HESI HEALTH ASSESSMENT EXAM VERSION 3
COMPLETE EXAM QUESTIONS ANDCORRECT DETAILED
ANSWERS AGRADE
What is gamma globulin and when is it used? - ANSWER: Gamma globulin, which is
an immune globulin, contains most of the antibodies circulating in the blood. When
injected into an individual, it prevents a specific antigen from entering a host cell. So
the antigen is neutralized by the antibodies gamma globulin supplies. Used when a
pt is exposed to Hep A
A nurse is obtaining a health history from the newly admitted client who has chronic
pain in the knee. What should the nurse include in the pain assessment? Select all
that apply.
1
Pain history, including location, intensity, and quality of pain
2
Client's purposeful body movement in arranging the papers on the bedside table
3
Pain pattern, including precipitating and alleviating factors
4
Vital signs, such as increased blood pressure and heart rate
5
The client's family statement about increases in pain with ambulation - ANSWER: 1 &
3
Why not others?? Physiological responses such as elevated blood pressure and heart
rate are most likely to be absent in the client with chronic pain. Pain is a subjective
experience, and therefore the nurse has to ask the client directly instead of
accepting the statement of the family members.
Pressure Ulcers and stages - ANSWER: stage I pressure ulcer- an area of persistent
redness with no break in skin integrity.
stage II pressure ulcer-partial-thickness wound with skin loss involving the
epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion,
blister, or shallow crater
stage III pressure ulcer- full-thickness tissue loss with visible subcutaneous fat. Bone,
tendon, and muscle are not exposed.
stage IV- full thickness tissue loss with exposed bone, tendon, muscle, bone (slough
or eschar may be present within wound bed)
unstageable- contains necrotic tissue, necrotic tissue must be removed before the
wound can be staged.
While assessing a client's skin, a nurse notices that the skin is dry. What is the
probable etiology of the condition? Select all that apply. - ANSWER: The use of hard
soap and frequent bathing may result in dry skin. A skin allergy may result in skin
,rashes, but not dry skin. Using tanning pills and petroleum products may result in
skin cancer.
The community nurse is assessing an elderly client who lives alone at home. the
client refrains from physical activity for fear of falling when walking. Which
interventions by the nurse are most beneficial to promote a healthy lifestyle? -
ANSWER: Encourage the client to wear nonskid shoes.
Suggest that the client use an assistive device.
Help the client rearrange furniture in the house.
Which features distinguish nursing diagnoses from medical diagnoses? Select all that
apply.
1
Nursing diagnoses involve the client when possible.
2
Nursing diagnoses are based on results of diagnostic tests and procedures.
3
Nursing diagnoses are the identification of a disease condition in the client.
4
Nursing diagnoses involve the sorting of health problems within the nursing domain.
5
Nursing diagnoses involve clinical judgment about the client's response to health
problems. - ANSWER: Nursing diagnoses involve (client participation) the client when
possible.
Nursing diagnoses involve the sorting of health problems within the nursing domain.
Nursing diagnoses involve clinical judgment about the client's response to health
problems.
WRONG ANSWER:
Nursing diagnoses are based on results of diagnostic tests and procedures.
WRONG ANSWER:
Nursing diagnoses are the identification of a disease condition in the client.
A 50-year-old client with a 30-year history of smoking reports a chronic cough and
shortness of breath related to chronic obstructive pulmonary disease (COPD). The
clinical data on admission are as follows: a heart rate of 100, a blood pressure of
138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen
saturation of 80%. Which vital signs obtained by the nurse during the therapy
indicates a positive outcome? Select all that apply.
1
Radial pulse: 70
2
Temperature: 37 °C
3
Respiratory rate: 14
4
Blood pressure: 110/70
5
,Oxygen saturation: 96% - ANSWER: 3,4,5
Why not 1&2? The radial pulse indicates a positive outcome of the therapy if the
client has a history of heart disease. A body temperature reading of 36.8 °C is
considered normal and not a sign of COPD.
Which client is at an increased risk for right-sided heart failure?
