HESI Health Assessment Questions And Correct Detailed Answers (Verified Answers) Already Graded A+ TESTBANK

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HESI Health Assessment Questions And Correct Detailed Answers (Verified Answers) Already Graded A+ TESTBANK

• A 28 year-old is brought to the emergency department. He is disoriented and

hallucinating, and vital signs are elevated. The nurse suspects that the patient is experiencing withdrawal symptoms from which substance?

• Alcohol
• Cocaine
• Cannabis
• Opiates

Correct Answer: A

• The nurse is assessing a newborn infant. How should the nurse measure the heart

rate (HR)?

• Palpate the radial pulse for 15 seconds and multiply by four.
• Palpate the brachial pulse for 30 seconds and multiply by two.
• Auscultate the apical site for 60 seconds.
• Apply a pulse oximeter to obtain both the HR and SpO2.

Correct Answer: C

• An elderly client with pneumonia is being treated in the intensive care unit (ICU). He

is acutely agitated, restless, and disoriented. The nurse documents his level of

consciousness as:

• Manic
• Demented
• Drowsy
• Delirious

Correct Answer: D

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• While collecting the pulse on a 26 year-old client, the nurse notes that the heart rate

seems to speed up and then slow down in accordance with respirations. The pulse is counted at 80 beats per minute. What should the nurse do next?

• Obtain orthostatic vital signs.
• Notify the physician.
• Document "sinus arrhythmia."
• Use a doppler to confirm the finding.

Correct Answer: C

• An 18 year-old presents to the emergency department with "headache." Which of

these assessment findings alerts the nurse to recent opioid use?

• Pupillary constriction
• Hallucinations
• Fever
• Tachypnea

Correct Answer: A

• A father brings his 13 month-old child in for "fever" and he reports that the child has

been "pulling on his left ear". Upon entering the exam room, the child is asleep in the father's arms. The nurse should perform which assessment first?

• Use the otoscope to look inside the ear.
• Use a penlight to check the eyes and nose.
• Auscultate the lungs, heart, and abdomen.
• Assess gross motor skills using the Denver II screening tool.

Correct Answer: C

• A man is at the clinic for a complete physical exam. He states that he is "very

anxious". What steps can the nurse take to make him more comfortable?

• Appear confident and unhurried during the exam.
• Measure vital signs at the end to allow the patient sufficient time to relax.
• Let him leave his clothes on during the examination.

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• Obtain another nurse to examine the patient.

Correct Answer: A

• The nurse obtains which piece of data during the general survey?
• Client is alert and calm.
• Client's heart rate is 80 beats per minute.
• Client's body mass index (BMI) is 30.
• Client's lung sounds are "clear" to auscultation.

Correct Answer: 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.

Correct Answer: B

• 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.

Correct Answer: A

• 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.

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• There are no differences in temperature between a young and old adult.
• Older adults body temperature runs lower than that of an adult.

Correct Answer: 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.

Correct Answer: B

• 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

Correct Answer: 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.

Correct Answer: A

• As a mandatory reporter, the nurse notifies the authorities with which of the

following?