HESI HEALTH ASSESSMENT VERSION 5 LATEST 2024 ACTUAL EXAM
100+ QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |A+ GRADED
120. During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors
when he reaches for something and his head is always nodding. There is no associated rigidity with
movement. Which of these statements is most accurate?
A) These are normal findings resulting from aging.
B) These could be related to hyperthyroidism.
C) These are the result of Parkinson disease.
D) This patient should be evaluated for a cerebellar lesion. - ANSA) These are normal findings resulting
from aging.
Page: 659. Senile tremors occasionally occur. These benign tremors include an intention tremor of the
hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson
disease include rigidity, slowness, and weakness of voluntary movement. The other responses are
incorrect.
121. While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days
earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding
is indicative of:
A) a great sense of humor.
B) uncooperative behavior.
C) inability to understand questions.
D) decreased level of consciousness. - ANSD) decreased level of consciousness.
Pages: 660-661. A change in consciousness may be subtle. The nurse should notice any decreasing level
of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a
previously combative person. The other responses are incorrect.
122. The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial
pressure, what would the nurse include in the assessment?
A) Cranial nerves, motor function, and sensory function
,HESI HEALTH ASSESSMENT VERSION 5 LATEST 2024 ACTUAL EXAM
100+ QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |A+ GRADED
B) Deep tendon reflexes, vital signs, and coordinated movements
C) Level of consciousness, motor function, pupillary response, and vital signs
D) Mental status, deep tendon reflexes, sensory function, and pupillary response - ANSC) Level of
consciousness, motor function, pupillary response, and vital signs
Pages: 660-661. Some hospitalized persons have head trauma or a neurologic deficit from a systemic
disease process. These people must be monitored closely for any improvement or deterioration in
neurologic status and for any indication of increasing intracranial pressure. The nurse should use an
abbreviation of the neurologic examination in the following sequence: level of consciousness, motor
function, pupillary response, and vital signs.
123. During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours
ago, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated
and nonreactive, left pupil is 4 mm and reacts to light. What does finding this suggest?
A) Injury to the right eye
B) Increased intracranial pressure
C) Test was not performed accurately
D) Normal response after a head injury - ANSB) Increased intracranial pressure
Pages: 662-663. In a brain-injured person, a sudden, unilateral, dilated, and nonreactive pupil is
ominous. Cranial nerve III runs parallel to the brainstem. When increasing intracranial pressure pushes
the brainstem down (uncal herniation), it puts pressure on cranial nerve III, causing pupil dilation. The
other responses are incorrect.
124. The nurse knows that determining whether a person is oriented to his or her surroundings will test
the functioning of which of these structures?
A) Cerebrum
B) Cerebellum
C) Cranial nerves
D) Medulla oblongata - ANSA) Cerebrum
,HESI HEALTH ASSESSMENT VERSION 5 LATEST 2024 ACTUAL EXAM
100+ QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |A+ GRADED
Pages: 621-622 | Page: 660. The cerebral cortex is responsible for thought, memory, reasoning,
sensation, and voluntary movement. The other options structures are not responsible for a person's
level of consciousness.
1. In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which
statement is true regarding note-taking?
A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors.
B) Note-taking allows the patient to continue at his or her own pace as the nurse records what is said.
C) Note-taking allows the nurse to shift attention away from the patient, resulting in an increased
comfort level.
D) Note-taking allows the nurse to break eye contact with the patient, which may increase his or her
level of comfort. - ANSA) Note-taking may impede the nurse's observation of the patient's nonverbal
behaviors.
Page: 31 Some use of history forms and note-taking may be unavoidable. But be aware that note-taking
during the interview has disadvantages. It breaks eye contact too often, and it shifts attention away
from the patient, which diminishes his or her sense of importance. It also may interrupt the patient's
narrative flow, and it impedes the observation of the patient's nonverbal behavior.
2. During an interview, the nurse states, "You mentioned shortness of breath. Tell me more about that."
Which verbal skill is used with this statement?
A) Reflection
B) Facilitation
C) Direct question
D) Open-ended question - ANSD) Open-ended question
Page: 32 The open-ended question asks for narrative information. It states the topic to be discussed but
only in general terms. The nurse should use it to begin the interview, to introduce a new section of
questions, and whenever the person introduces a new topic.
, HESI HEALTH ASSESSMENT VERSION 5 LATEST 2024 ACTUAL EXAM
100+ QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |A+ GRADED
3. A nurse is taking complete health histories on all of the patients attending a wellness workshop. On
the history form, one of the written questions asks, "You don't smoke, drink, or take drugs, do you?"
This question is an example of:
A) talking too much.
B) using confrontation.
C) using biased or leading questions.
D) using blunt language to deal with distasteful topics. - ANSC) using biased or leading questions.
Page: 36 This is an example of using leading or biased questions. Asking, "You don't smoke, do you?"
implies that one answer is "better" than another. If the person wants to please someone, he or she is
either forced to answer in a way corresponding to their implied values or is made to feel guilty when
admitting the other answer.
4. During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer
begins to discuss his son's treatment, however, he suddenly crosses his arms against his chest and
crosses his legs. This would suggest that the parent is:
A) just changing positions.
B) more comfortable in this position.
C) tired and needs a break from the interview.
D) uncomfortable talking about his son's treatment. - ANSD) uncomfortable talking about his son's
treatment.
Page: 37 Note the person's position. An open position with the extension of large muscle groups shows
relaxation, physical comfort, and a willingness to share information. A closed position with the arms and
legs crossed tends to look defensive and anxious. Note any change in posture. If a person in a relaxed
position suddenly tenses, it suggests possible discomfort with the new topic.
5. The nurse is interviewing a patient who has a hearing impairment. What techniques would be most
beneficial in communicating with this patient?
