Hesi Rn Fundamental NSG | Comprehensive Coverage | Detailed Answer Keys | Flexible Learning | Your Path to NCLEX Success
Nursing Certifications
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The nurse asks a 50-year-old female client what her natural hair color is. The client replies, "I've been dyeing my hair for so long, I'm not even sure ... I just know that this month it's ravishing red." Based on this information, the nurse expects to obtain which finding when palpating this client's scalp hair?
Coarse, dry, brittle texture.
Excess vellus hair.
Fine, thin, limp texture.
Receding front hairline.
Correct Answer:
A. Coarse, dry, brittle texture.
Explanation
Frequent hair dyeing, especially with permanent dyes, can damage the hair shaft, leading to a coarse, dry, and brittle texture. Chemical treatments strip natural oils and can weaken the hair structure over time, making this the expected finding on palpation.
Why the other options are incorrect:
B. Excess vellus hair. Vellus hair is soft, fine, and lightly pigmented hair typically found on much of the body, not the scalp. Dyeing does not cause an increase in vellus hair, making this unrelated.
C. Fine, thin, limp texture. While some people naturally have fine or thin hair, dyeing typically makes hair more brittle rather than making it fine or limp. This option does not align with the expected result of frequent dyeing.
D. Receding front hairline. Hair dyeing alone does not generally cause a receding hairline. A receding hairline is more commonly associated with genetic factors, androgenic alopecia, or hormonal changes, not chemical hair treatment
During a routine physical examination of a middle-aged female client, chest palpation is determined to be normal except for a 2-inch diameter area of crepitus over the upper right anterior chest. Which is the most accurate interpretation of this finding?
Trapped subcutaneous air causing crepitus will be absorbed, so the finding is not significant.
Crepitus is always abnormal and should be followed up with a more detailed assessment.
Since this client has only a small area of crepitus, it probably is not a significant finding.
Since a fractured rib often creates crepitus, a chest x-ray should be scheduled immediately.
Correct Answer:
B. Crepitus is always abnormal and should be followed up with a more detailed assessment.
Explanation:
Crepitus, which refers to a crackling or popping sensation felt under the skin, often indicates the presence of air or gas under the skin, typically due to trauma or an underlying injury. It is never considered normal and warrants further investigation. In this case, even though the crepitus is localized to a small area, it is an abnormal finding that should not be ignored. The most likely cause could be subcutaneous emphysema, which can occur due to trauma (such as rib fractures, lung injury, or a surgical procedure) or infection. A more detailed assessment and imaging (such as a chest x-ray or CT scan) are needed to determine the cause and extent of the issue.
Why the Other Options are Incorrect:
A. Trapped subcutaneous air causing crepitus will be absorbed, so the finding is not significant: While subcutaneous air from trauma or other causes may eventually be reabsorbed by the body, it is not safe to assume that the finding is not significant without further evaluation. Crepitus should always be investigated to rule out potential serious underlying conditions, such as fractures, pneumothorax, or infections.
C. Since this client has only a small area of crepitus, it probably is not a significant finding: Size does not dictate the seriousness of the condition. Even a small area of crepitus could signal a potentially serious issue, such as a rib fracture or lung injury. Further assessment is needed to determine the cause.
D. Since a fractured rib often creates crepitus, a chest x-ray should be scheduled immediately: While a fractured rib can create crepitus, this is not the only possible cause, and a chest x-ray should be considered based on the full clinical picture. Further evaluation should be done to assess whether a rib fracture, pneumothorax, or another issue is present. However, a chest x-ray would be part of a more comprehensive assessment following the recognition of an abnormal finding like crepitus.
During an assessment for jugular vein distension of a client with right sided heart failure (HF), the nurse observes distension bilaterally using tangential lighting with the client in a semi-Fowler's position. Which action should the nurse take next?
Flex the client's neck with a pillow and repeat assessment.
Repeat without using the lighting.
Document the findings as observed.
Position the client supine and repeat the assessment.
Correct Answer:
C. Document the findings as observed.
Explanation:
If the nurse observes jugular vein distension (JVD) in the semi-Fowler's position using tangential lighting, and it is clear and consistent with the signs of right-sided heart failure (HF), the findings should be documented. JVD is a key indicator of increased central venous pressure, which is commonly seen in clients with right-sided heart failure. Since the assessment has already been performed correctly with the use of tangential lighting, and the client is in a semi-Fowler's position (which is typically sufficient for assessing JVD), the nurse can document the findings as observed.
Why the Other Options are Incorrect:
A. Flexing the client's neck with a pillow and repeating the assessment is unnecessary unless there is a need for a further change in the client’s position to provide better visualization. The semi-Fowler's position is generally sufficient for assessing JVD.
