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BIO 101LFundamentals of Nursing Health and Physical Assessment HESI Quiz 2021/2022.
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BIO 101LFundamentals of Nursing Health and Physical Assessment HESI Quiz 2021/2022.
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The nurse recognizes that which is the mental process most sensitive to deterioration with aging?1
Judgment
2
Intelligence
3
Creative thinking
Correct 4
Short-term memory
During the aging process there is a progressive atrophy of the convolutions of the brain with a decrease in
its blood supply, which may produce a tendency to become forgetful, a reduction in short-term memory,
and susceptibility to personality changes. There should be little or no change in judgment. There is little or
no intellectual deterioration; intelligence scores show no decline. Creativity is not affected by aging; many
people remain creative until very late in life.
The nurse is assessing a client after surgery. Which assessment finding does the nurse obtain from the
primary source?
1
X-ray reports
Correct 2
Severity of pain
3
Results of blood work
4
Family caregiver interview
The primary source of information during an assessment is the client. The nurse gathers information about
the client’s pain from the primary source, the client. Medical records such as x-ray reports and results of
blood work are secondary sources of information. The client’s family caregiver is a secondary source of
information.
When should the nurse consider family members as the primary source of information? Select all that
apply.
1
The client is an elderly adult.
Correct 2
The client is an infant or child.
Correct 3
The client is brought in as an emergency.
Correct 4
The client is critically ill and disoriented.
5
The client visits the outpatient department.
The nurse interviews the parents who care for the infant or child. Thus, the parents become the primary
source of information. A client who is brought to the emergency department may not be in a position to
explain the circumstances that led to the visit. In this case, the family or significant others who accompany
the client become the primary source of information. The family becomes the primary source of
information when the client is critically ill, disoriented, and unable to answer questions. Generally, the
client is the primary source of information. The elderly adult who is conscious, alert, and able to answer
the
,nurse’s questions is the primary source of information. The client who visits the outpatient department is
capable of providing accurate answers to the nurse’s questions. This client is the primary source of
information during assessment.
What is the correct order of steps of the nursing diagnostic process?
Correct
1.
Assess the client’s health
status. Incorrect
2.
Interpret the meaning of the data.
Incorrect
3.
Cluster data.
Incorrect
4.
Look for defining characteristics.
Incorrect
5.
Identify the client’s
needs. Incorrect
6.
Formulate nursing diagnoses.
Incorrect
7.
Validate the data with other sources.
The diagnostic reasoning process involves the use of assessment data for the client. The assessment data
is obtained from the client, family, and health care resources. The nurse validates and ensures the data is
accurate and uses critical thinking to interpret and analyze the data before it is classified and organized
into data clusters. This organization helps the nurse identify the client’s health needs. The nurse then
formulates the nursing diagnoses using standard formal nursing diagnostic statements.
The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by
the nurse is an example of subjective data?
1
The client weighs 151 lbs (68.5 Kg).
Correct 2
The client’s pain is 7 on a scale of 1 to 10.
3
The client’s fasting blood sugar is 95
mg/dL. 4
The client’s blood pressure is 140/90 mm/Hg.
Subjective data is information conveyed to the nurse by the client, such as the client’s feelings, perceptions,
and self-reporting of symptoms. The client rates pain as a 7 on a scale of 1 to 10, therefore it is subjective
data. Objective data are observations or measurements of a client’s health status. The client’s weight is
measured on a weighing scale; therefore, it is objective data. A laboratory result such as fasting blood sugar
and blood pressure are measurable quantities.
A client with a recent history of head trauma is at risk for orthostatic hypotension. Which assessment
findings observed by the nurse would relate to this diagnosis? Select all that apply.
Correct 1
Fainting
,2
Headache
Correct 3
Weakness
Correct 4
Lightheadedness
5
Shortness of breath
Head trauma may cause blood loss and clients with recent blood loss are at risk for orthostatic hypotension.
Symptoms of hypotension include fainting, lightheadedness, and weakness. Headaches and shortness of
breath are symptoms of hypertension.
A client with a head injury underwent a physical examination. The nurse observes that the client’s
temperature assessments do not correspond with the client’s condition. An injury to which part of the brain
may be the reason for this condition?
1
Pons
Incorrect 2
Medulla
3
Thalamus
Correct 4
Hypothalamus
The hypothalamus controls the body temperature. Damage to the hypothalamus may cause abnormalities in
the body temperature values during a physical assessment. The pons is responsible for maintaining level of
consciousness. The medulla controls heart rate and breathing. The thalamus performs motor and sensory
functions.
While assessing a client’s vascular system, the nurse finds that pulse strength is diminished or barely
palpable. Which documentation is appropriate in this situation?
Correct 1
1+
2
2+
3
3+
4
4+
A diminished or barely palpable pulse is documented as 1+. A normal and expected pulse strength is
documented as 2+. A full, strong pulse is documented as 3+. A bounding pulse is documented as 4+.
A client with internal bleeding is in the intensive care unit (ICU) for observation. At the change of shift an
alarm sounds, indicating a decrease in blood pressure. What is the initial nursing action?
Correct 1
Perform an assessment of the client before resuming the change-of-shift report.
2
Continue the change-of-shift report and include the decrease in blood pressure.
, 3
Lower the diastolic pressure limits on the monitor during the change-of-shift report.
4
Turn off the alarm temporarily and alert the oncoming nurse to the decrease in blood pressure.
The cause of the alarm should be investigated and appropriate intervention instituted; after the client’s
needs are met, then other tasks can be performed. An alarm should never be ignored; the client’s status
takes priority over the change-of-shift report. The diastolic pressure limit has been prescribed by the
primary healthcare provider and should not be changed for the convenience of the nurse. Alarms always
should remain on; the alarm indicates that the client’s blood pressure has decreased and immediate
assessment is required.
A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing
has been prescribed when there is no history of health problems. What is an appropriate nursing response?
1
"You will need to ask your healthcare provider; it is not part of the usual tests for people your age."
2
"There must be concern of a family history of colon cancer; that is a primary reason for an occult blood
stool test."
Correct 3
"It is performed routinely starting at your age as part of an assessment for colon cancer."
4
"There must have been a positive finding after a digital rectal examination performed by your healthcare
provider."
The primary reason for a stool specimen for guaiac occult blood testing is that it is part of a routine
examination for colon cancer in any client over the age of 40. Age, family history of polyps, and a positive
finding after a digital rectal examination are factors related to colon cancer and secondary reasons for the
occult blood test (guaiac test).
A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more
obvious on inspiration. This assessment should be documented as what?
1
Vesicular
2
Bronchial
Correct 3
Crackles
4
Rhonchi
Crackles are abnormal breath sounds described as soft, crackling, bubbling sounds produced by air
moving across fluid in the alveoli. Vesicular breath sounds are normal. They are quiet, soft, and inspiration
sounds that are short and almost silent on expiration. They are heard over the lung periphery. Bronchial
breath sounds are normal and consist of a full inspiration and expiratory phase with the expiratory phase
being louder. They are heard over the trachea and large bronchi of the lungs. Rhonchi are abnormal breath
sounds heard over the large airways of the lungs. They consist of a low pitch and are caused by the
movement of secretions in the larger airways; they usually clear with coughing.
While examining a client, a nurse finds a circumscribed elevation of the skin filled with serous fluid on the
cheek. The lesion is 0.6 cm in diameter. What does the nurse suspect the finding to be?
1
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