A) Determine the communication method he prefers.
100+ QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |A+ GRADED
120. During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors
when he reaches for something and his head is always nodding. There is no associated rigidity with
movement. Which of these statements is most accurate?
A) These are normal findings resulting from aging.
B) These could be related to hyperthyroidism.
C) These are the result of Parkinson disease.
D) This patient should be evaluated for a cerebellar lesion. - ANSA) These are normal findings resulting
from aging.
Page: 659. Senile tremors occasionally occur. These benign tremors include an intention tremor of the
hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson
disease include rigidity, slowness, and weakness of voluntary movement. The other responses are
incorrect.
121. While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days
earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding
is indicative of:
A) a great sense of humor.
B) uncooperative behavior.
C) inability to understand questions.
D) decreased level of consciousness. - ANSD) decreased level of consciousness.
Pages: 660-661. A change in consciousness may be subtle. The nurse should notice any decreasing level
of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a
previously combative person. The other responses are incorrect.
122. The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial
pressure, what would the nurse include in the assessment?
A) Cranial nerves, motor function, and sensory function
,HESI HEALTH ASSESSMENT VERSION 5 LATEST 2024 ACTUAL EXAM
100+ QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |A+ GRADED
B) Deep tendon reflexes, vital signs, and coordinated movements
C) Level of consciousness, motor function, pupillary response, and vital signs
D) Mental status, deep tendon reflexes, sensory function, and pupillary response - ANSC) Level of
consciousness, motor function, pupillary response, and vital signs
Pages: 660-661. Some hospitalized persons have head trauma or a neurologic deficit from a systemic
disease process. These people must be monitored closely for any improvement or deterioration in
neurologic status and for any indication of increasing intracranial pressure. The nurse should use an
abbreviation of the neurologic examination in the following sequence: level of consciousness, motor
function, pupillary response, and vital signs.
123. During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours
ago, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated
and nonreactive, left pupil is 4 mm and reacts to light. What does finding this suggest?
A) Injury to the right eye
B) Increased intracranial pressure
C) Test was not performed accurately
D) Normal response after a head injury - ANSB) Increased intracranial pressure
Pages: 662-663. In a brain-injured person, a sudden, unilateral, dilated, and nonreactive pupil is
ominous. Cranial nerve III runs parallel to the brainstem. When increasing intracranial pressure pushes
the brainstem down (uncal herniation), it puts pressure on cranial nerve III, causing pupil dilation. The
other responses are incorrect.
124. The nurse knows that determining whether a person is oriented to his or her surroundings will test
the functioning of which of these structures?
A) Cerebrum
B) Cerebellum
C) Cranial nerves
D) Medulla oblongata - ANSA) Cerebrum
,HESI HEALTH ASSESSMENT VERSION 5 LATEST 2024 ACTUAL EXAM
100+ QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |A+ GRADED
Pages: 621-622 | Page: 660. The cerebral cortex is responsible for thought, memory, reasoning,
sensation, and voluntary movement. The other options structures are not responsible for a person's
level of consciousness.
1. In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which
statement is true regarding note-taking?
A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors.
B) Note-taking allows the patient to continue at his or her own pace as the nurse records what is said.
C) Note-taking allows the nurse to shift attention away from the patient, resulting in an increased
comfort level.
D) Note-taking allows the nurse to break eye contact with the patient, which may increase his or her
level of comfort. - ANSA) Note-taking may impede the nurse's observation of the patient's nonverbal
behaviors.
Page: 31 Some use of history forms and note-taking may be unavoidable. But be aware that note-taking
during the interview has disadvantages. It breaks eye contact too often, and it shifts attention away
from the patient, which diminishes his or her sense of importance. It also may interrupt the patient's
narrative flow, and it impedes the observation of the patient's nonverbal behavior.
2. During an interview, the nurse states, "You mentioned shortness of breath. Tell me more about that."
Which verbal skill is used with this statement?
A) Reflection
B) Facilitation
C) Direct question
D) Open-ended question - ANSD) Open-ended question
Page: 32 The open-ended question asks for narrative information. It states the topic to be discussed but
only in general terms. The nurse should use it to begin the interview, to introduce a new section of
questions, and whenever the person introduces a new topic.
, HESI HEALTH ASSESSMENT VERSION 5 LATEST 2024 ACTUAL EXAM
100+ QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |A+ GRADED
3. A nurse is taking complete health histories on all of the patients attending a wellness workshop. On
the history form, one of the written questions asks, "You don't smoke, drink, or take drugs, do you?"
This question is an example of:
A) talking too much.
B) using confrontation.
C) using biased or leading questions.
D) using blunt language to deal with distasteful topics. - ANSC) using biased or leading questions.
Page: 36 This is an example of using leading or biased questions. Asking, "You don't smoke, do you?"
implies that one answer is "better" than another. If the person wants to please someone, he or she is
either forced to answer in a way corresponding to their implied values or is made to feel guilty when
admitting the other answer.
4. During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer
begins to discuss his son's treatment, however, he suddenly crosses his arms against his chest and
crosses his legs. This would suggest that the parent is:
A) just changing positions.
B) more comfortable in this position.
C) tired and needs a break from the interview.
D) uncomfortable talking about his son's treatment. - ANSD) uncomfortable talking about his son's
treatment.
Page: 37 Note the person's position. An open position with the extension of large muscle groups shows
relaxation, physical comfort, and a willingness to share information. A closed position with the arms and
legs crossed tends to look defensive and anxious. Note any change in posture. If a person in a relaxed
position suddenly tenses, it suggests possible discomfort with the new topic.
5. The nurse is interviewing a patient who has a hearing impairment. What techniques would be most
beneficial in communicating with this patient?
A) Determine the communication method he prefers.