Client A:
R Jugular Venous Pressure: 2.5 cm
L Jugular Venous Pressure: 3.0 cm
Client B:
RJVP = 2.0
LJVP = 1.5
Client C:
RJVP = 1.5
LJVP = 1.0 - ANSWER: Client A
Bilateral pressures higher than 2.5 cm are considered elevated and are a sign of
right-sided heart failure. Client A has both right and left jugular venous pressure
above 2.5 cm. Therefore this client is at risk for right-sided heart failure.
why not B/C: One-sided pressure elevation is caused by obstruction, as observed in
clients B, C
Right sided heart failure risk - ANSWER: Bilateral pressures higher than 2.5 cm are
considered elevated and are a sign of right-sided heart failure. Client A has both right
and left jugular venous pressure above 2.5 cm. Therefore this client is at risk for
right-sided heart failure. One-sided pressure elevation is caused by obstruction, as
observed in clients B, C, and D. in clients B,C, D the right jugular venous pressure is .5
cm high than the left jugular venous pressure
The community nurse is assessing an elderly client who lives alone at home. The
nurse finds that the client refrains from physical activity for fear of falling when
walking. Which interventions by the nurse are most beneficial to promote a healthy
lifestyle? Select all that apply.
1
Instruct the client to apply bed side rails.
2
Encourage the client to wear nonskid shoes.
3
Suggest that the client use an assistive device.
4
Ask the client to install hand rails in the bathroom.
5
Help the client rearrange furniture in the house. - ANSWER: 2,3,5
, Why not 1,4? The bed side rails protect the client from falling from the bed. The
hand rails in the bathroom assist provide support while using the bathroom.
What clinical indicators should the nurse expect a client with hyperkalemia to
exhibit? Select all that apply.
1
Tetany
2
Seizures
3
Diarrhea
4
Weakness
5
Dysrhythmias - ANSWER: 3,4,5
Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause
diarrhea, weakness, and cardiac dysrhythmias.
Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are
associated with low calcium or sodium levels.
What are the different types of fevers? - ANSWER: Remittent: temp spikes and falls,
while still staying febrile, without a return to normal temp levels
Sustained: constant body temp above 38 degrees with little fluctuation
Intermittent: fever spikes are interspersed with normal temp levels
Relapsing: periods of febrile episodes and periods with acceptable temperature
values (often for longer than 24 hours)
The nurse is assessing a client following abdominal surgery. Which assessment
findings should the nurse use to form a data cluster? Select all that apply.
1
The client reports pain with movement.
2
The client has pain over the surgical area.
3
The client wants to know when he can go home.
4
The client rates the pain as 8 on a scale of 0 to 10.
5
The client has concerns about caring for the wound. - ANSWER: 1,2,4
The nurse groups all information that contains a defining characteristic such as pain.
The nurse clusters all assessments related to pain. The client reports pain with
COMPLETE EXAM QUESTIONS ANDCORRECT DETAILED
ANSWERS AGRADE
What is gamma globulin and when is it used? - ANSWER: Gamma globulin, which is
an immune globulin, contains most of the antibodies circulating in the blood. When
injected into an individual, it prevents a specific antigen from entering a host cell. So
the antigen is neutralized by the antibodies gamma globulin supplies. Used when a
pt is exposed to Hep A
A nurse is obtaining a health history from the newly admitted client who has chronic
pain in the knee. What should the nurse include in the pain assessment? Select all
that apply.
1
Pain history, including location, intensity, and quality of pain
2
Client's purposeful body movement in arranging the papers on the bedside table
3
Pain pattern, including precipitating and alleviating factors
4
Vital signs, such as increased blood pressure and heart rate
5
The client's family statement about increases in pain with ambulation - ANSWER: 1 &
3
Why not others?? Physiological responses such as elevated blood pressure and heart
rate are most likely to be absent in the client with chronic pain. Pain is a subjective
experience, and therefore the nurse has to ask the client directly instead of
accepting the statement of the family members.
Pressure Ulcers and stages - ANSWER: stage I pressure ulcer- an area of persistent
redness with no break in skin integrity.
stage II pressure ulcer-partial-thickness wound with skin loss involving the
epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion,
blister, or shallow crater
stage III pressure ulcer- full-thickness tissue loss with visible subcutaneous fat. Bone,
tendon, and muscle are not exposed.
stage IV- full thickness tissue loss with exposed bone, tendon, muscle, bone (slough
or eschar may be present within wound bed)
unstageable- contains necrotic tissue, necrotic tissue must be removed before the
wound can be staged.
While assessing a client's skin, a nurse notices that the skin is dry. What is the
probable etiology of the condition? Select all that apply. - ANSWER: The use of hard
soap and frequent bathing may result in dry skin. A skin allergy may result in skin
,rashes, but not dry skin. Using tanning pills and petroleum products may result in
skin cancer.
The community nurse is assessing an elderly client who lives alone at home. the
client refrains from physical activity for fear of falling when walking. Which
interventions by the nurse are most beneficial to promote a healthy lifestyle? -
ANSWER: Encourage the client to wear nonskid shoes.
