2021 – 2022 HESI HEALTH ASSESSMENT NURSING RN V1 100 Questions with answers

Examination For 2021 – 2022 HESI HEALTH ASSESSMENT NURSING RN V1 100 Questions with answers

2020/2021 HESI HEALTH ASSESSMENT NURSING RN V1 100 Questions with answers 1. Throughout a psychological standing examination, the nurse desires to evaluate a affected person’s have an effect on. The nurse ought to ask the affected person which query? 2. The nurse is planning to evaluate new reminiscence with a affected person. The easiest way for the nurse to do that could be to: 3. A forty five-12 months-previous lady is on the clinic for a psychological standing evaluation. In giving her the 4 Unrelated Phrases Take a look at, the nurse could be involved if she couldn’t 4 unrelated phrases . 4. Throughout a psychological standing evaluation, which query by the nurse would greatest assess an individual’s judgment? 5. Which of those people would the nurse take into account at highest danger for a suicide try? 6. When reviewing the usage of alcohol by older adults, the nurse notes that older adults have a number of traits that may improve the chance of alcohol use. Which might improve the bioavailability of alcohol within the blood for longer durations within the older grownup? 7. Throughout an evaluation, the nurse asks a feminine affected person, “What number of alcoholic drinks do you may have per week?” Which reply by the affected person would point out at-danger ingesting? 8. The nurse is asking an adolescent about illicit substance abuse. The adolescent answers, “Sure, I’ve used marijuana at events with my mates.” What’s the subsequent query the nurse ought to ask? 9. The nurse has accomplished an evaluation on a affected person who got here to the clinic for a leg damage. Because of the evaluation, the nurse has decided that the affected person has at-danger alcohol use. Which motion by the nurse is most applicable presently? 10. A affected person is delivered to the emergency division. He’s stressed, has dilated pupils, is sweating, has a runny nostril and tearing eyes, and complains of muscle and joint pains. His girlfriend thinks he has influenza, however she turned involved when his temperature went as much as 39.4° C. She admits that he has been a heavy drug person, however he has been making an attempt to cease on his personal. The nurse suspects that the affected person is experiencing withdrawal signs from which substance? 11. Affected person taking ipratropium reviews nausea, blurred imaginative and prescient, has, insomnia after utilizing the inhaler. RN motion to implement 12. A affected person has instantly developed shortness of breath and seems to be in important respiratory misery. After calling the doctor and inserting the affected person on oxygen, which of those actions is the most effective for the nurse to take when additional assessing the affected person? 13. The nurse is instructing a category on primary evaluation abilities. Which of those statements is true relating to the stethoscope and its use? 14. The nurse is getting ready to make use of a stethoscope for auscultation. Which assertion is true relating to the diaphragm of the stethoscope? The diaphragm: 15. Earlier than auscultating the stomach for the presence of bowel sounds on a affected person, the nurse ought to: 16. Whereas measuring a affected person’s blood stress, the nurse recollects that sure elements, comparable to , assist decide blood stress. 17. A nurse helps at a well being honest at a neighborhood mall. When taking blood pressures on quite a lot of individuals, the nurse retains in thoughts that: 8. The nurse notices a colleague is getting ready to examine the blood stress of a affected person who’s overweight through the use of an ordinary-sized blood stress cuff. The nurse ought to count on the studying to: 19. A scholar is late for his appointment and has rushed throughout campus to the well being clinic. The nurse ought to: 20. Hypoptysis (new cough) or modifications in persistent cough 21. The nurse is assessing a affected person’s ache. The nurse is aware of that probably the most dependable indicator of ache could be the: 22. A affected person has had arthritic ache in her hips for a number of years since a hip fracture. She is ready to transfer round in her room and has not provided any complaints to date this morning. Nevertheless, when requested, she states that her ache is “unhealthy this morning” and charges it at an 8 on a 1-to-10 scale. What does the nurse suspect? The affected person: 23. The nurse is reviewing the ideas of ache. Which sort of ache is because of an irregular processing of the ache impulse via the peripheral or central nervous system? 24. The nurse hears bilateral loud, lengthy, and low tones when percussing over the lungs of a 4-12 months-previous baby. The nurse ought to: 25. When assessing the standard of a affected person’s ache, the nurse ought to ask which query? 