HEALTH ASSESSMENT HESI #2 BSN 246 UPDATED
ACTUAL QUESTIONS AND CORRECT ANSWERS
Question:
1. The registered nurse (RN) is developing the plan of care for a client who is admitted for alcohol
detoxification. Which goal should be most important for the RN to primarily focus the client's care?
The client maintains optimal nutritional status. The client will remain alert and oriented. The client will
remain free from injury. The client will remain alcohol free during hospitalization.
Answer:
The client will remain free from injury.
Rationale The client is at highest risk for injury due to altered cognitive and sensory disturbances as well as
delirium tremors during withdrawal. Remaining free from injury is the most important goal for the acute
phase of alcohol withdrawal.
Question:
2. A client with progressive hearing loss appears distressed when the registered nurse (RN) asks
open-ended questions about the client's health history. Which forms of communication should the RN
use?Select all that apply
Face the client so the client can see the RN's mouth. Increase one's speech volume when interacting with
the client. Repeat information to the client if misunderstood. Check if the client's hearing aides are working
properly. Reduce environmental noise surrounding the client.
Answer:
Face the client so the client can see the RN's mouth. Check if the client's hearing aides are working
properly. Reduce environmental noise surrounding the client.
Question:
3. The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the
RN document that are consistent with diminished peripheral circulation? (Select all that apply.)
Diminished hair on legs Bruising on extremities Skin cool to touch Capillary refill less than 3 seconds
Darkened skin on extremities
Answer:
Diminished hair on legs Skin cool to touch No on the Darkened skin on extremities - indicates hemosiderin
staining caused by the destruction of red blood cells and the release of the pigment heme within
hemoglobin. Occurs with peripheral vascular disease.
Rationale Diminished hair on the legs and skin that is cool to touch are symptoms of decreased arterial
blood flow. The other options are not indicators for impaired peripheral circulation.
Question:
4. A female client calls the clinic and talks with the registered nurse (RN) to inquire about a possible
reaction after taking amoxicillin for 5 days. She reports having vaginal discomfort, itching, and a white
discharge. The RN should discuss which action with the client?
Discontinue the antibiotic because original symptoms have subsided. Continue taking medication until
finished until the symptoms subside. Consult with healthcare provider about another treatment for this
effect. Use an over-the-counter (OTC) vaginal wash to flush out the secretions. **Think best
intervention**
, Answer:
Consult with healthcare provider about another treatment for this effect.
Rationale A superinfection with normal flora yeast may occur during antibiotic therapy. If suspected, the
new onset of findings should be reported to the healthcare provider for another prescribed treatment to
treat the superinfection.
Question:
5. The registered nurse (RN) is administering haloperidol
0.5 mg IM PRN to a client for the first time. What side effects should the RN assess the client for during
the initial dose?
Bradykinesia. Dystonia. Somatization. Akathisia.
Answer:
Dystonia: a neurological movement disorder that causes involuntary muscle contractions, resulting in
abnormal postures, repetitive movements, and sometimes pain Think in terms of ADVERSE REACTION
Rationale Dystonia can be a sudden adverse reaction to this psychotropic medication which should be
discontinued to resolve dystonia, and the healthcare provider notified immediately.
Question:
6. A client who is uses ipratropium reports having nausea, blurred vision, headaches, and insomnia after
using the inhaler. Which action should the registered nurse (RN) implement first?
Withhold medication and report symptoms and vital signs to healthcare provider. Give PRN medication
for nausea and vomiting and evaluate client in 30 minutes. Reassure client that the ipratropium given will
alleviate the symptoms. Delay administration of ipratropium until next maintenance medication is
scheduled.
Answer:
Withhold medication and report symptoms and vital signs to healthcare provider. **Again think beneficial
to the patient overall as a primary concern
Rationale Headache, nausea, blurred vision and insomnia are symptoms of excessive use of ipratropium,
so withholding the medication until the healthcare provider is notified should be initiated to maintain client
safety.
Question:
7. While caring for a client who has esophageal varices, which nursing intervention is most important for
the registered nurse (RN) to implement?
Monitor infusing IV fluids and any replacement blood products. Prepare for esophagogastroduodenoscopy
(EGD). Maintain the client on strict bedrest. Insert a nasogastric tube (NGT) for intermittent suction.
Answer:
Monitor infusing IV fluids and any replacement blood products. What is an esophagogastroduodenoscopy
(EGD) - a procedure that examines the upper gastrointestinal (GI) tract using a flexible tube with a camera
and light on the end.
Rationale Maintaining hemodynamic stability in a client with esophageal varicescan precipitatea
life-threatening crisis if esophageal varies leak or rupture and can result in hemorrhage. The priority is
assessing and monitoring infusions of IV fluids and any replacement blood products.
Question:
8. The registered nurse (RN) is caring for a client with acute pancreatitis and assesses the admission
laboratory results. What laboratory value should the RN anticipate being elevated with this diagnosis?