B. Repeating without using the lighting is unnecessary. Tangential lighting helps the nurse to clearly see the veins and is a valuable tool for assessing JVD. It should be used effectively to ensure an accurate evaluation.
D. Positioning the client supine may not be necessary if the JVD is already visible in the semi-Fowler’s position. While supine positioning can sometimes provide clearer visualization, the semi-Fowler’s position is often sufficient to assess for JVD.
The nurse is performing a cranial nerve exam on an older adult client. The nurse notes that the client has a reduced upward gaze, a decreased corneal reflex, a high-frequency hearing loss, and a reduced gag reflex. Which action should the nurse take next?
Continue the assessment of the next pairs of cranial nerves.
Implement neurological (neuro) vital signs every 2 hours to detect Cushing's triad.
Review past history for any episodes of a cerebral cortex lesion.
Assess the spinal reflexes for demyelination symptoms.
Correct Answer:
A. Continue the assessment of the next pairs of cranial nerves.
Explanation:
In this scenario, the nurse has observed several age-related changes that affect the cranial nerves. A reduced upward gaze, decreased corneal reflex, high-frequency hearing loss, and a reduced gag reflex are common findings in older adults due to natural aging processes, such as the slowing of neural conduction and changes in sensory functions. These findings do not necessarily suggest a serious neurological issue but should be noted. Therefore, the best action is to continue with the cranial nerve exam to complete the assessment of all 12 cranial nerves. The findings might be part of normal aging, but a comprehensive exam will help confirm that.
Why the Other Options Are Incorrect:
B. Implement neurological (neuro) vital signs every 2 hours to detect Cushing's triad:
Cushing's triad is a clinical syndrome that includes hypertension, bradycardia, and irregular respirations, and is often seen with increased intracranial pressure (ICP). The symptoms described here (reduced upward gaze, decreased corneal reflex, etc.) do not suggest ICP or Cushing's triad. Therefore, regular neuro vital signs every 2 hours are not warranted in this case.
C. Review past history for any episodes of a cerebral cortex lesion:
While it's always important to review the client's medical history, the symptoms described are more indicative of age-related changes than a cerebral cortex lesion. A lesion of the cerebral cortex would likely cause more pronounced neurological deficits, such as motor or sensory abnormalities, cognitive impairments, or severe deficits in cranial nerve function. Given that the client is older, it is more reasonable to consider these findings as part of the normal aging process.
D. Assess the spinal reflexes for demyelination symptoms:
Demyelination typically affects the spinal cord or peripheral nervous system and presents with more significant motor deficits, sensory loss, and other neurologic abnormalities. The symptoms presented here (reduced upward gaze, decreased corneal reflex, etc.) are more likely related to age-related changes rather than demyelination. This makes spinal reflex assessment unnecessary at this point.
A client tells the nurse how they hate the way their boss orders them around and never listens to their suggestions. Which response is best for the nurse to provide?
"Why do you allow your boss to get you so upset?"
"How do you feel when your boss does not listen to your suggestions?"
"Maybe you should use a different approach with your boss."
"It must be difficult for you to work in a situation that makes you feel so unhappy."
Correct Answer:
"How do you feel when your boss does not listen to your suggestions?"
Explanation:
This is the best therapeutic communication response because it invites the client to express their feelings in a nonjudgmental, open-ended way. It facilitates emotional exploration, which is key in helping the client process their experience.
Why Other Options are Wrong:
"Why do you allow your boss to get you so upset?"
This sounds accusatory and places blame on the client, which can make them defensive rather than supported.
"Maybe you should use a different approach with your boss."
This shifts too quickly into problem-solving without first validating the client’s emotions, which can feel dismissive.
"It must be difficult for you to work in a situation that makes you feel so unhappy."
While empathetic, this is more of a reflective statement. It doesn’t open up the conversation as effectively as asking how the client feels, which promotes deeper communication.
To assess a client’s dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes, but does not feel a pulsation. Which action should the nurse take next?
Document in the nurses’ notes that the dorsalis pedis pulse is not palpable.
Reduce the amount of pressure being applied on the top of the foot.
Obtain a doppler stethoscope to auscultate the pulse at the same site.
Palpate the site on the inner side of the ankle below the medial malleolus.
Correct Answer:
Reduce the amount of pressure being applied on the top of the foot.
Explanation:
Using excessive pressure can occlude a weak pulse, making it unpalpable even if it is present. Reducing the pressure allows the nurse to better assess whether the dorsalis pedis pulse can be felt. This is a simple correction before proceeding to more invasive or advanced interventions.
Why Other Options are Wrong:
Document in the nurses’ notes that the dorsalis pedis pulse is not palpable.
This should not be done until the nurse has confirmed using proper technique. If the pressure was too firm, the pulse might still be present and detectable with correct palpation.
