HESI Health Assessment
HESI Health Assessment (Questions and
Answers) A+ Rated
What is gamma globulin and when is it used?
Gamma globulin, which is
... [Show More] 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
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
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.
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?
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 [Show Less]