HESI HEALTH ASSESSMENT EXAM VERSION 3
COMPLETE EXAM QUESTIONS ANDCORRECT DETAILED
ANSWERS AGRADE
SOAP modified format - ANSWER: Subjective
Objective
Assessment
Plan
What color ink should be used when documenting on paper - ANSWER: Permanent
black ink
What is the correct order for vital signs - ANSWER: T, P, RR, BP, extremity, pt
position, SPO2
What should be at the top of every page of documentation - ANSWER: Patient initials
and date and time of entry
What should be at the end of every documentation entry - ANSWER: Interviewers
signature
How do you correct a mistake in documentation - ANSWER: 1) Draw a single line
through the incorrect documentation
2) Write error above the entry
3) Initial and date the crossed out entry
Documentation tips - ANSWER: 1) Avoid complete sentences
2) Do not use A, an, the
3) Do not put opinion in notes
4) Avoid use of normal or within normal limits
Normal oral temp range - ANSWER: 96.4 - 99.1 F
Febrile - ANSWER: With fever
Afebrile - ANSWER: Without fever
Hyperthermia symptoms - ANSWER: 1) Cessation of shivering
2) Bradycardia
3) Decrease in respiratory minute volume
Most common and easy method of assessing temperature - ANSWER: Oral
What methods of assessing temperature reflects core temperature - ANSWER: 1)
Oral
2) Rectal
,3) Tympanic
4) Temporal Artery
What is the least accurate method of assessing temperature - ANSWER: axillary
Which patients are contraindicated for rectal temperature readings - ANSWER:
Patients with increased HR
Preferred method of taking infants and small children's temperatures - ANSWER:
Rectal
Pulse deficit - ANSWER: - Difference between apical peripheral pulse
Pulse amplitude scale - ANSWER: 0 = no pulse
1 = diminished, weak
2 = normal and expected
3 = full or strong
4 = bounding
Which pulses are assessed during a routine physical assessment? - ANSWER: 1)
Apical
2) Radial
3) Dorsalis pedis
4) Posterior tibialis
Normal heart rate in resting adult - ANSWER: 60 to 100 bpm
Well trained athletes heart rate - ANSWER: Heart rate less than 60 bpm
When is it normal for someone to have a rapid heart rate over 100 bpm - ANSWER:
Someone with anxiety and right after exercise
Eupnea - ANSWER: Normal RR, rhythm and depth
Normal SPO2 value - ANSWER: 95-100%
What level is poor oxygenation - ANSWER: below 90%
Systolic BP - ANSWER: Maximum pressure on the artery during ventricular
contraction
Diastolic BP - ANSWER: Resting pressure during ventricular filling
Pulse pressure - ANSWER: Difference between systolic and diastolic
Stroke volume - ANSWER: Amount of blood ejected with each beat
,How does age affect BP - ANSWER: BP increases with age
What BP is pre hypertensive? - ANSWER: Sustained BP over 120/80
What extremities should you avoid taking a BP in - ANSWER: Extremities with IV
lines, invasive lines, history of mastectomy/lymph node issues
Orthostatic hypertension - ANSWER: - Decreased BP with change in position
- Drop in SBP of 25 mmHg or DBP of 10 mmHG
- Symptoms
1) Dizziness
2) Weakness
3) Blurred vision
4) Syncope
5) Changes in BP/HR
- Causes
1) Hypovolemia
2) Impaired vasoconstriction
3) Medications
Precautions in someone with orthostatic hypertension - ANSWER: - change positions
slowly
- falls risk
- assist back to bed if symptomatic
What is the main objective of the health history - ANSWER: - To gather accurate
information to provide immediate care
- Establish rapport with the client
What does establishing a positive patient relationship depend on - ANSWER: 1)
courtesy
2) comfort
3) connection
4) confirmation
5) confidentiality
What questions should you begin with for a health history interview - ANSWER:
Open ended questions
Approaching Sensitive Issues - ANSWER: - Use language that is understandable.
- Do not apologize for broaching the issue.
- Ensure privacy.
- Be direct and firm.
- Do not preach.
- Do not push too hard.
CAGE questionnaire - ANSWER: Cutting down
, Annoyance
Guilty feeling
Eye-openers
- Helps diagnose alcoholism
TACE questionnaire - ANSWER: T - how many drinks does it TAKE to make you feel
right
A - Have people ANNOYED you by criticizing your drinking
C - Have you felt you out to cut down on your drinking
E - Have you had an EYE -OPENER first thing in the morning
CRAFFT questionnaire - ANSWER: - Screening tool for alcohol and substance abuse in
adolescents
Car
Relax
Alone
Forget
Friends
Trouble
What is the goal of a screening tool? - ANSWER: To find out if the problem exists
Three questions to detect partner violence - ANSWER: - Have you ever been hit,
kicked, punched, or otherwise hurt by someone within the past year?
- Do you feel safe in your current relationship?
- Is there a partner from a previous relationship who is making you feel unsafe now?
HITS questionnaire - ANSWER: The wording of the question is "In the last year how
often did your partner:
1) Hurt you physically?"
2) Insult or talk down to you?"
3) Threaten you with physical harm?"
4) Scream or curse at you?"
