NSG 121 Health Assessment HESI
Final Exam, Hesi 1 and 2 Remediation
packages, NSG 261 Final HESI, Health
Assessment HESI Exam New update
Open Ended Question - Answer--When obtaining a nursing history, use the
open-ended question technique to allow the patient a wide range of possible
responses.
Interpreter - Answer--Person who can translate between languages.
For patients who do not speak English, use an interpreter whenever possible
Interrupting Client - Answer--Do not interrupt clients, in health care settings, it is
better to listen than to talk and to ask good questions rather than have all of the right
answers.
BMI Risk Assessment - Answer--An assessment of risk factors includes questions
about past medical and surgical histories, medication and supplement use, family
history, food and fluid intake patterns, and the patient's psychosocial profile
Low BMI - Answer--Below 18.5
Normal BMI - Answer--18.5-24.9
Nutritional Assessment - Answer--Risk factors to review in a nutritional assessment
include medical history, abnormal weight history, appetite or taste changes,
gastrointestinal symptoms, food allergies or intolerances, changes in eating or fluid
patterns, poor food habits, inability to cook, social isolation, multiple medications,
inappropriate supplements or lack of supplements, and alcohol or drug use.
Consider a board range of influences on patient's food choices
Mental Orientation - Answer--Person, Place, Time, Situation
CAGE - Answer--CAGE is a self report questionnaire used as an assessment tool for
drugs and alcohol. Yes to two or more of the questions indicate a potential problem
Cutdown,Annoyed,Guilty,Eye Opener
Abstract Thinking - Answer--Assessment of thought processes:
,Patient's thoughts are easy to follow, logical, coherent, relevant, goal directed,
consistent, and abstract
Abstract Thinking: Ability to understand concepts that are real
Referred Pain Appendicitis - Answer--Referred pain originates from a specific site,
but the person experiencing it feels the pain at another site along the innervating
spinal nerve
It will "refer" pain often to the mid upper abdomen, the epigastrum. Because the
appendix is a piece of intestine, it follows a similar referral pattern.
Nail Ridges in Geriatric Patients - Answer--Longitudinal ridging is common in aging
patients
Skin Turger Assessment - Answer--Assess skin turgor. Gently grasp a fold of the
patient's skin between your fingers and pull up, then release. Below clavicle
Tenting indicates dehydration, poor skin turgor is also associated with aging
Clubbing Oxygen Saturation - Answer--Clubbing of the nails indicates chronic
hypoxia. Clubbing is identified when the angle of the nail to the finger is more than
160º
Emphysema or congestive heart failure
Pallor Dark Skin - Answer--Normal skin color is pink, noting the usual undertones
present with even dark skin. The tongue, lips, nail beds, and buccal mucosa are less
pigmented areas and may be the best indicators of pallor or cyanosis. Patients with
darker skin may normally have hypopigmented skin on the palms and soles
Lesion Assessment & Primary vs. Secondary Lesion - Answer--Primary Lesion: arise
from previously normal skin
Secondary Lesion: follow primary lesions (scare tissue)
If observed, note the shape and measure the length, width, and depth with a ruler. If
a wound is deep or tunneled, insert a cotton applicator to measure depth.
Goiter Assessment - Answer--Palpation of Thyroid, Unilateral Bulging
Fall Assessment After a Fall - Answer--Falls or sudden jerking of the head and neck
(whiplash) are particularly likely to result in dislocation of the cervical vertebrae.
Fractures may also occur with headfirst falls. Any history of falls or sudden jerks of
the neck requires careful investigation.
Snellen Test - Answer--Tests for far vision & visual acuity.
