NSG 121 Health Assessment HESI Final
Exam, Hesi 1 and 2 Remediation
packages, NSG 261 Final HESI, Health
Assessment HESI Exam latest review
Open Ended Question - ANS When obtaining a nursing history, use the open-ended question
technique to allow the patient a wide range of possible responses.
Interpreter - ANS Person who can translate between languages.
For patients who do not speak English, use an interpreter whenever possible
Interrupting Client - ANS 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 - ANS 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 - ANS Below 18.5
Normal BMI - ANS 18.5-24.9
Nutritional Assessment - ANS 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 - ANS Person, Place, Time, Situation
CAGE - ANS 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 - ANS 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 - ANS 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 - ANS Longitudinal ridging is common in aging patients
Skin Turger Assessment - ANS 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 - ANS 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 - ANS 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 - ANS 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 - ANS Palpation of Thyroid, Unilateral Bulging
Fall Assessment After a Fall - ANS 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 - ANS 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 - ANS Tinnitus: buzzing or ringing in one or both ears that does not correspond with
external sound
Conductive Hearing Loss - ANS 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 - ANS 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 - ANS 97.7 F to 98.6 F (36.5 C to 37 C)
Newborn Flaring Nares - ANS Nasal flaring is a sign of respiratory distress
ADLs - ANS Mobility impairments affecting activities of daily living (ADLs) and instrumental
activities of daily living (IADLs)
Carotene Rich Foods - ANS 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 - ANS 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 - ANS 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 - ANS 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 - ANS Drinking ginger in water or tea can help decrease nausea &
vomiting
, When does ovulation occur? - ANS On average 28-day menstrual cycle, ovulation occurs 14
days before the start of the next menstrual period.
Deep Tendon Reflexes Assessment - ANS 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 - ANS 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 - ANS 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 - ANS 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 - ANS Patient is unresponsive and can be aroused only briefly
by vigorous, repeated stimulation.
Neurological Assessment LOC - ANS Spontaneous, Normal Voice, Loud Voice, Tactile,
Noxious (pain)
Heberden's Nodes - ANS Outgrowths that are boney and found on the hands are due to bone
spur formation
Heberden's Node (most common): found on the distal interphalangeal joint (joint closest to the
finger nail)
Exam, Hesi 1 and 2 Remediation
packages, NSG 261 Final HESI, Health
Assessment HESI Exam latest review
Open Ended Question - ANS When obtaining a nursing history, use the open-ended question
technique to allow the patient a wide range of possible responses.
Interpreter - ANS Person who can translate between languages.
For patients who do not speak English, use an interpreter whenever possible
Interrupting Client - ANS 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 - ANS 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 - ANS Below 18.5
Normal BMI - ANS 18.5-24.9
Nutritional Assessment - ANS 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 - ANS Person, Place, Time, Situation
CAGE - ANS 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 - ANS 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 - ANS 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 - ANS Longitudinal ridging is common in aging patients
Skin Turger Assessment - ANS 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 - ANS 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 - ANS 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 - ANS 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 - ANS Palpation of Thyroid, Unilateral Bulging
Fall Assessment After a Fall - ANS 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 - ANS 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 - ANS Tinnitus: buzzing or ringing in one or both ears that does not correspond with
external sound
Conductive Hearing Loss - ANS 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 - ANS 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 - ANS 97.7 F to 98.6 F (36.5 C to 37 C)
Newborn Flaring Nares - ANS Nasal flaring is a sign of respiratory distress
ADLs - ANS Mobility impairments affecting activities of daily living (ADLs) and instrumental
activities of daily living (IADLs)
Carotene Rich Foods - ANS 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 - ANS 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 - ANS 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 - ANS 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 - ANS Drinking ginger in water or tea can help decrease nausea &
vomiting
, When does ovulation occur? - ANS On average 28-day menstrual cycle, ovulation occurs 14
days before the start of the next menstrual period.
Deep Tendon Reflexes Assessment - ANS 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 - ANS 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 - ANS 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 - ANS 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 - ANS Patient is unresponsive and can be aroused only briefly
by vigorous, repeated stimulation.
Neurological Assessment LOC - ANS Spontaneous, Normal Voice, Loud Voice, Tactile,
Noxious (pain)
Heberden's Nodes - ANS Outgrowths that are boney and found on the hands are due to bone
spur formation
Heberden's Node (most common): found on the distal interphalangeal joint (joint closest to the
finger nail)
