Question

To assess for the presence of kyphosis, which action should the nurse take?

Answer 1

Correct Answers:

Observe the client's overall body posture.

Rationale :

🔹 Kyphosis is best identified by visual inspection of the thoracic spine for curvature.

🔹 The nurse observes for a forward rounding of the upper back, common in older adults.

🔹 Bone density exams diagnose osteoporosis, not kyphosis.

🔹 Range of motion checks mobility but not curvature.

🔹 Palpation detects tenderness/edema, not spinal deformity.

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Answer 2

Correct Answers:

Compare muscle strength bilaterally.

Rationale :

🟢 Muscle atrophy suggests disuse, neurological disease, or vascular compromise.

🟢 Comparing strength bilaterally helps determine if weakness matches the atrophy.

🟢 BMI is unrelated; it evaluates body fat, not muscle wasting.

🟢 Vital signs don’t explain localized muscle loss.

🟢 Skin elasticity measures hydration, not muscular health.

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Answer 3

Correct Answers:

Ask the client to swallow while palpating along the sides of the trachea.

Rationale :

🔵 The thyroid gland rises with swallowing, making it easier to palpate.

🔵 This technique differentiates thyroid from other neck structures.

🔵 Deep palpation is dangerous—it can damage the thyroid.

🔵 Deferring exam risks missing an enlarged thyroid/goiter.

🔵 Documentation without assessment is inaccurate.

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Answer 4

Correct Answers:

Usual bed time and time of awakenings.

Rationale :

💎 The first step in assessing sleep disturbances is to establish a baseline sleep pattern.

💎 This helps identify whether the issue is insomnia, fragmented sleep, or early awakening.

💎 Causes like allergies, caffeine, nocturia are explored later.

💎 Understanding sleep patterns directs further questioning.

💎 Initial assessment builds rapport and avoids overwhelming the patient.

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Answer 5

Correct Answers:

"You sound angry. Would you like to tell me about it?"

Rationale :

🟠 This uses therapeutic communication by acknowledging emotion.

🟠 Encourages the patient to verbalize concerns instead of escalating.

🟠 Ignoring dismisses the patient’s feelings.

🟠 Touching without consent may be misinterpreted.

🟠 Apologizing/deflecting avoids the issue and undermines trust.

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Answer 6

Correct Answers:

Pain in the neck, jaw, or medial side of the left arm.

Rationale :

🔹 Referred pain to the jaw, neck, or arm is classic for acute myocardial infarction (AMI).

🔹 Unlike musculoskeletal chest pain, this pain is unrelieved by rest or palpation.

🔹 Between scapulae pain suggests gallbladder or esophageal issues.

🔹 Localized chest pain on palpation = musculoskeletal.

🔹 Recognizing classic cardiac pain ensures rapid treatment and better outcomes.

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Answer 7

Correct Answers:

Open ended questioning.

Rationale :

🟢 Asking “Describe your sputum” allows the patient to provide quality, quantity, and color details.

🟢 Closed-ended limits the patient’s description.

🟢 Leading questions bias responses.

🟢 Detailed symptom questions come after open-ended exploration.

🟢 Open-ended questioning builds rapport and gathers comprehensive data.

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Answer 8

Correct Answers:

Keep the examination room warm, and warm the stethoscope
Ensure the room is as quiet as possible
Wet the chest hair before auscultating
Reach under a gown to listen and take care that no clothing rubs on the stethoscope

Rationale :

🟡 Warm stethoscope/room prevents shivering artifacts.

🟡 Quiet room reduces external noise interference.

🟡 Wet chest hair minimizes crackling sounds from hair rubbing against diaphragm.

🟡 Listening under gown avoids clothing artifact.

🟡 Documenting artifacts as abnormal findings is incorrect.

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Answer 9

Correct Answers:

Document the findings as observed.

Rationale :

🔵 Bilateral jugular vein distension in semi-Fowler’s is an expected finding in right-sided HF.

🔵 Supine positioning exaggerates JVD, not necessary.

🔵 No lighting makes veins harder to assess.

🔵 Neck flexion falsely compresses veins.

🔵 Proper technique is semi-Fowler’s with tangential lighting.