Snellen test, measure and place a mark or piece of masking tape on the floor 6 m
(about 20 ft) from the chart
,Tinnitus - Answer--Tinnitus: buzzing or ringing in one or both ears that does not
correspond with external sound
Conductive Hearing Loss - Answer--BC that is longer than or the same as AC is
evidence of conductive hearing loss. Conductive hearing loss on one side may
indicate external or middle ear disease. Patients with conductive hearing loss should
have an assessment of the auricle and external auditory canal to look for blockage
Assessment of Mouth/Tongue - Answer--Holding a light in the nondominant hand
and a tongue blade in the dominant one, gently separate areas to fully inspect the
buccal mucosa, noting color and pigmentation
Small, isolated, white or yellow papules (Fordyce granules) may be noted on the
cheeks, tongue, and lips. These sebaceous cysts or salivary tissues are insignificant
Newborn Temperature - Answer--97.7 F to 98.6 F (36.5 C to 37 C)
Newborn Flaring Nares - Answer--Nasal flaring is a sign of respiratory distress
ADLs - Answer--Mobility impairments affecting activities of daily living (ADLs) and
instrumental activities of daily living (IADLs)
Carotene Rich Foods - Answer--The richest sources of beta-carotene are yellow,
orange, and green leafy fruits and vegetables (such as carrots, spinach, lettuce,
tomatoes, sweet potatoes, broccoli, cantaloupe, and winter squash). In general, the
more intense the color of the fruit or vegetable, the more beta-carotene it has
APGAR - Answer--1 min & 5 min
7-10 indicates vigorous newborn adapting well
If the 5-minute score is less than 7, continue to score every 5 minutes up to 20
minutes until the score is above 7, the newborn is intubated, or the newborn is
transferred to the nursery.
A score of 4-6 indicates the newborn is moderately depressed, and 0-3 indicates
severe respiratory depression and requires observation and care in a NICU.
Pregnancy Weight Gain - Answer--A simple rule of thumb for a woman of normal
prepregnant weight is that she will gain about 10 lb by 20 weeks and about 1 lb/week
for the remaining 20 weeks, for a total of 25-30 lb
Pregnancy Back Pain - Answer--Backache due to breast changes
Backaches are common during the second and third trimesters, partly from lumbar
lordosis of pregnancy and partly from poor back support when lifting or sleeping.
Increased weight from the fetus and breast tissue, with the accompanying change in
the center of gravity, places increased strain on the abdominal muscles. Teach the
pregnant woman exercises to strengthen her abdominal muscles (pelvic tilts), and
, suggest a support band, which may provide some relief. Increased levels of relaxin
loosen the cartilage between the pelvic bones, resulting in the characteristic
"waddling" gait of the third trimester.
Morning Sickness Help - Answer--Drinking ginger in water or tea can help decrease
nausea & vomiting
When does ovulation occur? - Answer--On average 28-day menstrual cycle,
ovulation occurs 14 days before the start of the next menstrual period.
Deep Tendon Reflexes Assessment - Answer--Deep Tendon Reflexes. DTRs tested
include biceps, triceps, brachioradialis, patellar, and Achilles
These reflexes are observed for symmetry when tested bilaterally and for briskness
of reflex movement. DTRs are graded on a scale of 0-4, with 0 representing absent
reflexes and 4 corresponding to significantly hyperactive responses.
4+—Very brisk, hyperactive with clonus
3+—Brisker than average
2+—Average, normal
1+—Diminished; low normal
0—No response
Temperature Tactile Differentiation - Answer--Temperature Sensation. Test
temperature sense only if pain or touch sensation is abnormal. Use one prong of a
tuning fork that has been warmed with the hands or use test tubes containing warm
and cold water. Ask the patient to close the eyes. Touch the skin with warm or cold
objects. Have the patient identify when he or she feels warm or cold.
Two Point Discrimination - Answer--Two-Point Discrimination. This test is done only if
other findings are abnormal. With the patient eyes open, demonstrate what the
cotton swabs feel like. Then ask the patient to close the eyes. Hold the blunt end of
two cotton swabs approximately 5 cm (2 in.) apart and move them together until the
patient feels them as one point (the ends of an opened paperclip may also be used)
Romberg Sign - Answer--In the Romberg test, ask the patient to stand with feet
together and arms at sides. Note any swaying (stand close enough to prevent the
patient from falling). Ask the patient to close the eyes during the Romberg test for
additional assessment. Slight swaying may be normal because visual cues help
humans to maintain balance
Stuporous Neurological Status - Answer--Patient is unresponsive and can be
aroused only briefly by vigorous, repeated stimulation.
