HEALTH ASSESSMENT HESI EXAM REVISION GUIDE GRADED A

HEALTH ASSESSMENT HESI EXAM REVISION GUIDE GRADED A 1) A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination? a) Auscultate the lungs and heart while the infant is still sleeping. b) Examine the infant’s hips because this procedure is uncomfortable. c) Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach. D}Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems. 2) A 2-year-old child has been brought to the clinic for a well-child check-up. The best way for the nurse to begin the assessment is reflected by which statement? a) Ask the parent to place the child on the examining table. b) Have the parent remove all of the child’s clothing before the examination. c) Allow the child to keep a security object such as a toy or blanket during the examination. d) Initially focus interactions on the child, essentially “ignoring” the parent, until the child’s trust has been obtained. 3) The nurse is examining a 2-year-old child and asks, “May I listen to your heart now?” Which critique of the nurse’s technique is most accurate? a) Asking questions enhances the child’s autonomy. b) Asking the child for permission helps to develop a sense of trust. c) This is an appropriate statement because children at this age like to have choices. d) Children at this age like to say “No.” The examiner should not offer a choice when there is none 4) A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse’s best course of action? a) The nurse should plan to perform a complete mental status examination. b) The nurse should refer him to a psychometrician. c) The nurse should plan to integrate the mental status examination into the history and physical examination. d) The nurse should reassure his wife that memory loss after a physical shock is normal and willsubside soon. 5) The nurse is conducting a patient interview. Which statement made by the patient should the nurse explore more fully during the interview? The patient states that he: a) “Sleeps like a baby” b) Has no health problems c) “Never did too good in school” d) Currently is not taking any medication 6) A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient's speech is dysarthric and that she is lethargic. The nurse’s best approach regarding this examination is to: a) Plan to defer the rest of the mental status examination b) Skip the language portion of the examination and go on to assess mood and affect c) Do an in-depth speech evaluation and defer the mental status examination to another time d) Go ahead and assess for suicidal thoughts because dysarthria is often accompanied by severe depression 7) A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes: a) She probably doesn’t have any problems at all. b) She is just trying to shock people and her dress should be ignored. c) She has manic syndrome because of her abnormal dress and grooming. d) That more information should be gathered to decide whether her dress is appropriate. 8) A patient has been in the intensive care unit for 10 days. He has just been moved to the medical surgical unit, and the admitting nurse is planning to perform a mental status examinationon him. During the tests of cognitive function, the nurse would expect that he: a) May display some disruption in thought content b) Will state, “I am so relieved to be out of intensive care” c) Will be oriented to place and person but may not be certain of the date d) May show evidence of some clouding of his level of consciousness 9) During a mental status examination, the nurse wants to assess a patient’s affect. The nurse should ask the patient which question? a) “How do you feel today?” b) “Would you please repeat the following words?” c) “Have these medications had any effect on your pain?” d) “Has this pain affected your ability to get dressed by yourself?” 10) The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to: a) Administer the FACT test. b) Ask him to describe his first job. c) Give him the Four Unrelated Words test. d) Ask him to describe what television show he was watching before coming to the clinic. 11) A 29-year-old woman tells the nurse that she has “excruciating pain” in her back. Which would be an appropriate response by the nurse to the woman’s statement? a) “How does your family react to your pain?” b) “That must be terrible. You probably pinched a nerve.” c) “I’ve had back pain myself, and it can be excruciating.” d) “How would you say the pain affects your ability to do your daily activities?” 12) In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? a) Patient denies usual childhood illnesses. b) Patient states he was a “very healthy” child. c) Patient states sister had measles, but he didn’t. d) Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.