Suggest that the client use an assistive device.
Help the client rearrange furniture in the house.
Which features distinguish nursing diagnoses from medical diagnoses? Select all that
apply.
1
Nursing diagnoses involve the client when possible.
2
Nursing diagnoses are based on results of diagnostic tests and procedures.
3
Nursing diagnoses are the identification of a disease condition in the client.
4
Nursing diagnoses involve the sorting of health problems within the nursing domain.
5
Nursing diagnoses involve clinical judgment about the client's response to health
problems. - ANSWER: Nursing diagnoses involve (client participation) the client when
possible.
Nursing diagnoses involve the sorting of health problems within the nursing domain.
Nursing diagnoses involve clinical judgment about the client's response to health
problems.
WRONG ANSWER:
Nursing diagnoses are based on results of diagnostic tests and procedures.
WRONG ANSWER:
Nursing diagnoses are the identification of a disease condition in the client.
A 50-year-old client with a 30-year history of smoking reports a chronic cough and
shortness of breath related to chronic obstructive pulmonary disease (COPD). The
clinical data on admission are as follows: a heart rate of 100, a blood pressure of
138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen
saturation of 80%. Which vital signs obtained by the nurse during the therapy
indicates a positive outcome? Select all that apply.
1
Radial pulse: 70
2
Temperature: 37 °C
3
Respiratory rate: 14
4
Blood pressure: 110/70
5
,Oxygen saturation: 96% - ANSWER: 3,4,5
Why not 1&2? The radial pulse indicates a positive outcome of the therapy if the
client has a history of heart disease. A body temperature reading of 36.8 °C is
considered normal and not a sign of COPD.
Which client is at an increased risk for right-sided heart failure?
Client A:
R Jugular Venous Pressure: 2.5 cm
L Jugular Venous Pressure: 3.0 cm
Client B:
RJVP = 2.0
LJVP = 1.5
Client C:
RJVP = 1.5
LJVP = 1.0 - ANSWER: Client A
Bilateral pressures higher than 2.5 cm are considered elevated and are a sign of
right-sided heart failure. Client A has both right and left jugular venous pressure
above 2.5 cm. Therefore this client is at risk for right-sided heart failure.
why not B/C: One-sided pressure elevation is caused by obstruction, as observed in
clients B, C
Right sided heart failure risk - ANSWER: Bilateral pressures higher than 2.5 cm are
considered elevated and are a sign of right-sided heart failure. Client A has both right
and left jugular venous pressure above 2.5 cm. Therefore this client is at risk for
right-sided heart failure. One-sided pressure elevation is caused by obstruction, as
observed in clients B, C, and D. in clients B,C, D the right jugular venous pressure is .5
cm high than the left jugular venous pressure
The community nurse is assessing an elderly client who lives alone at home. The
nurse finds that the client refrains from physical activity for fear of falling when
walking. Which interventions by the nurse are most beneficial to promote a healthy
lifestyle? Select all that apply.
1
Instruct the client to apply bed side rails.
2
Encourage the client to wear nonskid shoes.
3
Suggest that the client use an assistive device.
4
Ask the client to install hand rails in the bathroom.
5
Help the client rearrange furniture in the house. - ANSWER: 2,3,5
, Why not 1,4? The bed side rails protect the client from falling from the bed. The
hand rails in the bathroom assist provide support while using the bathroom.
What clinical indicators should the nurse expect a client with hyperkalemia to
exhibit? Select all that apply.
1
Tetany
2
Seizures
3
Diarrhea
4
Weakness
5
Dysrhythmias - ANSWER: 3,4,5
Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause
diarrhea, weakness, and cardiac dysrhythmias.
Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are
associated with low calcium or sodium levels.
What are the different types of fevers? - ANSWER: Remittent: temp spikes and falls,
while still staying febrile, without a return to normal temp levels
Sustained: constant body temp above 38 degrees with little fluctuation
Intermittent: fever spikes are interspersed with normal temp levels
Relapsing: periods of febrile episodes and periods with acceptable temperature
values (often for longer than 24 hours)
The nurse is assessing a client following abdominal surgery. Which assessment
findings should the nurse use to form a data cluster? Select all that apply.
1
The client reports pain with movement.
2
The client has pain over the surgical area.
3
The client wants to know when he can go home.
4
The client rates the pain as 8 on a scale of 0 to 10.
5
The client has concerns about caring for the wound. - ANSWER: 1,2,4
The nurse groups all information that contains a defining characteristic such as pain.
The nurse clusters all assessments related to pain. The client reports pain with