Triglycerides. Amylase. Creatinine. Uric acid.
ACTUAL QUESTIONS AND CORRECT ANSWERS
Question:
1. The registered nurse (RN) is developing the plan of care for a client who is admitted for alcohol
detoxification. Which goal should be most important for the RN to primarily focus the client's care?
The client maintains optimal nutritional status. The client will remain alert and oriented. The client will
remain free from injury. The client will remain alcohol free during hospitalization.
Answer:
The client will remain free from injury.
Rationale The client is at highest risk for injury due to altered cognitive and sensory disturbances as well as
delirium tremors during withdrawal. Remaining free from injury is the most important goal for the acute
phase of alcohol withdrawal.
Question:
2. A client with progressive hearing loss appears distressed when the registered nurse (RN) asks
open-ended questions about the client's health history. Which forms of communication should the RN
use?Select all that apply
Face the client so the client can see the RN's mouth. Increase one's speech volume when interacting with
the client. Repeat information to the client if misunderstood. Check if the client's hearing aides are working
properly. Reduce environmental noise surrounding the client.
Answer:
Face the client so the client can see the RN's mouth. Check if the client's hearing aides are working
properly. Reduce environmental noise surrounding the client.
Question:
3. The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the
RN document that are consistent with diminished peripheral circulation? (Select all that apply.)
Diminished hair on legs Bruising on extremities Skin cool to touch Capillary refill less than 3 seconds
Darkened skin on extremities
Answer:
Diminished hair on legs Skin cool to touch No on the Darkened skin on extremities - indicates hemosiderin
staining caused by the destruction of red blood cells and the release of the pigment heme within
hemoglobin. Occurs with peripheral vascular disease.
Rationale Diminished hair on the legs and skin that is cool to touch are symptoms of decreased arterial
blood flow. The other options are not indicators for impaired peripheral circulation.
Question:
4. A female client calls the clinic and talks with the registered nurse (RN) to inquire about a possible
reaction after taking amoxicillin for 5 days. She reports having vaginal discomfort, itching, and a white
discharge. The RN should discuss which action with the client?
Discontinue the antibiotic because original symptoms have subsided. Continue taking medication until
finished until the symptoms subside. Consult with healthcare provider about another treatment for this
effect. Use an over-the-counter (OTC) vaginal wash to flush out the secretions. **Think best
intervention**
, Answer:
Consult with healthcare provider about another treatment for this effect.
Rationale A superinfection with normal flora yeast may occur during antibiotic therapy. If suspected, the
new onset of findings should be reported to the healthcare provider for another prescribed treatment to
treat the superinfection.
Question:
5. The registered nurse (RN) is administering haloperidol
0.5 mg IM PRN to a client for the first time. What side effects should the RN assess the client for during
the initial dose?
Bradykinesia. Dystonia. Somatization. Akathisia.
Answer:
Dystonia: a neurological movement disorder that causes involuntary muscle contractions, resulting in
abnormal postures, repetitive movements, and sometimes pain Think in terms of ADVERSE REACTION
Rationale Dystonia can be a sudden adverse reaction to this psychotropic medication which should be
discontinued to resolve dystonia, and the healthcare provider notified immediately.
Question:
6. A client who is uses ipratropium reports having nausea, blurred vision, headaches, and insomnia after
using the inhaler. Which action should the registered nurse (RN) implement first?
Withhold medication and report symptoms and vital signs to healthcare provider. Give PRN medication
for nausea and vomiting and evaluate client in 30 minutes. Reassure client that the ipratropium given will
alleviate the symptoms. Delay administration of ipratropium until next maintenance medication is
scheduled.
Answer:
Withhold medication and report symptoms and vital signs to healthcare provider. **Again think beneficial
to the patient overall as a primary concern
Rationale Headache, nausea, blurred vision and insomnia are symptoms of excessive use of ipratropium,
so withholding the medication until the healthcare provider is notified should be initiated to maintain client
safety.
Question:
7. While caring for a client who has esophageal varices, which nursing intervention is most important for
the registered nurse (RN) to implement?
Monitor infusing IV fluids and any replacement blood products. Prepare for esophagogastroduodenoscopy
(EGD). Maintain the client on strict bedrest. Insert a nasogastric tube (NGT) for intermittent suction.
Answer:
Monitor infusing IV fluids and any replacement blood products. What is an esophagogastroduodenoscopy
(EGD) - a procedure that examines the upper gastrointestinal (GI) tract using a flexible tube with a camera
and light on the end.
Rationale Maintaining hemodynamic stability in a client with esophageal varicescan precipitatea
life-threatening crisis if esophageal varies leak or rupture and can result in hemorrhage. The priority is
assessing and monitoring infusions of IV fluids and any replacement blood products.
Question:
8. The registered nurse (RN) is caring for a client with acute pancreatitis and assesses the admission
laboratory results. What laboratory value should the RN anticipate being elevated with this diagnosis?
Triglycerides. Amylase. Creatinine. Uric acid.
