HESI HEALTH ASSESSMENT TEST BANK QUE
n n n n n
STIONSAND ANSWERS 100% CORRECT n n n n
The nurse is caring for a patient with chronic lower back pain. The nurse know
n n n n n n n n n n n n n n
sthat the most reliable indicator of pain in this client is:
n n n n n n n n n n n
The patient is reporting "6/10" pain.
n n n n n n
The patient is refusing to get out of be
n n n n n n n n
d.The patient is refusing to eat breakf
n n n n n n n
ast.
The patient's heart rate is 90 beats per minu
n n n n n n n n
te.A n
Which of the following actions should the nurse take to ensure an accurate blo
n n n n n n n n n n n n n
odpressure (BP) reading?
n n n
Ensure the width of the BP cuff is equal to 80% of the arm circumference.
n n n n n n n n n n n n n n
Ensure the client's back is supported and feet are flat on the groun
n n n n n n n n n n n n
d.Take two BP readings 20 seconds apart.
n n n n n n n
,Ensure that the patient's arm is above heart level.
n n n n n n n n
B
The patient's arm should be supported at heart level. Separate BP readings
n n n n n n n n n n n
mayneed to be taken, but not one right after the other. The length of the B
n n n n n n n n n n n n n n n n n
P bladdershould equal 80% of the arm circumferen
n n n n n n n n
The nurse obtains which piece of data during the general survey?C
n n n n n n n n n n n
lient is alert and calm.n n n n
Client's heart rate is 80 beats per minun n n n n n n
te.Client's body mass index (BMI) is 3
n n n n n n n
0.
Client's lung sounds are "clear" to auscultati
n n n n n n
on.A n
A man is at the clinic for a complete physical exam. He states that he is "v
n n n n n n n n n n n n n n n n
eryanxious". What steps can the nurse take to make him more comfortabl
n n n n n n n n n n n n
e?
Appear confident and unhurried during the exam.
n n n n n n
Measure vital signs at the end to allow the patient sufficient time to rela
n n n n n n n n n n n n n
x.Let him leave his clothes on during the examination.
n n n n n n n n n
Obtain another nurse to examine the patie
n n n n n n
nt.A n
A father brings his 13 month-
n n n n n
old child in for "fever" and he reports that the child has been "pulling on his lef
n n n n n n n n n n n n n n n n
t ear". Upon entering the exam room, the child is asleepin the father's arms. Th
n n n n n n n n n n n n n n n
e nurse should perform which assessment first?
n n n n n n
Use the otoscope to look inside the ear.
n n n n n n n n
Use a penlight to check the eyes and nos
n n n n n n n n
,e.
Auscultate the lungs, heart, and abdomen. n n n n n
Assess gross motor skills using the Denver II screening to
n n n n n n n n n
ol.C n
An 18 year- n n
old presents to the emergency department with "headache." Which ofthese ass
n n n n n n n n n n n
essment findings alerts the nurse to recent opioid use?
n n n n n n n n
Pupillary constrictio n
nHallucinations.
n
Fever.
Tachypnea.
A- constricted pupils are a sign of recent opioid use, the rest are withdrawals
n n n n n n n n n n n n n
While collecting the pulse on a 26 year-
n n n n n n n
old client, the nurse notes that the heart rateseems to speed up and then slow
n n n n n n n n n n n n n n n n
down in accordance with respirations. The pulse is counted at 80 beats per mi
n n n n n n n n n n n n n
nute. What should the nurse do next?
n n n n n n
Obtain orthostatic vital signs.Non n n n
tify the physician.
n n
Document "sinus arrhythmia." n n
Use a doppler to confirm the findin
n n n n n n
g.C n
An elderly client with pneumonia is being treated in the intensive care unit (I
n n n n n n n n n n n n n
CU).He is acutely agitated, restless, and disoriented. The nurse documents his
n n n n n n n n n n n
level of consciousness as:
n n n n
Manic.
, Demente
d.
Drowsy.
Delirious
.D n
The nurse is assessing a newborn infant. How should the nurse measure the he
n n n n n n n n n n n n n
artrate (HR)? n n
Palpate the radial pulse for 15 seconds and multiply by four
n n n n n n n n n n
. Palpate the brachial pulse for 30 seconds and multiply by t
n n n n n n n n n n n
wo.
Auscultate the apical site for 60 seconds. n n n n n n
Apply a pulse oximeter to obtain both the HR and SpO
n n n n n n n n n n
2.C n
A 28 year-
n n
old is brought to the emergency department. He is disoriented and hallucinati
n n n n n n n n n n n
ng, and vital signs are elevated. The nurse suspects that the patient isexperienc
n n n n n n n n n n n n n
ing withdrawal symptoms from which substance?
n n n n n
Alcohol. n
Cocaine. n
Cannabis
.
Opiates.
