H
ealth
Assessment
Hesi
Practice
Questions
&
Answers
2024/2025
Verified
Answers
A+
Guaranteed!
A
nurse
conducting
a
physical
assessment
is
observing
the
client's
balance
and
performing
tests
to
determine
the
client's
sense
of
equilibrium.
Which
cranial
nerve
is
the
nurse
assessing?
1.
Cranial
nerve
II
2.
Cranial
nerve
IX
3.
Cranial
nerve
VII
4.
Cranial
nerve
VIII
-
ANSWER
4.
Cranial
nerve
VIII
Cranial
nerve
VIII
is
the
acoustic
nerve.
Hearing
tests
are
performed
to
assess
the
cochlear
portion
of
this
nerve.
Tests
to
assess
equilibrium,
such
as
observation
of
the
client's
balance
when
the
client
is
walking
or
standing,
involve
the
vestibular
portion.
A
nurse
performing
a
neurological
assessment
of
a
client
who
has
sustained
a
stroke
(brain
attack)
is
preparing
to
check
for
stereognosis.
Which
action
should
the
nurse
take
to
perform
this
assessment?
1.
Placing
an
object
in
the
client's
hand
and
asking
the
client
to
identify
it
2.
Tracing
a
number
on
the
client's
hand
and
asking
the
client
to
identify
it
3.
Moving
the
client's
finger
up
and
down
and
asking
the
client
which
way
it
is
being
moved 4.
Making
two
simultaneous
pinpricks
on
the
skin
and
asking
the
client
to
distinguish
them
-
ANSWER
1.
Placing
an
object
in
the
client's
hand
and
asking
the
client
to
identify
it
Stereognosis
is
the
client's
ability
to
recognize
objects
placed
in
his
or
her
hand.
A
nurse
performing
an
abdominal
assessment
of
a
client
is
preparing
to
auscultate
for
bowel
sounds.
In
which
part
of
the
abdomen
should
the
nurse
place
the
stethoscope
first?
1.
Left
upper
quadrant
2.
Left
lower
quadrant
3.
Right
upper
quadrant
4.
Right
lower
quadrant
-
ANSWER
4.
Right
lower
quadrant
To
auscultate
for
bowel
sounds,
the
nurse
places
the
diaphragm
endpiece
of
the
stethoscope
lightly
against
the
skin,
then
begins
to
auscultate
in
the
right
lower
abdominal
quadrant,
in
the
area
of
the
ileocecal
valve,
because
bowel
sounds
are
always
present
there
normally .
A
nurse
performing
a
physical
assessment
of
a
client
is
checking
the
client's
mouth
and
throat.
As
part
of
the
assessment,
the
nurse
plans
to
assess
the
function
of
cranial
nerve
XII.
What
should
the
nurse
ask
the
client
to
do
as
a
means
of
assessing
this
nerve?
1.
Frown
2.
Show
the
teeth
3.
Stick
out
the
tongue
4.
Say
"ah"
as
the
tongue
is
depressed
with
a
tongue
blade
-
ANSWER
3.
Stick
out
the
tongue
To
assess
the
function
of
cranial
nerve
XII
(the
hypoglossal
nerve),
the
nurse
asks
the
client
to
stick
out
the
tongue.
The
nurse
then
notes
the
forward
thrust
in
the
midline
as
the
client
protrudes
the
tongue.
The
nurse
also
asks
the
client
to
verbalize
certain
words
and
then
listen
for
clear ,
distinct
speech.