26. When assessing a affected person’s ache, the nurse is aware of that an instance of visceral ache could be: 27. A 75-12 months-previous lady who has a historical past of diabetes and peripheral vascular illness has been making an attempt to take away a corn on the underside of her foot with a pair of scissors. The nurse will encourage her to cease making an attempt to take away the corn with scissors as a result of: 28. The nurse retains in thoughts {that a} thorough pores and skin evaluation is extraordinarily necessary as a result of the pores and skin holds details about an individual’s: 29. A affected person is available in for a bodily examination and complains of “freezing to dying” whereas ready for her examination. The nurse notes that her pores and skin is pale and funky and attributes this discovering to: 30. A affected person involves the clinic and tells the nurse that he has been confined to his recliner chair for roughly 3 days with his toes down and he asks the nurse to judge his toes. Throughout the evaluation, the nurse may look forward to finding: 31.The nurse will carry out a palpated stress earlier than auscultating blood stress. The explanation for that is to: 32. A affected person tells the nurse that he has observed that one among his moles has began to burn and bleed. When assessing his pores and skin, the nurse pays particular consideration to the hazard indicators for pigmented lesions and is anxious with which extra discovering? 33. sarcoidosis – autoimmune inflammatory illness affecting a number of organs 34. A 19-12 months-previous faculty scholar is delivered to the emergency division with a extreme headache he describes as, “Like nothing I’ve ever had earlier than.” His temperature is 40° C, and he has a stiff neck. The nurse seems for different indicators and signs of which drawback? 35. Throughout a properly-child checkup, the nurse notices {that a} 1-week-previous toddler’s face seems small in contrast with his skull, which appears enlarged. On additional examination, the nurse additionally notices dilated scalp veins and downcast or “setting solar” eyes. The nurse suspects which situation? 36. The nurse must palpate the temporomandibular joint for crepitation. This joint is situated slightly below the temporal artery and anterior to the: 37. A affected person has are available for an examination and states, “I’ve this spot in entrance of my ear lobe on my cheek that appears to be getting greater and is tender. What do you assume it’s?” The nurse notes swelling under the angle of the jaw and suspects that it might be an irritation of his: 38. A male affected person with a historical past of acquired immunodeficiency syndrome (AIDS) has are available for an examination and he states, “I feel that I’ve the mumps.” The nurse would start by inspecting the: 39. In performing an examination of a 3-12 months-previous baby with a suspected ear an infection, the nurse would: 40. The nurse is getting ready to carry out an otoscopic examination of a new child toddler. Which assertion is true relating to this examination? 41. The nurse assesses the listening to of a 7-month-previous by clapping fingers. What’s the anticipated response? The toddler: 42. The nurse is performing an ear examination of an 80-12 months-previous affected person. Which of those findings could be thought of regular? 43. An evaluation of a 23-12 months-previous affected person reveals the next: an auricle that’s tender and reddish-blue in coloration with small vesicles. The nurse would wish to know extra data that features which of those? 44. A pregnant lady states that she is anxious about her gums as a result of she has observed they’re swollen and have began bleeding. What could be an applicable response by the nurse? 45. A 40-12 months-previous affected person who has simply completed chemotherapy for breast most cancers tells the nurse that she is anxious about her mouth. Throughout the evaluation the nurse finds areas of buccal mucosa which are uncooked and pink with some bleeding, in addition to different areas which have a white, tacky coating. The nurse acknowledges that this abnormality is: 46. The nurse is assessing a affected person within the hospital who has acquired quite a few antibiotics and notices that his tongue seems to be black and bushy. In response to his concern, what would the nurse say? 47. The nurse is assessing a affected person with a historical past of intravenous drug abuse. In assessing his mouth, the nurse notices a darkish pink confluent macule on the laborious palate. This might be an early signal of: 48. A mom brings her 4-month-previous toddler to the clinic with issues relating to a small pad in the course of the higher lip that has been there since 1 month of age. The toddler has no well being issues. On bodily examination, the nurse notices a 0.5-cm, fleshy, elevated space in the course of the higher lip. No proof of irritation or drainage is noticed. What would the nurse inform this mom? 49. which discovering ought to RN assess for a pt for a danger of DI (diabetes insipidus) 50. Throughout percussion, the nurse is aware of {that a} boring percussion word elicited over a lung lobe most definitely outcomes from: . 51. The nurse is observing the auscultation strategy of one other nurse. The proper methodology to make use of when progressing from one auscultatory website on the thorax to a different is _______ comparability. 52. When auscultating the lungs of an grownup affected person, the nurse notes that low-pitched, smooth breath sounds are heard over the posterior decrease lobes, with inspiration being longer than expiration. The nurse interprets that these sounds are: 53.The nurse is auscultating the chest in an grownup. Which approach is right? 