HESI Extra Credit Module 2 Exam Health Promotion and Disease Prevention [NEW!!] 2022 (73 Pages)
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A nurse is performing an abdominal assessment of a client with suspected cholecystitis. Which
of the following findings does the nurse expect to note if cholecystitis is present?
A. Homan sign
B. Murphy sign Correct
C. Blumberg sign
D. McBurney sign
Rationale: The Murphy sign is an indicator ...
hesi extra credit module 2 exam health promotion and disease prevention new 2022 73 pages
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Module 2 Exam
1. .ID: 383733703
A nurse is performing an abdominal assessment of a client with suspected cholecystitis. Which
of the following findings does the nurse expect to note if cholecystitis is present?
A. Homan sign
B. Murphy sign Correct
C. Blumberg sign
D. McBurney sign
Rationale: The Murphy sign is an indicator of gallbladder disease. The client is asked to inhale
while the examiner’s fingers are hooked under the liver border, at the bottom of the rib cage.
Inspiration causes the gallbladder to descend onto the fingers, producing pain if the gallbladder
is inflamed. The Homan sign is pain in the calf area on sharp dorsiflexion of the client’s foot. The
Blumberg sign is the presence of rebound tenderness on palpation of the abdomen. Rebound
tenderness is a reliable sign of peritoneal irritation. The McBurney sign is a reaction of the client
indicating severe pain and extreme tenderness when the McBurney point (midway between the
umbilicus and the anterior iliac crest in the right lower quadrant of the abdomen) is palpated.
Such a reaction indicates appendicitis.
2.ID: 383733763
A nurse palpates a client's radial pulse, noting the rate, rhythm, and force, and concludes that
the client's pulse is normal. Which of the following notations would the nurse make in the client's
record to document the force of the client's pulse?
E. 4+
,F. 3+
G. 2+ Correct
H. 1+
Rationale: When assessing a pulse, the nurse should note the rhythm, amplitude, and symmetry
of pulses and should compare peripheral pulses on the two sides for rate, rhythm, and quality. A
4point scale may be used to assess the force (amplitude) of the pulse: 4+, bounding pulse; 3+,
increased pulse; 2+, normal pulse; 1+, weak pulse. In this case the nurse would grade the
client’s pulse as 2+.
3.ID: 383732836
A nurse performing a physical examination is assessing the client for costovertebral angle
tenderness. When the nurse percusses the area, the client complains of sharp pain. The nurse
interprets this finding as most indicative of:
I. Liver enlargement
J. Ovarian infection
K. Spleen enlargement
L. Kidney inflammation Correct
Rationale: When assessing for costovertebral angle tenderness, the nurse is checking for kidney
tenderness. Sharp pain that occurs on percussion of the costovertebral angle indicates
inflammation of the kidney or paranephric area. To assess the kidney, the nurse places one
hand over the 12th rib, at the costovertebral angle, on the back. The nurse then thumps that
hand with the ulnar edge of the other fist. The client normally feels a thud and should not
, experience pain. Ovarian infection, liver, or spleen enlargement are not associated with the
costovertebral angle.
4.ID: 383733729
A nurse performing a neurological examination is testing the cochlear portion of the acoustic
nerve (cranial nerve VIII). Which of the following actions does the nurse take to test this nerve?
M. Asking the client to raise his or her eyebrows and looking for symmetry
N. Asking the client to clench the teeth, then palpating the masseter muscles just
above the mandibular angle
O. Asking the client to close the eyes and then identify light and sharp touch with a
cotton ball and a pin on both sides of the face
P. Asking the client to close his or her eyes and then indicate when a ticking watch
is heard as the nurse brings the watch closer to the client's ear Correct
Rationale: To test the cochlear portion of the acoustic nerve, the nurse has the client close the
eyes and indicate when a ticking watch or rustling of the examiner’s fingertips is heard as the
stimulus is brought closer to the ear. To test the motor component of the trigeminal nerve, the
nurse asks the client to clench the teeth and palpates the masseter muscles just above the
mandibular angle. To test the sensory component of the trigeminal nerve (cranial nerve V), the
nurse has the client identify light and sharp touch on both sides of the face. Asking the client to
raise the eyebrows and watching for symmetry is one method of testing the function of the facial
nerve (cranial nerve VII).
1. 5.ID: 383732891
A nurse is preparing a female client for a rectal examination. Into which position does the nurse
assist the client?
, A. Supine
B. Standing
C. Lithotomy
D. Left lateral Correct
Rationale: A female client is placed in the left lateral position for a rectal examination. If the
examiner is examining the genitalia as well as the rectum, the woman is placed in the lithotomy
position. A male client is placed in the left lateral or standing position. It would be difficult to
perform a rectal examination on a client in the supine position.
TestTaking Strategy: Use the process of elimination and focus on the subject, a rectal
examination of a female client. Recalling that the left lateral position is used to administer an
enema will assist in directing you to the correct option. Review the procedure for performing a
rectal examination of a female client if you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medicalsurgical nursing: Patientcentered
collaborative care (6th ed., p. 1651). St. Louis: Saunders.
A nurse is preparing to listen to a client's breath sounds. The nurse should:
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