2020/2021 HESI HEALTH ASSESSMENT NURSING RN V1 100(Q&A)
• During a mental status examination, the nurse wants to assess a patient’s affect. The
nurse should askthe patient which question?
“How do you feel today?”
• The nurse is planning to assess new memory with a patient. The best way for the nurse
to do thiswould be to:
Give him the Four Unrelated Words Test.
• A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four
UnrelatedWords Test, the nurse would be concerned if she could not four
unrelated words .
Recall; after a 30-minute delay
• During a mental status assessment, which question by the nurse would best assess
a person’sjudgment?
“Tell me what you plan to do once you are discharged from the hospital.”
• Which of these individuals would the nurse consider at highest risk for a suicide attempt?
Older adult man who tells the nurse that he is going to “join his wife in heaven” tomorrow
andplans to use a gun
• When reviewing the use of alcohol by older adults, the nurse notes that older adults
have severalcharacteristics that can increase the risk of alcohol use. Which would increase
the bioavailability of alcohol in the blood for longer periods in the older adult?
Decreased liver and kidney functioning
• During an assessment, the nurse asks a female patient, “How many alcoholic drinks do
you have aweek?” Which answer by the patient would indicate at-risk drinking?
“I have seven or eight drinks a week, but I never get drunk.”
• The nurse is asking an adolescent about illicit substance abuse. The adolescent
answers, “Yes, I’veused marijuana at parties with my friends.” What is the next question
the nurse should ask?
“When was the last time you used marijuana?”
, • The nurse has completed an assessment on a patient who came to the clinic for a leg injury. As
a result of the assessment, the nurse has determined that the patient has at-risk alcohol use.
Which actionby the nurse is most appropriate at this time?
State, “You are drinking more than is medically safe. I strongly recommend that you
quitdrinking, and I’m willing to help you.”
• A patient is brought to the emergency department. He is restless, has dilated pupils, is
sweating, hasa runny nose and tearing eyes, and complains of muscle and joint pains. His
girlfriend thinks he has influenza, but she became concerned when his temperature went up to
39.4° C. She admits that he has been a heavy drug user, but he has been trying to stop on his
own. The nurse suspects that the patient isexperiencing withdrawal symptoms from which
substance?
Heroin
• Patient taking ipratropium reports nausea, blurred vision, has, insomnia after using
the inhaler. RNaction to implement
- withhold med and report symptoms
• A patient has suddenly developed shortness of breath and appears to be in significant
respiratory distress. After calling the physician and placing the patient on oxygen, which of
these actions is the bestfor the nurse to take when further assessing the patient?
Bilaterally percuss the thorax, noting any differences in percussion tones.
• The nurse is teaching a class on basic assessment skills. Which of these statements is
true regardingthe stethoscope and its use?
Although the stethoscope does not magnify sound, it does block out extraneous room
noise.
• The nurse is preparing to use a stethoscope for auscultation. Which statement is
true regarding thediaphragm of the stethoscope? The diaphragm:
Is used to listen for high-pitched sounds.
• Before auscultating the abdomen for the presence of bowel sounds on a patient, the
nurse should:
Check the temperature of the room, and offer blankets to the patient if he or she feels cold.
• While measuring a patient’s blood pressure, the nurse recalls that certain factors, such as
, help determine blood pressure.
Peripheral vascular resistance
• A nurse is helping at a health fair at a local mall. When taking blood pressures on a variety
of people,the nurse keeps in mind that:
• During a mental status examination, the nurse wants to assess a patient’s affect. The
nurse should askthe patient which question?
“How do you feel today?”
• The nurse is planning to assess new memory with a patient. The best way for the nurse
to do thiswould be to:
Give him the Four Unrelated Words Test.
• A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four
UnrelatedWords Test, the nurse would be concerned if she could not four
unrelated words .
Recall; after a 30-minute delay
• During a mental status assessment, which question by the nurse would best assess
a person’sjudgment?
“Tell me what you plan to do once you are discharged from the hospital.”
• Which of these individuals would the nurse consider at highest risk for a suicide attempt?
Older adult man who tells the nurse that he is going to “join his wife in heaven” tomorrow
andplans to use a gun
• When reviewing the use of alcohol by older adults, the nurse notes that older adults
have severalcharacteristics that can increase the risk of alcohol use. Which would increase
the bioavailability of alcohol in the blood for longer periods in the older adult?
Decreased liver and kidney functioning
• During an assessment, the nurse asks a female patient, “How many alcoholic drinks do
you have aweek?” Which answer by the patient would indicate at-risk drinking?
“I have seven or eight drinks a week, but I never get drunk.”
• The nurse is asking an adolescent about illicit substance abuse. The adolescent
answers, “Yes, I’veused marijuana at parties with my friends.” What is the next question
the nurse should ask?
“When was the last time you used marijuana?”
, • The nurse has completed an assessment on a patient who came to the clinic for a leg injury. As
a result of the assessment, the nurse has determined that the patient has at-risk alcohol use.
Which actionby the nurse is most appropriate at this time?
State, “You are drinking more than is medically safe. I strongly recommend that you
quitdrinking, and I’m willing to help you.”
• A patient is brought to the emergency department. He is restless, has dilated pupils, is
sweating, hasa runny nose and tearing eyes, and complains of muscle and joint pains. His
girlfriend thinks he has influenza, but she became concerned when his temperature went up to
39.4° C. She admits that he has been a heavy drug user, but he has been trying to stop on his
own. The nurse suspects that the patient isexperiencing withdrawal symptoms from which
substance?
Heroin
• Patient taking ipratropium reports nausea, blurred vision, has, insomnia after using
the inhaler. RNaction to implement
- withhold med and report symptoms
• A patient has suddenly developed shortness of breath and appears to be in significant
respiratory distress. After calling the physician and placing the patient on oxygen, which of
these actions is the bestfor the nurse to take when further assessing the patient?
Bilaterally percuss the thorax, noting any differences in percussion tones.
• The nurse is teaching a class on basic assessment skills. Which of these statements is
true regardingthe stethoscope and its use?
Although the stethoscope does not magnify sound, it does block out extraneous room
noise.
• The nurse is preparing to use a stethoscope for auscultation. Which statement is
true regarding thediaphragm of the stethoscope? The diaphragm:
Is used to listen for high-pitched sounds.
• Before auscultating the abdomen for the presence of bowel sounds on a patient, the
nurse should:
Check the temperature of the room, and offer blankets to the patient if he or she feels cold.
• While measuring a patient’s blood pressure, the nurse recalls that certain factors, such as
, help determine blood pressure.
Peripheral vascular resistance
• A nurse is helping at a health fair at a local mall. When taking blood pressures on a variety
of people,the nurse keeps in mind that:
