinal pigmented bands and red brown linear streaks of recent onset. B. Thinned depressed nails with lateral edges tilting up to form a concave profile and proximal subungual fungal infection. C. Transverse furrows and nail plate white spots that move forward with nail growth. D. A nail base angle greater than 180 degrees and nail plate loosened at the distal-lateral edge, progressing proximally.

Answer and Explanation

Choice A:

Longitudinal pigmented bands and red-brown linear streaks of recent onset. This description is more indicative of longitudinal melanonychia, which presents as pigmented bands along the length of the nail plate. It's not typically associated with finger clubbing.

Choice B:

Thinned, depressed nails with lateral edges tilting up to form a concave profile and proximal subungual fungal infection. This description suggests koilonychia, also known as spoon nails, which are characterized by thin, depressed nails with lateral edges tilting up. The mention of a fungal infection points to a different condition. It doesn't align with finger clubbing.

Choice C:

Transverse furrows and nail plate white spots that move forward with nail growth. This description corresponds to Beau's lines and leukonychia, which are not associated with finger clubbing. Beau's lines are transverse furrows or depressions in the nail plate, while leukonychia manifests as white spots or lines.

Choice D:

A nail base angle greater than 180 degrees and nail plate loosened at the distal-lateral edge, progressing proximally. This description fits the characteristics of finger clubbing, where there's an increased nail base angle (greater than 180 degrees) and the nail plate is loosened at the distal-lateral edge, progressing proximally. This choice aligns with the assessment finding.

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Question 2:

The nurse is calculating the one-minute Apgar score for a newborn infant and determines that the heart rate is 150 beats/minute, a vigorous cry is present, muscle tone is good with total flexion, quick reflex irritability noted, and skin color is dusky and cyanotic.

Which Apgar score should the nurse assign to this infant?

(Enter numeric value only.)

Answer and Explanation

Correct Answer: "9"

Explanation

To determine the Apgar score for the newborn infant, we assess five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each parameter is scored from 0 to 2, with 2 being the highest score. Let's evaluate each parameter:

Heart rate: 150 beats/minute --> Score of 2.
Respiratory effort: Vigorous cry present --> Score of 2.
Muscle tone: Good muscle tone with total flexion --> Score of 2.
Reflex irritability: Quick reflex irritability noted --> Score of 2.
Color: Dusky and cyanotic skin color --> Score of 1.

Now, we sum up the scores: 2+2+2+2+1=92+2+2+2+1=9

Therefore, the Apgar score for this infant is 9.

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Question 3:

The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

A. Auscultate the lymph node for the presence of a bruit. B. Ask the client about any localized tenderness at the site. C. Cover the inflamed area and notify the healthcare provider. D. Record this normal finding in the assessment record.

Answer and Explanation

Choice A:

Auscultate the lymph node for the presence of a bruit.Auscultating for a bruit over a lymph node may not be the most immediate or relevant action in this situation. While it could provide additional information about blood flow, it may not necessarily explain the cause of the enlarged lymph node.

Choice B:

Ask the client about any localized tenderness at the site.This is an appropriate action. Localized tenderness at the site of an enlarged lymph node could indicate inflammation or infection. Gathering information about tenderness can help in understanding the possible cause of the lymphadenopathy.

Choice C:

Cover the inflamed area and notify the healthcare provider.This is a reasonable action. Covering the inflamed area can help protect it from further irritation or infection. Notifying the healthcare provider is important because they can assess the lymph node, gather additional history, and determine if further evaluation or treatment is necessary.

Choice D:

Record this normal finding in the assessment record.This option is incorrect. An enlarged, visible lymph node is not considered a normal finding. It could indicate underlying infection, inflammation, or another health issue. Recording it as a normal finding could lead to overlooking potential health concerns.

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Question 4:

A woman comes to the clinic for her first prenatal visit. The nurse is conducting a health history and the woman begins to cry when asked about previous pregnancies. Which response is best for the nurse to provide?

A. Allow the client to compose herself then change the subject. B. "Why don't I come back in a few minutes after you are more composed." C. "I'm so sorry that I made you cry. I didn't mean to upset you." D. Offer a tissue and sit quietly until the crying subsides.

Answer and Explanation

Choice A:

Allow the client to compose herself then change the subject.This response allows the client some time to regain composure, which can be helpful. However, abruptly changing the subject may make the client feel dismissed or unheard. It's essential to address the emotional response with sensitivity.

