ATI HESI Health Assessment 2024 QUESTIONS AND ANSWERS RATED & GRADED A+ BY EXPERTS 100% CORRECT

are under tension, such as in intestinal obstruction. Therefore, options 2, 3, and 4 are incorrect.

The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation?

A. An involuntary rhythmic, rapid twitching of the eyeballs.
B. A dorsiflexion of the ankle and great toe with fanning of the other toes.
C. A significant sway when the client stands erect with feet together, arms at the side and the eyes closed.
D. A lack of sense of position when the client is unable to return extended fingers to a point of reference.
- ANSWER>>Correct Answer: C

Rationale:In Romberg's test, the client is asked to stand with the feet together and the arms at the sides, and to close the eyes and hold the position; normally the client can maintain posture and balance. A positive Romberg's sign is a vestibular neurological sign that is found when a client exhibits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A lack of normal sense of position coupled with an inability to return extended fingers to a point of reference is a finding that indicates a problem with coordination. A positive gaze nystagmus evaluation results in an involuntary rhythmic, rapid twitching of the eyeballs. A positive Babinski's test results in dorsiflexion of the ankle and great toe with fanning of the other toes; if this occurs in anyone older than 2 years, it indicates the presence of central nervous system disease.

A client with pneumonia is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history?

A.Focus only on the physical assessment.
B.Obtain all history information from the family members.
C.Plan short sessions with the client to obtain data.
D.Use the primary healthcare provider's medical history.
- ANSWER>>Correct Answer: C

Rationale:The best source of information is the client. Option 1 is incorrect; the physical examination is not part of the health history. Option 2 is incorrect because it refers to all information. Option 4 is incorrect because the primary health care provider's medical history provides data that are different from the nurse's assessment. All efforts need to be made to obtain as much information as possible from the client, using short sessions and closed-ended questions.

The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?

A.The client rigidly extends the arms with pronated forearms and plantar flexion of the feet.
B.The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended.
C.The client passively flexes his hip and knee in response to neck flexion and reports pain in the vertebral column.
D.The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.
- ANSWER>>Correct Answer:C