Discontinuous
high-pitched
crackling
sounds
heard
during
inspiration
that
do
not
clear
with
coughing
-
ANSWER
Fine
Crackles Loud,
low-pitched
bubbling
and
gurgling
sounds
heard
on
inspiration
(may
be
present
on
expiration);
may
decrease
with
coughing
or
suctioning
but
reappear
-
ANSWER
Coarse
Crackles
High-pitched,
continuous
musical
sounds
heard
during
inspiration
or
expiration
-
ANSWER
Wheezing
Loud,
low-pitched,
coarse
rumbling
sounds
heard
during
inspiration
or
expiration;
may
be
cleared
by
coughing
-
ANSWER
Rhonchi
Dry,
grating
quality
sounds
heard
best
during
inspiration;
does
not
clear
with
coughing
-
ANSWER
Pleural
Friction
Rub
Moderately
pitched;
heard
over
the
major
bronchi
-
ANSWER
Bronchovesicular
sounds
Low-pitched
rustling;
heard
over
the
peripheral
lung
fields
-
ANSWER
Vesicular
sounds
High-pitched,
with
a
harsh,
hollow ,
tubular
quality
heard
over
the
trachea
and
larynx
-
ANSWER
Bronchial
sounds
A
nurse
preparing
to
perform
a
respiratory
assessment
of
an
adult
client
is
reading
the
client's
medical
record.
The
nurse
sees
that
the
health
care
provider
noted
resonance
on
percussion
of
the
client's
posterior
chest.
What
interpretation
does
the
nurse
make
of
this
finding?
1.
The
client
has
normal,
healthy
lungs.
2.
The
client
may
have
a
pneumothorax.
3.
The
client
most
likely
has
a
lung
tumor .
4.
An
excessive
amount
of
air
is
present
in
the
lungs.
-
ANSWER
1.
The
client
has
normal,
healthy
lungs.
Resonance
on
percussion
predominates
in
healthy
adult
lung
tissue.
When
too
much
air
is
present
such
as
in
the
case
of
emphysema
where
it
is
trapped
in
the
alveoli
and
pneumothorax
where
it
is
trapped
in
the
pleural
space
leading
to
lung
collapse.
-
ANSWER
Hyperresonance Indicates
an
abnormal
density
in
the
lungs,
such
as
that
noted
in
pneumonia,
pleural
effusion,
or
atelectasis
or
in
the
presence
of
a
tumor .
-
ANSWER
Dull
note
on
percussion
of
the
lungs
A
nurse
performing
a
breast
examination
is
preparing
to
palpate
the
client's
breasts.
Into
which
position
should
the
nurse
assist
the
client
to
perform
palpation?
1.
A
standing
position,
with
the
client
holding
both
arms
above
her
head
2.
A
standing
position,
with
the
client
holding
her
hands
firmly
on
her
hips
3.
A
supine
position,
with
the
arm
on
the
side
being
examined
positioned
across
the
chest
4.
A
supine
position,
with
the
arm
on
the
side
being
examined
positioned
behind
the
head
and
a
small
pillow
placed
under
the
shoulder
on
the
same
side
-
ANSWER
4.
A
supine
position,
with
the
arm
on
the
side
being
examined
positioned
behind
the
head
and
a
small
pillow
placed
under
the
shoulder
on
the
same
side
To
palpate
the
breasts,
the
nurse
assists
the
client
into
a
supine
position
and
positions
the
client's
arm
on
the
side
being
examined
behind
the
head.
A
small
pillow
is
placed
under
the
shoulder
on
the
same
side.
The
nurse
uses
the
pads
of
the
first
three
fingers
to
gently
compress
the
breast
tissue
against
the
chest
wall
and
notes
tissue
consistency .
Palpation
is
performed
systematically ,
with
care
taken
to
ensure
that
the
entire
breast
and
tail
are
palpated.
A
nurse
performing
a
neck
assessment
of
a
client
is
testing
the
status
of
cranial
nerve
XI.
What
does
the
nurse
ask
the
client
to
do
to
enable
assessment
of
this
nerve?
1.
Smile
2.
Lift
the
eyebrows
3.
Stick
out
the
tongue
4.
Shrug
the
shoulders
against
resistance
-
ANSWER
4.
Shrug
the
shoulders
against
resistance
Cranial
nerve
XI
(spinal
accessory
nerve)
is
tested
by
asking
the
client
to
shrug
the
shoulders
against
the
resistance
of
the
nurse's
hand
and
to
turn
the
head
to
each
side
as
the
nurse
tries
to
resist
the
client's
movement.
Increased
lumbar
curvature
-
ANSWER
Lordosis
(Swayback)
Exaggeration
of
the
posterior
curvature
of
the
thoracic
spine
-
ANSWER
Kyphosis
(hunchback)
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