Choice B:

"Why don't I come back in a few minutes after you are more composed."While this response acknowledges the client's emotional state, it may unintentionally communicate a lack of availability or willingness to support the client in that moment. It's important for the nurse to offer support and empathy immediately rather than suggesting a delay.

Choice C:

"I'm so sorry that I made you cry. I didn't mean to upset you."This response acknowledges the client's emotional response and expresses empathy, which is a crucial aspect of providing patient-centered care. However, it's important to avoid taking personal responsibility for the client's emotional reaction, as it may not have been caused solely by the nurse's questions.

Choice D:

Offer a tissue and sit quietly until the crying subsides.This response demonstrates empathy and support by providing a tissue and offering a non-verbal gesture of comfort. Sitting quietly allows the client the space to express her emotions while feeling supported by the nurse's presence.

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Question 5:

The school nurse is interviewing an adolescent who wants to go home from school because of "back pain." Which question should the nurse ask first?

A. "What were you doing when you first noticed the problem?" B. "Have you taken any medications to relieve the pain?" C. "Do you remember ever having this type of pain in the past?" D. "Does changing your position make the pain worse?

Answer and Explanation

Choice A:

"What were you doing when you first noticed the problem?"This question helps to identify any specific activities or events that may have triggered the onset of back pain. Understanding the circumstances surrounding the pain can provide valuable information about its potential cause.

Choice B:

"Have you taken any medications to relieve the pain?"While it's important to assess if the adolescent has taken any medications, such as over-the-counter pain relievers, to manage the pain, this question may not be the most immediate priority. It's essential to first gather information about the nature and onset of the pain to guide further assessment and management.

Choice C:

"Do you remember ever having this type of pain in the past?"This question helps to determine if the adolescent has a history of similar back pain episodes. Past episodes of back pain can provide insight into potential underlying conditions or recurrent issues that may be contributing to the current complaint.

Choice D:

"Does changing your position make the pain worse?"This question is crucial in assessing the characteristics of the pain and its response to movement or positional changes. It can help differentiate between musculoskeletal causes of back pain, which may worsen with movement, and other potential causes.

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Question 6:

While the nurse is obtaining a health history, the client reports experiencing shortness of breath at times. The nurse determines that the client's respirations are regular and deep and respiratory rate is 14 breaths/minute. Which is the best nursing action?

A. Explain to the client the possible causes of dyspnea or "shortness of breath." B. Ask the client to describe the episodes of dyspnea in more detail. C. Document "dyspnea on exertion" in the client's medical record. D. Ask the client to perform light exercise and observe the respiratory effort.

Answer and Explanation

Choice A:

Explain to the client the possible causes of dyspnea or "shortness of breath.": While the nurse might eventually explain this, it's premature without more information about the client's specific shortness of breath experience.

Choice B:

Ask the client to describe the episodes of dyspnea in more detail: This is the most appropriate next step. Understanding the characteristics, triggers, and severity of the dyspnea will help determine the cause and guide further assessment.

Choice C:

Document "dyspnea on exertion" in the client's medical record: The client only reports experiencing shortness of breath "at times," not necessarily with exertion. More details are needed before documenting.

Choice D:

Ask the client to perform light exercise and observe the respiratory effort: This could worsen the client's condition if the shortness of breath is severe. Observation during rest provides a safer approach initially.

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Question 7:

While the nurse is taking a health history, the client announces, "I don't have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide?

A. "I am sorry you feel that way. Perhaps you'd like to return when you have more time." B. "You sound angry. Would you like to tell me about it?" C. Ignore the angry outburst and continue with the history questions. D. Move closer and place a hand on the client's shoulder to demonstrate concern.

Answer and Explanation

Choice A:

"I am sorry you feel that way. Perhaps you'd like to return when you have more time."While this response acknowledges the client's feelings, it may inadvertently dismiss the client's concerns and fail to address the immediate need for treatment. It's important for the nurse to engage with the client and explore their concerns rather than suggesting they come back later.

Choice B:

"You sound angry. Would you like to tell me about it?"This response demonstrates empathy and acknowledges the client's emotions. By inviting the client to express their feelings further, the nurse opens the door for communication and understanding. It allows the nurse to explore the underlying reasons for the client's frustration and address their concerns.

Choice C:

Ignore the angry outburst and continue with the history questions.Ignoring the client's emotional outburst may cause the client to feel unheard or invalidated, potentially escalating the situation further. It's essential for the nurse to address the client's concerns and emotions to maintain a therapeutic relationship and provide effective care.

