HESI HEALTH ASSESSMENT NURSING RN V1 100 Questions with answers 1. During a mental status examination, the nurse wants to assess a patient’s affect. The
... [Show More] nurse should ask the patient which question? 2. The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to: 3. A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not ____ four unrelated words ____. 4. During a mental status assessment, which question by the nurse would best assess a person’s judgment? 5. Which of these individuals would the nurse consider at highest risk for a suicide attempt? 6. When reviewing the use of alcohol by older adults, the nurse notes that older adults have several characteristics that can increase the risk of alcohol use. Which would increase the bioavailability of alcohol in the blood for longer periods in the older adult? 7. During an assessment, the nurse asks a female patient, “How many alcoholic drinks do you have a week?” Which answer by the patient would indicate at-risk drinking? 8. The nurse is asking an adolescent about illicit substance abuse. The adolescent answers, “Yes, I’ve used marijuana at parties with my friends.” What is the next question the nurse should ask? 9. The nurse has completed an assessment on a patient who came to the clinic for a leg injury. As a result of the assessment, the nurse has determined that the patient has at-risk alcohol use. Which action by the nurse is most appropriate at this time? 10. A patient is brought to the emergency department. He is restless, has dilated pupils, is sweating, has a runny nose and tearing eyes, and complains of muscle and joint pains. His girlfriend thinks he has influenza, but she became concerned when his temperature went up to 39.4° C. She admits that he has been a heavy drug user, but he has been trying to stop on his own. The nurse suspects that the patient is experiencing withdrawal symptoms from which substance? 11. Patient taking ipratropium reports nausea, blurred vision, has, insomnia after using the inhaler. RN action to implement 12. A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient? 13. The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? 14. The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: 15. Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should: 16. While measuring a patient’s blood pressure, the nurse recalls that certain factors, such as __________, help determine blood pressure. 17. A nurse is helping at a health fair at a local mall. When taking blood pressures on a variety of people, the nurse keeps in mind that: 8. The nurse notices a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading to: 19. A student is late for his appointment and has rushed across campus to the health clinic. The nurse should: 20. Hypoptysis (new cough) or changes in persistent cough 21. The nurse is assessing a patient’s pain. The nurse knows that the most reliable indicator of pain would be the: 22. A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is “bad this morning” and rates it at an 8 on a 1-to-10 scale. What does the nurse suspect? The patient: 23. The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system? 24. The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. The nurse should: 25. When assessing the quality of a patient’s pain, the nurse should ask which question? 26. When assessing a patient’s pain, the nurse knows that an example of visceral pain would be: 27. A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because: 28. The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a person’s: 29. A patient comes in for a physical examination and complains of “freezing to death” while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: 30. A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find: 31.The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to: 32. A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? 33. sarcoidosis - autoimmune inflammatory disease affecting multiple organs 34. A 19-year-old college student is brought to the emergency department with a severe headache he describes as, “Like nothing I’ve ever had before.” His temperature is 40° C, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem? 35. During a well-baby checkup, the nurse notices that a 1-week-old infant’s face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notices dilated scalp veins and downcast or “setting sun” eyes. The nurse suspects which condition? 36. The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the: 37. A patient has come in for an examination and states, “I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is?” The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his: 38. A male patient with a history of acquired immunodeficiency syndrome (AIDS) has come in for an examination and he states, “I think that I have the mumps.” The nurse would begin by examining the: 39. In performing an examination of a 3-year-old child with a suspected ear infection, the nurse would: 40. The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination? 41. The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? The infant: 42. The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal? 43. An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. The nurse would need to know additional information that includes which of these? 44. A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would be an appropriate response by the nurse? 45. A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is: 46. The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? 47. The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of: 48. A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notices a 0.5-cm, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is observed. What would the nurse tell this mother? 49. which finding should RN assess for a pt for a risk of DI (diabetes insipidus) 50. During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from: . 51. The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is _______ comparison. 52. When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets that these sounds are: 53.The nurse is auscultating the chest in an adult. Which technique is correct? 54. The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs will reveal: 55. During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. .
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