Final Exam, Hesi 1 and 2 Remediation
packages, NSG 261 Final HESI, Health
Assessment HESI Exam New update
Open Ended Question - Answer--When obtaining a nursing history, use the
open-ended question technique to allow the patient a wide range of possible
responses.
Interpreter - Answer--Person who can translate between languages.
For patients who do not speak English, use an interpreter whenever possible
Interrupting Client - Answer--Do not interrupt clients, in health care settings, it is
better to listen than to talk and to ask good questions rather than have all of the right
answers.
BMI Risk Assessment - Answer--An assessment of risk factors includes questions
about past medical and surgical histories, medication and supplement use, family
history, food and fluid intake patterns, and the patient's psychosocial profile
Low BMI - Answer--Below 18.5
Normal BMI - Answer--18.5-24.9
Nutritional Assessment - Answer--Risk factors to review in a nutritional assessment
include medical history, abnormal weight history, appetite or taste changes,
gastrointestinal symptoms, food allergies or intolerances, changes in eating or fluid
patterns, poor food habits, inability to cook, social isolation, multiple medications,
inappropriate supplements or lack of supplements, and alcohol or drug use.
Consider a board range of influences on patient's food choices
Mental Orientation - Answer--Person, Place, Time, Situation
CAGE - Answer--CAGE is a self report questionnaire used as an assessment tool for
drugs and alcohol. Yes to two or more of the questions indicate a potential problem
Cutdown,Annoyed,Guilty,Eye Opener
Abstract Thinking - Answer--Assessment of thought processes:
,Patient's thoughts are easy to follow, logical, coherent, relevant, goal directed,
consistent, and abstract
Abstract Thinking: Ability to understand concepts that are real
Referred Pain Appendicitis - Answer--Referred pain originates from a specific site,
but the person experiencing it feels the pain at another site along the innervating
spinal nerve
It will "refer" pain often to the mid upper abdomen, the epigastrum. Because the
appendix is a piece of intestine, it follows a similar referral pattern.
Nail Ridges in Geriatric Patients - Answer--Longitudinal ridging is common in aging
patients
Skin Turger Assessment - Answer--Assess skin turgor. Gently grasp a fold of the
patient's skin between your fingers and pull up, then release. Below clavicle
Tenting indicates dehydration, poor skin turgor is also associated with aging
Clubbing Oxygen Saturation - Answer--Clubbing of the nails indicates chronic
hypoxia. Clubbing is identified when the angle of the nail to the finger is more than
160º
Emphysema or congestive heart failure
Pallor Dark Skin - Answer--Normal skin color is pink, noting the usual undertones
present with even dark skin. The tongue, lips, nail beds, and buccal mucosa are less
pigmented areas and may be the best indicators of pallor or cyanosis. Patients with
darker skin may normally have hypopigmented skin on the palms and soles
Lesion Assessment & Primary vs. Secondary Lesion - Answer--Primary Lesion: arise
from previously normal skin
Secondary Lesion: follow primary lesions (scare tissue)
If observed, note the shape and measure the length, width, and depth with a ruler. If
a wound is deep or tunneled, insert a cotton applicator to measure depth.
Goiter Assessment - Answer--Palpation of Thyroid, Unilateral Bulging
Fall Assessment After a Fall - Answer--Falls or sudden jerking of the head and neck
(whiplash) are particularly likely to result in dislocation of the cervical vertebrae.
Fractures may also occur with headfirst falls. Any history of falls or sudden jerks of
the neck requires careful investigation.
Snellen Test - Answer--Tests for far vision & visual acuity.