54. The nurse is percussing over the lungs of a affected person with pneumonia. The nurse is aware of that percussion over an space of atelectasis within the lungs will reveal: 55. Throughout the precordial evaluation on an affected person who’s 8 months pregnant, the nurse palpates the apical impulse on the fourth left intercostal area lateral to the midclavicular line. This discovering would point out: 56. In assessing for an S4 coronary heart sound with a stethoscope, the nurse would pay attention with the: 57. A 70-12 months-previous affected person with a historical past of hypertension has a blood stress of 180/100 mm Hg and a coronary heart charge of 90 beats per minute. The nurse hears an additional coronary heart sound on the apex instantly earlier than the S1. The sound is heard solely with the bell of the stethoscope whereas the affected person is within the left lateral place. With these findings and the affected person’s historical past, the nurse is aware of that this further coronary heart sound is most definitely a(n): 58. The nurse is performing a cardiac evaluation on a 65-12 months-previous affected person 3 days after her myocardial infarction (MI). Coronary heart sounds are regular when she is supine, however when she is sitting and leaning ahead, the nurse hears a excessive-pitched, scratchy sound with the diaphragm of the stethoscope on the apex. It disappears on inspiration. The nurse suspects: 59. When the nurse is testing the triceps reflex, what’s the anticipated response 60. The nurse is testing superficial reflexes on an grownup affected person. When stroking up the lateral facet of the only real and throughout the ball of the foot, the nurse notices the plantar flexion of the toes. How ought to the nurse doc this discovering? 61. OTC decongestants – – can improve ICP 62. Within the evaluation of a 1-month-previous toddler, the nurse notices an absence of response to noise or stimulation. The mom reviews that within the final week he has been sleeping the entire time, and when he’s awake all he does is cry. The nurse hears that the toddler’s cries are very excessive pitched and shrill. What ought to be the nurse’s applicable response to those findings? 63. Which of those checks would the nurse use to examine the motor coordination of an 11-month-previous toddler? 64. To evaluate the top management of a 4-month-previous toddler, the nurse lifts up the toddler in a susceptible place whereas supporting his chest. The nurse seems for what regular response? The toddler: 65. The nurse is aware of {that a} frequent evaluation discovering in a boy youthful than 2 years previous is: 66. Throughout an examination of an growing older man, the nurse acknowledges that ordinary modifications to count on could be: . 67. When performing a genital evaluation on a center-aged man, the nurse notices a number of smooth, moist, painless papules within the form of cauliflower-like patches scattered throughout the shaft of the penis. These lesions are attribute of: 68. A 15-12 months-previous boy is seen within the clinic for complaints of “boring ache and pulling” within the scrotal space. On examination, the nurse palpates a smooth, irregular mass posterior to and above the testis on the left. This mass collapses when the affected person is supine and refills when he’s upright. This description is constant with: 69. When performing a genitourinary evaluation on a 16-12 months-previous male adolescent, the nurse notices a swelling within the scrotum that will increase with elevated intra-stomach stress and reduces when he’s mendacity down. The affected person complains of ache when straining. The nurse is aware of that this description is most constant with a(n) ______ hernia. 70. A lady who’s 8 weeks pregnant is within the clinic for a checkup. The nurse reads on her chart that her cervix is softened and appears cyanotic. The nurse is aware of that the lady is exhibiting __________ signal and __________ signal. 71. Typically, the modifications usually related with menopause happen as a result of the cells within the reproductive tract are: 72. The nurse is reviewing the modifications that happen with menopause. Which modifications are related with menopause? . ry motive for instructing pt pursed lip respiratory 74. A 54-12 months-previous lady who has simply accomplished menopause is within the clinic right this moment for a yearly bodily examination. Which of those statements ought to the nurse embrace in affected person schooling? “A postmenopausal lady: 75. A lady is within the clinic for an annual gynecologic examination. The nurse ought to plan to start the interview with the: 76. Throughout an evaluation of a hospitalized affected person, the nurse pinches a fold of pores and skin underneath the clavicle or on the forearm to check the: 77. When assessing the neurologic system of a hospitalized affected person throughout morning rounds, the nurse ought to embrace which of those through the evaluation? 78. When assessing a affected person’s normal look, the nurse ought to embrace which query? 79. The nurse is palpating the fundus of a pregnant lady. Which assertion about palpation of the fundus is true? 80.The nurse is palpating the stomach of a lady who’s 35 weeks’ pregnant and notices that the fetal head is dealing with downward towards the pelvis. The nurse would doc this as fetal: 81. The nurse is palpating the uterus of a lady who’s 8 weeks’ pregnant. Which discovering could be thought of to be most constant with this stage of being pregnant? 82. A affected person who had current stomach surgical procedure is turning into more and more agitated and confused. He has pulled out his IV and his nasogastric tube. His pores and skin is pale and clammy, coronary heart charge 120 bpm, BP 130/60. The doctor has been known as. What nursing motion is most necessary presently? 