NSG 121 Health Assessment HESI Final Exam
questions with verified answers
Abdmoninal Palpation for Elderly Ans✓✓✓ Dividing the abdomen into
4 quadrants assists with location of the underlying organs. The elderly
are less likely to feel pain with abdominal conditions and do not always
present with classic symptoms and laboratory findings. They are more
likely to have vague diffuse pain and tend to have a less acute
presentation.
Abdomen Auscultation for Bruit Ans✓✓✓ Bruits are swishing sounds
that indicate turbulent blood flow resulting from constriction or dilation
of a tortuous vessel. Bruits in the hepatic area indicate liver cancer or
alcoholic hepatitis. Bruits over the aorta or renal arteries indicate partial
obstruction of the aorta or renal artery.
Abstract Thinking Ans✓✓✓ Assessment of thought processes:
Patient's thoughts are easy to follow, logical, coherent, relevant, goal
directed, consistent, and abstract
Abstract Thinking: Ability to understand concepts that are real
ADLs Ans✓✓✓ Mobility impairments affecting activities of daily
living (ADLs) and instrumental activities of daily living (IADLs)
Allen Test Ans✓✓✓ When indicated, perform the Allen test to assess
the patency of the collateral circulation of the hands (Fig. 18.9). Ask the
patient to make a fist. Occlude the radial and ulnar arteries of the same
, hand. Have the patient open the hand; release pressure on the ulnar
artery. Do the same with the radial artery.
APGAR Ans✓✓✓ 1 min & 5 min
7-10 indicates vigorous newborn adapting well
If the 5-minute score is less than 7, continue to score every 5 minutes up
to 20 minutes until the score is above 7, the newborn is intubated, or the
newborn is transferred to the nursery.
A score of 4-6 indicates the newborn is moderately depressed, and 0-3
indicates severe respiratory depression and requires observation and care
in a NICU.
Assessment for Anal Hemorrhoids Ans✓✓✓ Observe anus while
patient bears down, then lubricate index finger and have patient take
deep breath while you insert finger. Should feel full closure around
finger. Can be external or internal.
Hemorrhoids are usually caused by constant or excessive straining upon
defecation
Assessment of Mouth/Tongue Ans✓✓✓ Holding a light in the
nondominant hand and a tongue blade in the dominant one, gently
separate areas to fully inspect the buccal mucosa, noting color and
pigmentation
Small, isolated, white or yellow papules (Fordyce granules) may be
noted on the cheeks, tongue, and lips. These sebaceous cysts or salivary
tissues are insignificant
questions with verified answers
Abdmoninal Palpation for Elderly Ans✓✓✓ Dividing the abdomen into
4 quadrants assists with location of the underlying organs. The elderly
are less likely to feel pain with abdominal conditions and do not always
present with classic symptoms and laboratory findings. They are more
likely to have vague diffuse pain and tend to have a less acute
presentation.
Abdomen Auscultation for Bruit Ans✓✓✓ Bruits are swishing sounds
that indicate turbulent blood flow resulting from constriction or dilation
of a tortuous vessel. Bruits in the hepatic area indicate liver cancer or
alcoholic hepatitis. Bruits over the aorta or renal arteries indicate partial
obstruction of the aorta or renal artery.
Abstract Thinking Ans✓✓✓ Assessment of thought processes:
Patient's thoughts are easy to follow, logical, coherent, relevant, goal
directed, consistent, and abstract
Abstract Thinking: Ability to understand concepts that are real
ADLs Ans✓✓✓ Mobility impairments affecting activities of daily
living (ADLs) and instrumental activities of daily living (IADLs)
Allen Test Ans✓✓✓ When indicated, perform the Allen test to assess
the patency of the collateral circulation of the hands (Fig. 18.9). Ask the
patient to make a fist. Occlude the radial and ulnar arteries of the same
, hand. Have the patient open the hand; release pressure on the ulnar
artery. Do the same with the radial artery.
APGAR Ans✓✓✓ 1 min & 5 min
7-10 indicates vigorous newborn adapting well
If the 5-minute score is less than 7, continue to score every 5 minutes up
to 20 minutes until the score is above 7, the newborn is intubated, or the
newborn is transferred to the nursery.
A score of 4-6 indicates the newborn is moderately depressed, and 0-3
indicates severe respiratory depression and requires observation and care
in a NICU.
Assessment for Anal Hemorrhoids Ans✓✓✓ Observe anus while
patient bears down, then lubricate index finger and have patient take
deep breath while you insert finger. Should feel full closure around
finger. Can be external or internal.
Hemorrhoids are usually caused by constant or excessive straining upon
defecation
Assessment of Mouth/Tongue Ans✓✓✓ Holding a light in the
nondominant hand and a tongue blade in the dominant one, gently
separate areas to fully inspect the buccal mucosa, noting color and
pigmentation
Small, isolated, white or yellow papules (Fordyce granules) may be
noted on the cheeks, tongue, and lips. These sebaceous cysts or salivary
tissues are insignificant