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Answer 10

Correct Answers:

Right calf swelling and tenderness.

Rationale :

🔴 This finding suggests deep vein thrombosis (DVT) → risk of pulmonary embolism.

🔴 Requires immediate intervention: hold ambulation, notify provider, anticipate ultrasound.

🔴 Hair loss on legs = arterial insufficiency, chronic finding.

🔴 Stage 2 ulcer = serious but not immediately life-threatening.

🔴 Varicosities = chronic venous changes, not acute emergency

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☑️HESI RN Health Assessment spring 2025. 7.11.2025

No.

1 :
To assess for the presence of kyphosis, which action should the nurse take?

2 :
In completing a physical assessment of a young adult, the clinic nurse observes muscular atrophy of the right thigh and calf to gather additional data related to this finding, which action should the nurse take?

3 :
The nurse is assessing a client for a goiter and is unable to observe the thyroid gland. Which action should the nurse take?

4 :
The nurse assesses a client with a sleep pattern disturbance. While developing a plan of care (POC), which assessment data should the nurse obtain first?

5 :
While the nurse is taking a health history, the client announces, "l dont have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide?

6 :
The nurse assesses a male client who is brought to the emergency department (ED) by his family who believes he is having a heart attack. Which finding is the best indicator that a client is experiencing an acute myocardial infarction (AMI)?

7 :
While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

8 :
The client is a 35-year-old male with no history of any medical conditions presents to the clinic for an annual physical.

Answer Options

9 :
During an assessment for jugular vein distension of a client with right sided heart failure (HE), the nurse observes distension bilaterally using tangential lighting with the client in a semi-Fowler's position. Which action should the nurse take next?

10 :
When assessing a client's lower extremities, which finding requires immediate intervention by the nurse?

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☑️HESI RN Health Assessment spring 2025. 7.11.2025

No.

1 : To assess for the presence of kyphosis, which action should the nurse take?

2 : In completing a physical assessment of a young adult, the clinic nurse observes muscular atrophy of the right thigh and calf to gather additional data related to this finding, which action should the nurse take?

3 : The nurse is assessing a client for a goiter and is unable to observe the thyroid gland. Which action should the nurse take?

4 : The nurse assesses a client with a sleep pattern disturbance. While developing a plan of care (POC), which assessment data should the nurse obtain first?

5 : While the nurse is taking a health history, the client announces, "l dont have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide?

6 : The nurse assesses a male client who is brought to the emergency department (ED) by his family who believes he is having a heart attack. Which finding is the best indicator that a client is experiencing an acute myocardial infarction (AMI)?

7 : While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

8 : The client is a 35-year-old male with no history of any medical conditions presents to the clinic for an annual physical.

Answer Options

9 : During an assessment for jugular vein distension of a client with right sided heart failure (HE), the nurse observes distension bilaterally using tangential lighting with the client in a semi-Fowler's position. Which action should the nurse take next?

10 : When assessing a client's lower extremities, which finding requires immediate intervention by the nurse?

1 :
To assess for the presence of kyphosis, which action should the nurse take?

2 :
In completing a physical assessment of a young adult, the clinic nurse observes muscular atrophy of the right thigh and calf to gather additional data related to this finding, which action should the nurse take?

3 :
The nurse is assessing a client for a goiter and is unable to observe the thyroid gland. Which action should the nurse take?

4 :
The nurse assesses a client with a sleep pattern disturbance. While developing a plan of care (POC), which assessment data should the nurse obtain first?

5 :
While the nurse is taking a health history, the client announces, "l dont have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide?

6 :
The nurse assesses a male client who is brought to the emergency department (ED) by his family who believes he is having a heart attack. Which finding is the best indicator that a client is experiencing an acute myocardial infarction (AMI)?

7 :
While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

8 :
The client is a 35-year-old male with no history of any medical conditions presents to the clinic for an annual physical.

9 :
During an assessment for jugular vein distension of a client with right sided heart failure (HE), the nurse observes distension bilaterally using tangential lighting with the client in a semi-Fowler's position. Which action should the nurse take next?

10 :
When assessing a client's lower extremities, which finding requires immediate intervention by the nurse?