HESI Exam Health Assessment
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1. During her annual OB/GYN Correct: "One week after your period starts, or
exam, a 24-year-old woman when your breasts are least engorged."
asks the nurse when she b/c
should perform her breast In menstruating women, self breast exams are
exams. The nurse's best re- best performed 4-7 days after the start of a
sponse is: woman's cycle, when the breasts are least
engorged and painful.
2. While assessing for com- "Do you need to strain to start or maintain
mon signs and symptoms stream?"
of benign prostatic hyper- b/c
trophy (BPH), the nurse Hesitancy, weak stream, and dribbling are
should ask: common symptoms of BPH. The other ques-
tions are not useful to determine BPH.
incorrect: "Are you urinating more than twice
a day?", Is your urine bloody or cloudy?", "Do
you have to stand further from the toilet?"
3. A 19-year-old female How many pads are you soaking per hour?"
post-miscarriage presents b/c
with "vaginal bleeding." During the History of Present Illness, quantity
What is a priority health or severity should be assessed and document-
history question at this ed. For example: "Vaginal bleeding soaking
time? two pads per hour." Soaking one or more pads
per hour can indicate hemorrhage.
4. The nurse is educating "If you notice an enlarged testicle or a lump,
an adolescent male about call your health care provider."
testicular self-examination b/c
(TSE). The nurse includes If the patient notices a firm painless lump,
which point in the teach- a hard area, or an overall enlarged testicle,
ing? then he should call his health care provider for
further evaluation. The testicle normally feels
rubbery with a smooth surface. A good time to
examine the testicles is during the shower or
bath, when one's hands are warm and soapy
and the scrotum is warm. Testicular self-exam-
ination should be performed once a month.
, HESI Exam Health Assessment
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5. During a complete physi- Ask the patient when she first noticed the in-
cal exam, the RN notices version.
that a female patient has b/c
an inverted left nipple; the The nurse should distinguish between a re-
right one is everted. What cently retracted nipple from one that has been
should the nurse do next? inverted for many years or since puberty. Nor-
mal nipple inversion may be unilateral or bilat-
eral and usually can be pulled out; that is, if it
is not fixed. Recent nipple retraction signifies
acquired disease.
6. When examining an adult Suspect the presence of serous fluid in the
patient presenting with scrotum.
"scrotal pain", the nurse b/c
notices that a positive glow Normal scrotal contents do not allow light to
with transillumination. On pass through the scrotum. However, serous
the basis of this finding the fluid does transilluminate and shows as a red
nurse would: glow. Neither a mass nor a hernia would tran-
silluminate.
7. A 30 year-old female who is Ask if the woman has had a fever, fatigue, or
4 weeks postpartum calls chills.
the OB/GYN clinic to report b/c
that her left breast is red, If the woman is also experiencing flu-like
swollen, and very tender. symptoms,it is suspicious for mastitis, which
What should the nurse do stems from an infection or stasis caused by a
next? plugged duct. A plugged duct does not have
infection present.
8. A new mother presses her The first stool indicates anal patency.
call light to report that her b/c
baby "has had his first The first stool passed by the newborn is dark
poop." The nurse observes green meconium and occurs within 24 to 48
a dark green meconium hours of birth, indicating anal patency. The oth-
stool. The RN understands er responses are not correct.
that:
9. While assessing for hem- Performs a Valsalva maneuver.
orrhoids in a 28-year-old b/c
While inspecting the perianal area, instruct the
, HESI Exam Health Assessment
Study online at https://quizlet.com/_b7z32y
male, the nurse inspect the person to hold the breath and bear down by
anus while the client: performing a Valsalva maneuver. No break in
skin integrity or protrusion through the anal
opening should be present.
10. To assess for common "How often do you have a period?"
symptoms of Polycystic b/c
Ovary Syndrome (PCOS), Clients with PCOS will have amenorrhea or
the nurse asks: infrequent menses, infertility, acne, hirsutism,
and weight gain. Asking about family history
does not assess for common symptoms of
PCOS.
11. When assessing muscle "5/5" -correct
strength, the nurse ob- 2+
serves that a patient main- bounding
tain biceps flexion against full tone
resistance. How should the b/c
nurse document muscle Full strength against resistance is normal
strength? muscle strength and is recorded as grade 5/5
muscle strength. The other options are not cor-
rect.
12. An adult male presents to Gout.
the clinic with flank pain b/c
and blood in the urine. Tophi are collections of monosodium urate
During examination, the crystals resulting from chronic gout in and
nurse notices the presence around the joint that cause extreme swelling
of hard, painless nodules and joint deformity. Kidney stones are common
over the great toe; one has in gout as well. Tophi appear as hard, painless
burst open with a chalky nodules over the metatarsophalangeal joint of
discharge. The nurse sus- the first toe and they sometimes burst with a
pects: chalky discharge.
13. The nurse is examining a Limited movement on one side during the
newborn who was born Moro reflex
with assistance of forceps. b/c
Which assessment finding For a fractured clavicle, the nurse should ob-
alerts the nurse to the pos- serve for limited arm range of motion and uni-
lateral response to the Moro reflex.
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