Snellen test, measure and place a mark or piece of masking tape on the floor 6 m
(about 20 ft) from the chart
,Tinnitus - Answer--Tinnitus: buzzing or ringing in one or both ears that does not
correspond with external sound
Conductive Hearing Loss - Answer--BC that is longer than or the same as AC is
evidence of conductive hearing loss. Conductive hearing loss on one side may
indicate external or middle ear disease. Patients with conductive hearing loss should
have an assessment of the auricle and external auditory canal to look for blockage
Assessment of Mouth/Tongue - Answer--Holding a light in the nondominant hand
and a tongue blade in the dominant one, gently separate areas to fully inspect the
buccal mucosa, noting color and pigmentation
Small, isolated, white or yellow papules (Fordyce granules) may be noted on the
cheeks, tongue, and lips. These sebaceous cysts or salivary tissues are insignificant
Newborn Temperature - Answer--97.7 F to 98.6 F (36.5 C to 37 C)
Newborn Flaring Nares - Answer--Nasal flaring is a sign of respiratory distress
ADLs - Answer--Mobility impairments affecting activities of daily living (ADLs) and
instrumental activities of daily living (IADLs)
Carotene Rich Foods - Answer--The richest sources of beta-carotene are yellow,
orange, and green leafy fruits and vegetables (such as carrots, spinach, lettuce,
tomatoes, sweet potatoes, broccoli, cantaloupe, and winter squash). In general, the
more intense the color of the fruit or vegetable, the more beta-carotene it has
APGAR - Answer--1 min & 5 min
7-10 indicates vigorous newborn adapting well
If the 5-minute score is less than 7, continue to score every 5 minutes up to 20
minutes until the score is above 7, the newborn is intubated, or the newborn is
transferred to the nursery.
A score of 4-6 indicates the newborn is moderately depressed, and 0-3 indicates
severe respiratory depression and requires observation and care in a NICU.
Pregnancy Weight Gain - Answer--A simple rule of thumb for a woman of normal
prepregnant weight is that she will gain about 10 lb by 20 weeks and about 1 lb/week
for the remaining 20 weeks, for a total of 25-30 lb
Pregnancy Back Pain - Answer--Backache due to breast changes
Backaches are common during the second and third trimesters, partly from lumbar
lordosis of pregnancy and partly from poor back support when lifting or sleeping.
Increased weight from the fetus and breast tissue, with the accompanying change in
the center of gravity, places increased strain on the abdominal muscles. Teach the
pregnant woman exercises to strengthen her abdominal muscles (pelvic tilts), and
, suggest a support band, which may provide some relief. Increased levels of relaxin
loosen the cartilage between the pelvic bones, resulting in the characteristic
"waddling" gait of the third trimester.
Morning Sickness Help - Answer--Drinking ginger in water or tea can help decrease
nausea & vomiting
When does ovulation occur? - Answer--On average 28-day menstrual cycle,
ovulation occurs 14 days before the start of the next menstrual period.
Deep Tendon Reflexes Assessment - Answer--Deep Tendon Reflexes. DTRs tested
include biceps, triceps, brachioradialis, patellar, and Achilles
These reflexes are observed for symmetry when tested bilaterally and for briskness
of reflex movement. DTRs are graded on a scale of 0-4, with 0 representing absent
reflexes and 4 corresponding to significantly hyperactive responses.
4+—Very brisk, hyperactive with clonus
3+—Brisker than average
2+—Average, normal
1+—Diminished; low normal
0—No response
Temperature Tactile Differentiation - Answer--Temperature Sensation. Test
temperature sense only if pain or touch sensation is abnormal. Use one prong of a
tuning fork that has been warmed with the hands or use test tubes containing warm
and cold water. Ask the patient to close the eyes. Touch the skin with warm or cold
objects. Have the patient identify when he or she feels warm or cold.
Two Point Discrimination - Answer--Two-Point Discrimination. This test is done only if
other findings are abnormal. With the patient eyes open, demonstrate what the
cotton swabs feel like. Then ask the patient to close the eyes. Hold the blunt end of
two cotton swabs approximately 5 cm (2 in.) apart and move them together until the
patient feels them as one point (the ends of an opened paperclip may also be used)
Romberg Sign - Answer--In the Romberg test, ask the patient to stand with feet
together and arms at sides. Note any swaying (stand close enough to prevent the
patient from falling). Ask the patient to close the eyes during the Romberg test for
additional assessment. Slight swaying may be normal because visual cues help
humans to maintain balance
Stuporous Neurological Status - Answer--Patient is unresponsive and can be
aroused only briefly by vigorous, repeated stimulation.