FICA - ANSWER: Faith
Importance and Influence
Community
Address/action in care
Format of interview - ANSWER: CC
HPI
PMH
PSH
FH
SH
ROS
COMPLETE EXAM QUESTIONS ANDCORRECT DETAILED
ANSWERS AGRADE
SOAP modified format - ANSWER: Subjective
Objective
Assessment
Plan
What color ink should be used when documenting on paper - ANSWER: Permanent
black ink
What is the correct order for vital signs - ANSWER: T, P, RR, BP, extremity, pt
position, SPO2
What should be at the top of every page of documentation - ANSWER: Patient initials
and date and time of entry
What should be at the end of every documentation entry - ANSWER: Interviewers
signature
How do you correct a mistake in documentation - ANSWER: 1) Draw a single line
through the incorrect documentation
2) Write error above the entry
3) Initial and date the crossed out entry
Documentation tips - ANSWER: 1) Avoid complete sentences
2) Do not use A, an, the
3) Do not put opinion in notes
4) Avoid use of normal or within normal limits
Normal oral temp range - ANSWER: 96.4 - 99.1 F
Febrile - ANSWER: With fever
Afebrile - ANSWER: Without fever
Hyperthermia symptoms - ANSWER: 1) Cessation of shivering
2) Bradycardia
3) Decrease in respiratory minute volume
Most common and easy method of assessing temperature - ANSWER: Oral
What methods of assessing temperature reflects core temperature - ANSWER: 1)
Oral
2) Rectal
,3) Tympanic
4) Temporal Artery
What is the least accurate method of assessing temperature - ANSWER: axillary
Which patients are contraindicated for rectal temperature readings - ANSWER:
Patients with increased HR
Preferred method of taking infants and small children's temperatures - ANSWER:
Rectal
Pulse deficit - ANSWER: - Difference between apical peripheral pulse
Pulse amplitude scale - ANSWER: 0 = no pulse
1 = diminished, weak
2 = normal and expected
3 = full or strong
4 = bounding
Which pulses are assessed during a routine physical assessment? - ANSWER: 1)
Apical
2) Radial
3) Dorsalis pedis
4) Posterior tibialis
Normal heart rate in resting adult - ANSWER: 60 to 100 bpm
Well trained athletes heart rate - ANSWER: Heart rate less than 60 bpm
When is it normal for someone to have a rapid heart rate over 100 bpm - ANSWER:
Someone with anxiety and right after exercise
Eupnea - ANSWER: Normal RR, rhythm and depth
Normal SPO2 value - ANSWER: 95-100%
What level is poor oxygenation - ANSWER: below 90%
Systolic BP - ANSWER: Maximum pressure on the artery during ventricular
contraction
Diastolic BP - ANSWER: Resting pressure during ventricular filling
Pulse pressure - ANSWER: Difference between systolic and diastolic
Stroke volume - ANSWER: Amount of blood ejected with each beat
,How does age affect BP - ANSWER: BP increases with age
What BP is pre hypertensive? - ANSWER: Sustained BP over 120/80
What extremities should you avoid taking a BP in - ANSWER: Extremities with IV
lines, invasive lines, history of mastectomy/lymph node issues
Orthostatic hypertension - ANSWER: - Decreased BP with change in position
- Drop in SBP of 25 mmHg or DBP of 10 mmHG
- Symptoms
1) Dizziness
2) Weakness
3) Blurred vision
4) Syncope
5) Changes in BP/HR
- Causes
1) Hypovolemia
2) Impaired vasoconstriction
3) Medications
Precautions in someone with orthostatic hypertension - ANSWER: - change positions
slowly
- falls risk
- assist back to bed if symptomatic
What is the main objective of the health history - ANSWER: - To gather accurate
information to provide immediate care
- Establish rapport with the client
What does establishing a positive patient relationship depend on - ANSWER: 1)
courtesy
2) comfort
3) connection
4) confirmation
5) confidentiality
What questions should you begin with for a health history interview - ANSWER:
Open ended questions
Approaching Sensitive Issues - ANSWER: - Use language that is understandable.
- Do not apologize for broaching the issue.
- Ensure privacy.
- Be direct and firm.
- Do not preach.
- Do not push too hard.
CAGE questionnaire - ANSWER: Cutting down
, Annoyance
Guilty feeling
Eye-openers
- Helps diagnose alcoholism
TACE questionnaire - ANSWER: T - how many drinks does it TAKE to make you feel
right
A - Have people ANNOYED you by criticizing your drinking
C - Have you felt you out to cut down on your drinking
E - Have you had an EYE -OPENER first thing in the morning
CRAFFT questionnaire - ANSWER: - Screening tool for alcohol and substance abuse in
adolescents
Car
Relax
Alone
Forget
Friends
Trouble
What is the goal of a screening tool? - ANSWER: To find out if the problem exists
Three questions to detect partner violence - ANSWER: - Have you ever been hit,
kicked, punched, or otherwise hurt by someone within the past year?
- Do you feel safe in your current relationship?
- Is there a partner from a previous relationship who is making you feel unsafe now?
HITS questionnaire - ANSWER: The wording of the question is "In the last year how
often did your partner:
1) Hurt you physically?"
2) Insult or talk down to you?"
3) Threaten you with physical harm?"
4) Scream or curse at you?"
FICA - ANSWER: Faith
Importance and Influence
Community
Address/action in care
Format of interview - ANSWER: CC
HPI
PMH
PSH
FH
SH
ROS