83. Which affected person is at biggest danger for damage and requires the nurse’s instant consideration? The affected person who had a(n): 84. What may a nurse say who believed {that a} nursing scholar has an obligation to know pertinent medical data to make sound medical judgments? 85. As a graduate nurse, which assertion strongly suggests future success within the present nursing follow setting? 86. Which of the next is an instance of an nervousness-inflicting state of affairs under that’s probably attributable to a task transition from LPN/LVN to RN? 87. The affected person reviews intense ache and charges it 10/10. He’s speaking and laughing on the phone however interrupts his conversion to request ache medicine. The nurse would decide in regards to the administration of medicine primarily based on which indicator of ache? 88. The nurse asks a hospitalized affected person to signal the operative consent. The affected person tells the nurse, “I do not likely perceive what’s concerned within the surgical procedure.” The nurse ought to: 89. If a affected person refuses a medicine or is present process a diagnostic take a look at that ends in a missed dose of medicine, the nurse will doc the omission on the medicine administration file and: 90. A affected person weighed 200 lb 6 months in the past. He now weighs 160 lb. He has not been making an attempt to shed weight. Based mostly on the defining traits of vitamin, lower than physique necessities, the nurse’s greatest response could be: 91. The nurse enters the room of a sleeping affected person to manage the 0200 dose of antibiotic that has been ordered each 6 hours. Which motion would most successfully keep a therapeutic blood degree of this medicine? 92. The nurse is to take a meal tray to a affected person the nurse is aware of nothing about. Earlier than leaving the tray with the affected person, which is probably the most essential security issue the nurse ought to decide? 93. A nurse notices that the respiratory therapist assigned to his unit steadily forgets to lift the mattress rails after finishing therapies. The nurse’s greatest motion is to: 94. A nurse is assigned to look after an aged, confused affected person. The affected person’s son is sitting on the bedside and is watching a loud tv program. The nurse wants to finish the respiratory and cardiac evaluation and important indicators. What could be the most effective method to this example? 95. A graduate RN on the telemetry unit is on the way in which to the nurse’s station to chart and instantly hears from a affected person’s room, “Assist! Nurse!” This isn’t the nurse’s assigned affected person. Others additionally hear this cry for assist and rapidly run in with the crash cart whereas the graduate RN seems on. In planning look after this affected person, the start RN should notice the significance of figuring out and (choose all that apply): 96. Which feedback by the graduate RN are examples of interventions that can result in a profitable transition into skilled nursing? (Choose all that apply.) 97. When offering discharge instructing for a consumer with uric acid calculi, the nurse would come with an instruction to keep away from which sort of weight loss plan? . 98. Dad and mom of a kid recognized with bacterial meningitis are asking the nurse questions relating to the illness course of. Which description in regards to the improvement of sequelae in infants with bacterial meningitis is most correct? 99. The nurse is caring for a consumer with continual hypertension who struggles with medicine compliance due to monetary points. When reviewing current lab work outcomes, which displays the consumer’s blood stress points? Choose all that apply. 100. The nurse is caring for a consumer who has a sort I second-diploma atrioventricular (AV) block. Which ECG rhythm would the nurse count on to see? 101. The nurse is caring for a consumer who has been positioned on phenobarbital 30 mg day by day for newly recognized seizure exercise. Which instruction could be included in consumer instructing particularly associated to anticonvulsant drug efficacy? 102. The nurse is caring for a consumer on hemodialysis who has an arteriovenous (AV) fistula in the best arm. When managing a consumer’s plan of care, which nursing directions/actions are applicable? Choose all that apply. 103. A float nurse is assigned to a surgical unit. The nurse is receiving two purchasers from the postanesthesia care unit (PACU) on the similar time. When delegating duties to different unit personnel who will not be identified to the nurse, which query could be most necessary to ask? 103. The nurse is triaging cellphone calls at a neighborhood pediatrician’s workplace. Which assertion by the mum or dad of a kid being handled for pinworms signifies that additional instructing is required? 104. The nurse is caring for a homeless consumer with pneumonia. Laboratory testing reveals the next outcomes: blood urea nitrogen (BUN) 180 mg/dl (64 mmol/L), creatinine 30 mg/dl (2,652 mmol/L), potassium 6.2 mEq/L (6.2 mmol/L), and hemoglobin 6.2% (62 g/L). Based mostly on the well being care supplier’s order under, which drug order would the nurse query? 105. The nurse is caring for a consumer with a nasogastric tube and in mitt restraints. Which nursing motion is required each 1 to 2 hours?