An adult client is in the clinic for a regular physical examination. The nurse is assessing the client's hydration status by pinching and then releasing the client's skin. Which finding is indicative of good hydration status?
a. The skin remains tented. b. The skin appears blanched and returns to ...
N 243 HESI Practice Questions and
Correct Answers
An adult client is in the clinic for a regular physical examination. The nurse is assessing
the client's hydration status by pinching and then releasing the client's skin. Which
finding is indicative of good hydration status?
a. The skin remains tented.
b. The skin appears blanched and returns to pink.
c. The skin slowly falls back into place.
d. The skin immediately returns to normal position. ✅d.
Skin turgor refers to elasticity and is assessed by gently pinching and then releasing the
skin on the forearm, back of the hand, or under the clavicle. If skin turgor is normal, the
skin will return to a normal position immediately when released. Poor skin turgor is
indicative of dehydration and is determined when the tented skin does not return or
slowly returns back to place.
A client with progressive hearing loss appears distressed when the nurse asks open-
ended questions about the client's health history. Which forms of communication should
the nurse use? Select all that apply
a. Face the client so the client can see the nurse's mouth.
b. Increase one's speech volume when interacting with the client.
c. Repeat information to the client if misunderstood.
d. Check if the client's hearing aids are working properly.
e. Reduce environmental noise surrounding the client. ✅a, d, e.
A client with hearing loss can develop the ability to read "lips," so facing the client during
conversation allows visualization of the lips and directs the sound toward the client.
Inspection of the hearing aid device's functionality is a vital step in communication.
Hearing aids magnify all surrounding noise, so it is imperative to reduce outside
environmental noise during the interview process. Speaking clearly with enunciation and
in a regular tone is easier for a client to understand than increasing the volume of
speech. If a client shows signs of confusion, rephrasing the question, instead of
repeating, should be done to decrease client anxiety and facilitate understanding.
A postmenopausal female client is undergoing a routine physical examination. She has
reported nothing out of the ordinary. When performing the examination of the
genitourinary system, the nurse finds an irregularly enlarged uterus with firm, mobile,
painless nodules in the uterine wall. How should the nurse explain this finding to the
client?
a. You have benign fibroid tumors, a common occurrence in women your age.
b. This is a sign of uterine cancer and I will report this to the healthcare provider.
c. This is a sign of endometriosis, so we will need to biopsy the lesions.
, d. This is a very common finding in pregnancy and it will go away. ✅a.
With myomas (uterine fibroids), subjective findings are varied depending on the size
and location of the lesions. Often there are no symptoms. Symptoms that may occur
include vague discomfort, bloating, heaviness, pelvic pressure, dyspareunia, urinary
frequency, backache, or excessive uterine bleeding and anemia if myoma disturbs
endometrium. Objective findings include: the uterus is irregularly enlarged, firm, mobile,
and nodular with hard, painless nodules in the uterine wall. These benign tumors are
common after the age of 50.
The client is experiencing severe pruritus and small papules and burrows on areas over
one hand and the inner thighs. Which assessment data best explains the condition the
client is experiencing?
a. The client works in a daycare setting that has had a scabies outbreak.
b. The client has been using a chemical stripping agent for home remodeling.
c. The client has a family history of psoriasis in both parents and a sibling.
d. The client routinely works with clay and paint as a hobby. ✅a.
Scabies is a highly contagious condition that causes pruritus, small papules, vesicles,
and burrows in the skin as the scabies mite burrows into the superficial layer of the skin
to lay eggs. Scabies is often spread among children and others in close contact.
Which statement is accurate about assessing the spleen?
a. It must be enlarged at least three times normal size for it to be palpable.
b. It is easily felt by reaching the left hand behind the 11th and 12th ribs.
c. It is normally felt by rolling the client on the right side and palpating.
d. It is a firm mass palpated slightly left of midline in the upper abdomen. ✅a.
Normally the spleen is not palpable at all and must be enlarged by three times its
normal size to be felt. To search for it, the nurse must reach the left hand over the
abdomen and behind the left side at the 11th and 12th ribs and lift up for support. The
nurse should place the right hand obliquely on the left upper quadrant (with the fingers
pointing toward the left axilla) and push the hand deeply down and under the left costal
margin while asking the client to take a deep breath. Under normal circumstances, the
nurse should feel nothing firm
The nurse is assessing a client who has a history of aortic regurgitation. Where should
the nurse place the stethoscope diaphragm to listen for this condition?
a. 2nd intercostal space along the left sternal border.
b. 2nd intercostal space along the left sternal border.
c. 3rd intercostal space on the right midclavicular line.
d. 5th intercostal space on the left midclavicular line. ✅a.
The best way to listen for high-pitch aortic heart sounds, such as an aortic regurgitation
murmur, is to place the stethoscope diaphragm onto the 2nd intercostal space along the
left sternal border.
The nurse is examining the hip joint of a client who reports hip pain. Which other
assessment is most helpful in determining the cause of the client's pain?
a. Knee joint evaluation.
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