HESI Health Assessment
1280 Questions From Exams
With Verified Answers
,When evaluating the temperature of older adults, the nurse should
remember which aspect about an older adult's body temperature?
Fever is a reliable sign of infection in older adults.
The older adult's body temperature varies widely because of the thinner
subcutaneous layer.
There are no differences in temperature between a young and old adult.
Older adults body temperature runs lower than that of an adult. - ans D
Which error may result in a falsely low blood pressure (BP) reading?
The patient has a full bladder.
The arm is held above the level of the heart.
The cuff size is too small for the client.
The BP cuff is wrapped loosely around the arm. - ans B- at heart level
During a general survey of a post-operative patient, the nurse notes that
the patient's eyes are closed but they temporarily open with loud verbal
stimulus and a gentle shake to the shoulder. The nurse documents his level
of consciousness as:
Alert.
Somnolent.
Stuporous.
,Obtunded. - ans D
A 46-year-old male presents to the Emergency Department with syncope.
He says his cardiologist recently placed him on a new medication for his
blood pressure (BP). What should the nurse do first?
Obtain orthostatic vital signs.
Educate the patient on homeopathic methods to control his BP.
Administer a fluid bolus.
Advise the patient to stop taking this medication. - ans A
As a mandatory reporter, the nurse notifies the authorities with which of
the following?
Suspicion of child or elder abuse/neglect.
Proof of substance abuse in minors.
Any bruising on a child or older adult.
Proof of intimate partner violence. - ans A
A 50 year-old patient is in the intensive care unit (ICU) with septic shock.
The nurse receives an order to notify the provider if the patient's mean
arterial pressure (MAP) is <60 mmHg. What does the nurse understand to
be true?
A MAP >60 is needed to maintain adequate tissue perfusion.
, MAP can only be obtained by using a noninvasive blood pressure (NIBP)
monitor.
MAP is the average of the systolic and diastolic pressures.
A MAP of 40-60 mmHg indicates that the stroke volume is adequate. - ans
A
The nurse is caring for a patient with chronic lower back pain. The nurse
knows that the most reliable indicator of pain in this client is:
The patient is reporting "6/10" pain.
The patient is refusing to get out of bed.
The patient is refusing to eat breakfast.
The patient's heart rate is 90 beats per minute. - ans A
Which of the following actions should the nurse take to ensure an accurate
blood pressure (BP) reading?
Ensure the width of the BP cuff is equal to 80% of the arm circumference.
Ensure the client's back is supported and feet are flat on the ground.
Take two BP readings 20 seconds apart.
Ensure that the patient's arm is above heart level. - ans B
The patient's arm should be supported at heart level. Separate BP readings
may need to be taken, but not one right after the other. The length of the BP
bladder should equal 80% of the arm circumferen
1280 Questions From Exams
With Verified Answers
,When evaluating the temperature of older adults, the nurse should
remember which aspect about an older adult's body temperature?
Fever is a reliable sign of infection in older adults.
The older adult's body temperature varies widely because of the thinner
subcutaneous layer.
There are no differences in temperature between a young and old adult.
Older adults body temperature runs lower than that of an adult. - ans D
Which error may result in a falsely low blood pressure (BP) reading?
The patient has a full bladder.
The arm is held above the level of the heart.
The cuff size is too small for the client.
The BP cuff is wrapped loosely around the arm. - ans B- at heart level
During a general survey of a post-operative patient, the nurse notes that
the patient's eyes are closed but they temporarily open with loud verbal
stimulus and a gentle shake to the shoulder. The nurse documents his level
of consciousness as:
Alert.
Somnolent.
Stuporous.
,Obtunded. - ans D
A 46-year-old male presents to the Emergency Department with syncope.
He says his cardiologist recently placed him on a new medication for his
blood pressure (BP). What should the nurse do first?
Obtain orthostatic vital signs.
Educate the patient on homeopathic methods to control his BP.
Administer a fluid bolus.
Advise the patient to stop taking this medication. - ans A
As a mandatory reporter, the nurse notifies the authorities with which of
the following?
Suspicion of child or elder abuse/neglect.
Proof of substance abuse in minors.
Any bruising on a child or older adult.
Proof of intimate partner violence. - ans A
A 50 year-old patient is in the intensive care unit (ICU) with septic shock.
The nurse receives an order to notify the provider if the patient's mean
arterial pressure (MAP) is <60 mmHg. What does the nurse understand to
be true?
A MAP >60 is needed to maintain adequate tissue perfusion.
, MAP can only be obtained by using a noninvasive blood pressure (NIBP)
monitor.
MAP is the average of the systolic and diastolic pressures.
A MAP of 40-60 mmHg indicates that the stroke volume is adequate. - ans
A
The nurse is caring for a patient with chronic lower back pain. The nurse
knows that the most reliable indicator of pain in this client is:
The patient is reporting "6/10" pain.
The patient is refusing to get out of bed.
The patient is refusing to eat breakfast.
The patient's heart rate is 90 beats per minute. - ans A
Which of the following actions should the nurse take to ensure an accurate
blood pressure (BP) reading?
Ensure the width of the BP cuff is equal to 80% of the arm circumference.
Ensure the client's back is supported and feet are flat on the ground.
Take two BP readings 20 seconds apart.
Ensure that the patient's arm is above heart level. - ans B
The patient's arm should be supported at heart level. Separate BP readings
may need to be taken, but not one right after the other. The length of the BP
bladder should equal 80% of the arm circumferen