Obtain a doppler stethoscope to auscultate the pulse at the same site.
Using a Doppler is appropriate when a pulse is not palpable after ensuring correct technique. It is not the immediate next step—first, the nurse should reassess using less pressure.
Palpate the site on the inner side of the ankle below the medial malleolus.
This would assess the posterior tibial pulse, not the dorsalis pedis. While useful, it does not resolve whether the dorsalis pedis pulse is absent or just missed due to excessive pressure.
The nurse is completing an assessment for a client with uncontrolled diabetes mellitus (DM) who came to the clinic reporting frequent, painful urination. Which screening test should the nurse perform first?
Urine dipstick test
Nitazine pH strip
Rapid strep test
Fingerstick glucose
Correct Answer:
A. Urine dipstick test
Explanation:
Frequent, painful urination is a classic symptom of a urinary tract infection (UTI). Individuals with uncontrolled diabetes are at increased risk for UTIs due to high blood glucose levels, which can promote bacterial growth. A urine dipstick test is a quick, non-invasive screening tool used to detect leukocytes, nitrites, blood, and glucose in the urine—markers that can indicate infection or other abnormalities. This is the most appropriate initial test in this scenario to confirm or rule out a UTI.
Why the Other Options are Incorrect:
B. Nitazine pH strip is used to detect amniotic fluid in cases of suspected rupture of membranes in pregnancy, not for assessing urinary symptoms.
C. Rapid strep test screens for streptococcal pharyngitis, which is unrelated to urinary symptoms.
D. Fingerstick glucose is relevant for monitoring diabetes but does not address the acute urinary symptoms the client is currently experiencing.
The nurse is providing teaching to a client who receives a new medication prescription. Which action should the nurse use to evaluate the client’s understanding?
Inquire about frequency of administration.
Recognize sources of confusion for the client.
Ask the client for any additional questions.
Demonstrate how the medication will be taken.
Correct Answer:
Demonstrate how the medication will be taken.
Explanation:
The best way to evaluate a client's understanding is through the teach-back method or demonstration. When the client shows how they will take the medication, it gives the nurse a clear, observable indication of whether they grasp the correct procedure, timing, and technique.
Why Other Options are Wrong:
Inquire about frequency of administration.
This assesses what the client remembers but does not fully verify comprehensive understanding or practical application.
Recognize sources of confusion for the client.
This is a proactive teaching approach, but it doesn’t directly evaluate understanding. It’s useful before or during teaching, not as an assessment tool afterward.
Ask the client for any additional questions.
Encouraging questions is good communication but does not confirm whether the client has understood the medication instructions properly.
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?
Measure degree of skin elasticity.
Obtain vital signs and oxygen saturation.
Compare muscle strength bilaterally.
Calculate the body mass index (BMI).
Correct Answer:
C. Compare muscle strength bilaterally.
Explanation:
To gather additional data about the muscular atrophy observed in the right thigh and calf, the nurse should compare muscle strength bilaterally. This will help determine whether the muscle weakness or atrophy is limited to the right side or if there is also weakness or atrophy on the left side. A difference in strength between the two sides can give insight into the severity of the muscle loss and help differentiate between causes, such as neurological issues or local muscular problems.
Why the Other Options are Incorrect:
A. Measure degree of skin elasticity: Skin elasticity may be useful in evaluating hydration status or skin condition but does not provide information about muscular atrophy or muscle strength, which is the primary concern in this scenario.
B. Obtain vital signs and oxygen saturation: While vital signs and oxygen saturation are important in assessing overall health, they do not directly assess the extent or cause of muscle atrophy. They are not helpful for understanding the specific issue of muscular atrophy.
D. Calculate the body mass index (BMI): BMI is a general measurement used to assess overall body weight in relation to height. Although it may provide insight into overall health and nutritional status, it does not give specific information about muscle mass or muscle strength. Therefore, it is not the most relevant action to take in this case.
The nurse is caring for a client in the postanesthesia care unit (PACU). To assess the quality of the client’s pain, which approach should the nurse use?
Provide a numeric pain scale.
Observe body language and movement.
Identify effective pain relief measures.
Ask the client to describe the pain.
Correct Answer:
Ask the client to describe the pain.
Explanation:
Assessing quality of pain involves descriptive terms like "burning," "stabbing," "throbbing," or "aching." The only way to gather this information is by asking the client directly to describe what the pain feels like, making this the most accurate method to assess pain quality.
Why Other Options are Wrong:
Provide a numeric pain scale.
This assesses intensity, not quality, of pain.
Observe body language and movement.
This is useful for clients unable to verbalize pain, but it provides indirect signs—not a description of pain quality.
Identify effective pain relief measures.
This helps guide treatment but does not assess or clarify what the pain actually feels like to the client.
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