Choice D:

Move closer and place a hand on the client's shoulder to demonstrate concern.While physical touch can be comforting for some individuals, it's important to consider the client's preferences and boundaries, especially in a situation where the client is expressing frustration or impatience. Approaching the client physically without consent may not be appropriate and could further exacerbate the situation.

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Question 8:

A clinic nurse is assessing infants and toddlers for fine and gross motor development. Which child should the nurse refer to a healthcare provider for further evaluation?

A. 3-year-old preferring to walk on the tip toes. B. 1.5-year-old attempting to scribble on paper. C. 5-month-old with use of whole hand grasp. D. 3.5-month-old with diminished Moro reflex.

Answer and Explanation

Choice A:

3-year-old walking on tiptoes: While some children may walk on their tiptoes occasionally, it's not necessarily a cause for concern unless it's persistent or accompanied by other developmental delays.

Choice B:

1.5-year-old attempting to scribble: This is a typical stage for exploring hand and finger movements, leading to early attempts at drawing.

Choice C:

5-month-old with whole hand grasp: At this age, infants use their whole hand to grasp objects, which is a normal developmental step before developing a more refined pincer grasp.

Choice D:

3.5-month-old with diminished Moro reflex. The Moro reflex is a normal reflex in newborns that typically disappears by around 4 to 6 months of age. A diminished or absent Moro reflex before this age could indicate neurological concerns or developmental delays. Referral to a healthcare provider is necessary for further evaluation.

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Question 9:

On the first postpartum day, the nurse examines the breasts of a new mother. Which condition is the nurse most likely to find?

A. Firm, larger, and very tender to touch. B. Soft, with no change from before delivery. C. Filling and secreting colostrum. D. Slightly firm with immediate let-down response.

Answer and Explanation

Choice A:

Firm, larger, and very tender to touch. This option describes the characteristics of engorged breasts, which typically occur a few days after birth as milk production increases and the breasts become full. Engorged breasts can feel firm, swollen, and tender to the touch due to the increased blood flow and milk accumulation. However, on the first postpartum day, engorgement may not yet be fully developed.

Choice B:

Soft, with no change from before delivery. This option is unlikely as the breasts typically undergo changes during the postpartum period, especially with the initiation of lactation. Soft breasts with no change from before delivery would not be expected on the first postpartum day.

Choice C:

Filling and secreting colostrum. This option is the most likely finding on the first postpartum day. Colostrum, the early milk produced by the breasts, begins to be secreted during the late stages of pregnancy and continues after birth. On the first postpartum day, the breasts may be filling with colostrum, which is typically thicker and more concentrated than mature breast milk. It is produced in small amounts, about 40-50ml on the first day but that is all an infant normally needs at this time.

Choice D:

Slightly firm with immediate let-down response. While some firmness may be present due to the initiation of lactation, an immediate let-down response is less likely on the first postpartum day. The let-down reflex, which triggers the release of milk from the breast, may take some time to establish and may not occur immediately after delivery.

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Shateena: cOLOSTRUM COMES A FEW DAYS AFTER BIRTH SO THE ANSSWER WOULD BE B ~ 4mos ago

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Nico: It comes immediately after birth within the first 12 to 18hrs ~ 4mos ago

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Question 10:

A nurse is interacting with a client who is a victim of intimate partner violence (IPV). The client reports feeling unable to leave the relationship because of the children. The nurse responds by saying, "I know this must be very difficult for you." Which type of therapeutic communication is the nurse providing?

A. Open-ended question. B. Clarification. C. Empathizing. D. Paraphrasing.

Answer and Explanation

Choice A:

Open-ended question. This response is not an open-ended question. Open-ended questions typically invite the client to share more information or elaborate on their thoughts and feelings. Instead, the nurse's response acknowledges the client's feelings and demonstrates empathy without directly soliciting more information.

Choice B:

Clarification. This response is not clarification. Clarification involves seeking clarification or additional information to ensure understanding. The nurse's response does not seek clarification but rather acknowledges the client's emotions.

Choice C:

Empathizing. This response is empathizing. Empathizing involves recognizing and understanding the client's emotions and expressing empathy. The nurse's response acknowledges the client's difficult situation and validates their feelings of distress, demonstrating empathy and understanding.

Choice D:

Paraphrasing. This response is not paraphrasing. Paraphrasing involves restating the client's message in the nurse's own words to confirm understanding. The nurse's response does not restate the client's message but rather expresses empathy and validation of the client's emotions.

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Total Questions : 85

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HESI RN HEALTH ASSESSMENT

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