HESI Health Assessment
100+ Questions And
Answers 2024
,What is gamma globulin and when is it used? - ans 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 - ans
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 - ans 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. - ans 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? - ans 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. - ans 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% - ans 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 - ans Client A
100+ Questions And
Answers 2024
,What is gamma globulin and when is it used? - ans 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 - ans
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 - ans 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. - ans 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? - ans 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. - ans 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% - ans 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 - ans Client A