A- hallucinations and delirium are commonly seen w alcohol withdrawal
n n n n n n n n n
When evaluating the temperature of older adults, the nurse should remember w
n n n n n n n n n n n
hichaspect about an older adult's body temperature?
n n n n n n n
n n n n n
STIONSAND ANSWERS 100% CORRECT n n n n
The nurse is caring for a patient with chronic lower back pain. The nurse know
n n n n n n n n n n n n n n
sthat the most reliable indicator of pain in this client is:
n n n n n n n n n n n
The patient is reporting "6/10" pain.
n n n n n n
The patient is refusing to get out of be
n n n n n n n n
d.The patient is refusing to eat breakf
n n n n n n n
ast.
The patient's heart rate is 90 beats per minu
n n n n n n n n
te.A n
Which of the following actions should the nurse take to ensure an accurate blo
n n n n n n n n n n n n n
odpressure (BP) reading?
n n n
Ensure the width of the BP cuff is equal to 80% of the arm circumference.
n n n n n n n n n n n n n n
Ensure the client's back is supported and feet are flat on the groun
n n n n n n n n n n n n
d.Take two BP readings 20 seconds apart.
n n n n n n n
,Ensure that the patient's arm is above heart level.
n n n n n n n n
B
The patient's arm should be supported at heart level. Separate BP readings
n n n n n n n n n n n
mayneed to be taken, but not one right after the other. The length of the B
n n n n n n n n n n n n n n n n n
P bladdershould equal 80% of the arm circumferen
n n n n n n n n
The nurse obtains which piece of data during the general survey?C
n n n n n n n n n n n
lient is alert and calm.n n n n
Client's heart rate is 80 beats per minun n n n n n n
te.Client's body mass index (BMI) is 3
n n n n n n n
0.
Client's lung sounds are "clear" to auscultati
n n n n n n
on.A n
A man is at the clinic for a complete physical exam. He states that he is "v
n n n n n n n n n n n n n n n n
eryanxious". What steps can the nurse take to make him more comfortabl
n n n n n n n n n n n n
e?
Appear confident and unhurried during the exam.
n n n n n n
Measure vital signs at the end to allow the patient sufficient time to rela
n n n n n n n n n n n n n
x.Let him leave his clothes on during the examination.
n n n n n n n n n
Obtain another nurse to examine the patie
n n n n n n
nt.A n
A father brings his 13 month-
n n n n n
old child in for "fever" and he reports that the child has been "pulling on his lef
n n n n n n n n n n n n n n n n
t ear". Upon entering the exam room, the child is asleepin the father's arms. Th
n n n n n n n n n n n n n n n
e nurse should perform which assessment first?
n n n n n n
Use the otoscope to look inside the ear.
n n n n n n n n
Use a penlight to check the eyes and nos
n n n n n n n n
,e.
Auscultate the lungs, heart, and abdomen. n n n n n
Assess gross motor skills using the Denver II screening to
n n n n n n n n n
ol.C n
An 18 year- n n
old presents to the emergency department with "headache." Which ofthese ass
n n n n n n n n n n n
essment findings alerts the nurse to recent opioid use?
n n n n n n n n
Pupillary constrictio n
nHallucinations.
n
Fever.
Tachypnea.
A- constricted pupils are a sign of recent opioid use, the rest are withdrawals
n n n n n n n n n n n n n
While collecting the pulse on a 26 year-
n n n n n n n
old client, the nurse notes that the heart rateseems to speed up and then slow
n n n n n n n n n n n n n n n n
down in accordance with respirations. The pulse is counted at 80 beats per mi
n n n n n n n n n n n n n
nute. What should the nurse do next?
n n n n n n
Obtain orthostatic vital signs.Non n n n
tify the physician.
n n
Document "sinus arrhythmia." n n
Use a doppler to confirm the findin
n n n n n n
g.C n
An elderly client with pneumonia is being treated in the intensive care unit (I
n n n n n n n n n n n n n
CU).He is acutely agitated, restless, and disoriented. The nurse documents his
n n n n n n n n n n n
level of consciousness as:
n n n n
Manic.
, Demente
d.
Drowsy.
Delirious
.D n
The nurse is assessing a newborn infant. How should the nurse measure the he
n n n n n n n n n n n n n
artrate (HR)? n n
Palpate the radial pulse for 15 seconds and multiply by four
n n n n n n n n n n
. Palpate the brachial pulse for 30 seconds and multiply by t
n n n n n n n n n n n
wo.
Auscultate the apical site for 60 seconds. n n n n n n
Apply a pulse oximeter to obtain both the HR and SpO
n n n n n n n n n n
2.C n
A 28 year-
n n
old is brought to the emergency department. He is disoriented and hallucinati
n n n n n n n n n n n
ng, and vital signs are elevated. The nurse suspects that the patient isexperienc
n n n n n n n n n n n n n
ing withdrawal symptoms from which substance?
n n n n n
Alcohol. n
Cocaine. n
Cannabis
.
Opiates.
A- hallucinations and delirium are commonly seen w alcohol withdrawal
n n n n n n n n n
When evaluating the temperature of older adults, the nurse should remember w
n n n n n n n n n n n
hichaspect about an older adult's body temperature?
n n n n n n n
