HESI Health Assessment
1. The nurse is caring for a patient with chronic lower A
back pain. The nurse knows that the most reliable
indicator of pain in this client is:
The patient is reporting "6/10" pain.
The patient is refusing to get out of bed.
The patient is refusing to eat breakfast.
The patient's heart rate is 90 beats per minute.
2. Which of the following actions should the nurse take B
to ensure an accurate blood pressure (BP) reading? The patient's arm should
be supported at heart level.
Ensure the width of the BP cuff is equal to 80% of the Separate BP readings may
arm circumference. need to be taken, but not
one right after the other.
Ensure the client's back is supported and feet are flat
The length of the BP blad-
on the ground.
der should equal 80% of
the arm circumferen
Take two BP readings 20 seconds apart.
Ensure that the patient's arm is above heart level.
3. The nurse obtains which piece of data during the A
general survey?
Client is alert and calm.
Client's heart rate is 80 beats per minute.
Client's body mass index (BMI) is 30.
, HESI Health Assessment
Client's lung sounds are "clear" to auscultation.
4. A man is at the clinic for a complete physical exam. A
He states that he is "very anxious". What steps can
the nurse take to make him more comfortable?
Appear confident and unhurried during the exam.
Measure vital signs at the end to allow the patient
sufficient time to relax.
Let him leave his clothes on during the examination.
Obtain another nurse to examine the patient.
5. A father brings his 13 month-old child in for "fever" C
and he reports that the child has been "pulling on his
left ear". Upon entering the exam room, the child is
asleep in the father's arms. The nurse should perform
which assessment first?
Use the otoscope to look inside the ear.
Use a penlight to check the eyes and nose.
Auscultate the lungs, heart, and abdomen.
Assess gross motor skills using the Denver II screen-
ing tool.
6. An 18 year-old presents to the emergency depart- A- constricted pupils are a
ment with "headache." Which of these assessment sign of recent opioid use,
findings alerts the nurse to recent opioid use? the rest are withdrawals
, HESI Health Assessment
Pupillary constriction
Hallucinations.
Fever.
Tachypnea.
7. While collecting the pulse on a 26 year-old client, the C
nurse notes that the heart rate seems to speed up
and then slow down in accordance with respirations.
The pulse is counted at 80 beats per minute. What
should the nurse do next?
Obtain orthostatic vital signs.
Notify the physician.
Document "sinus arrhythmia."
Use a doppler to confirm the finding.
8. An elderly client with pneumonia is being treated in D
the intensive care unit (ICU). He is acutely agitated,
restless, and disoriented. The nurse documents his
level of consciousness as:
Manic.
Demented.
Drowsy.
, HESI Health Assessment
Delirious.
9. The nurse is assessing a newborn infant. How should C
the nurse measure the heart rate (HR)?
Palpate the radial pulse for 15 seconds and multiply
by four.
Palpate the brachial pulse for 30 seconds and multi-
ply by two.
Auscultate the apical site for 60 seconds.
Apply a pulse oximeter to obtain both the HR and
SpO2.
10. A 28 year-old is brought to the emergency depart- A- hallucinations and delir-
ment. He is disoriented and hallucinating, and vi- ium are commonly seen w
tal signs are elevated. The nurse suspects that the alcohol withdrawal
patient is experiencing withdrawal symptoms from
which substance?
Alcohol.
Cocaine.
Cannabis.
Opiates.
11. When evaluating the temperature of older adults, the D
nurse should remember which aspect about an older
adult's body temperature?
1. The nurse is caring for a patient with chronic lower A
back pain. The nurse knows that the most reliable
indicator of pain in this client is:
The patient is reporting "6/10" pain.
The patient is refusing to get out of bed.
The patient is refusing to eat breakfast.
The patient's heart rate is 90 beats per minute.
2. Which of the following actions should the nurse take B
to ensure an accurate blood pressure (BP) reading? The patient's arm should
be supported at heart level.
Ensure the width of the BP cuff is equal to 80% of the Separate BP readings may
arm circumference. need to be taken, but not
one right after the other.
Ensure the client's back is supported and feet are flat
The length of the BP blad-
on the ground.
der should equal 80% of
the arm circumferen
Take two BP readings 20 seconds apart.
Ensure that the patient's arm is above heart level.
3. The nurse obtains which piece of data during the A
general survey?
Client is alert and calm.
Client's heart rate is 80 beats per minute.
Client's body mass index (BMI) is 30.
, HESI Health Assessment
Client's lung sounds are "clear" to auscultation.
4. A man is at the clinic for a complete physical exam. A
He states that he is "very anxious". What steps can
the nurse take to make him more comfortable?
Appear confident and unhurried during the exam.
Measure vital signs at the end to allow the patient
sufficient time to relax.
Let him leave his clothes on during the examination.
Obtain another nurse to examine the patient.
5. A father brings his 13 month-old child in for "fever" C
and he reports that the child has been "pulling on his
left ear". Upon entering the exam room, the child is
asleep in the father's arms. The nurse should perform
which assessment first?
Use the otoscope to look inside the ear.
Use a penlight to check the eyes and nose.
Auscultate the lungs, heart, and abdomen.
Assess gross motor skills using the Denver II screen-
ing tool.
6. An 18 year-old presents to the emergency depart- A- constricted pupils are a
ment with "headache." Which of these assessment sign of recent opioid use,
findings alerts the nurse to recent opioid use? the rest are withdrawals
, HESI Health Assessment
Pupillary constriction
Hallucinations.
Fever.
Tachypnea.
7. While collecting the pulse on a 26 year-old client, the C
nurse notes that the heart rate seems to speed up
and then slow down in accordance with respirations.
The pulse is counted at 80 beats per minute. What
should the nurse do next?
Obtain orthostatic vital signs.
Notify the physician.
Document "sinus arrhythmia."
Use a doppler to confirm the finding.
8. An elderly client with pneumonia is being treated in D
the intensive care unit (ICU). He is acutely agitated,
restless, and disoriented. The nurse documents his
level of consciousness as:
Manic.
Demented.
Drowsy.
, HESI Health Assessment
Delirious.
9. The nurse is assessing a newborn infant. How should C
the nurse measure the heart rate (HR)?
Palpate the radial pulse for 15 seconds and multiply
by four.
Palpate the brachial pulse for 30 seconds and multi-
ply by two.
Auscultate the apical site for 60 seconds.
Apply a pulse oximeter to obtain both the HR and
SpO2.
10. A 28 year-old is brought to the emergency depart- A- hallucinations and delir-
ment. He is disoriented and hallucinating, and vi- ium are commonly seen w
tal signs are elevated. The nurse suspects that the alcohol withdrawal
patient is experiencing withdrawal symptoms from
which substance?
Alcohol.
Cocaine.
Cannabis.
Opiates.
11. When evaluating the temperature of older adults, the D
nurse should remember which aspect about an older
adult's body temperature?
