HESI HEALTH ASSESSMENT. ACTUAL 2024/2025 REAL EXAM UPDATES.

HESI HEALTH ASSESSMENT. ACTUAL 2024/2025 REAL EXAM UPDATES. SOAP modified format - Correct Answer: Subjective Objective Assessment Plan What color ink should be used when documenting on paper - Correct Answer -Permanent black ink What is the correct order for vital signs - Correct Answer: T, P, RR, BP, extremity, pt position, SPO2 What should be at the top of every page of documentation - Correct Answer -Patient initials and date and time of entry What should be at the end of every documentation entry - Correct Answer -Interviewers signature How do you correct a mistake in documentation - Correct Answer: 1) Draw a single line through the incorrect documentation Write error above the entry Initial and date the crossed out entry Documentation tips - Correct Answer: 1) Avoid complete sentences Do not use A, an, the Do not put opinion in notes Avoid use of normal or within normal limits Normal oral temp range - Correct Answer: 96.4 - 99.1 F Febrile - Correct Answer: With fever Afebrile - Correct Answer: Without fever Hyperthermia symptoms - Correct Answer: 1) Cessation of shivering Bradycardia Decrease in respiratory minute volume Most common and easy method of assessing temperature - Correct Answer -Oral What methods of assessing temperature reflects core temperature - Correct Answer: 1) Oral Rectal Tympanic Temporal Artery What is the least accurate method of assessing temperature - Correct Answer: axillary Which patients are contraindicated for rectal temperature readings - Correct Answer: Patients with increased HR Preferred method of taking infants and small children's temperatures - Correct Answer: Rectal Pulse deficit - Correct Answer: - Difference between apical peripheral pulse Pulse amplitude scale - Correct Answer: 0 = no pulse 1 = diminished, weak 2 = normal and expected 3 = full or strong 4 = bounding Which pulses are assessed during a routine physical assessment? - Correct Answer: 1) Apical Radial Dorsalis pedis Posterior tibialis Normal heart rate in resting adult - Correct Answer: 60 to 100 bpm Well trained athletes heart rate - Correct Answer: Heart rate less than 60 bpm When is it normal for someone to have a rapid heart rate over 100 bpm - Correct Answer: Someone with anxiety and right after exercise Eupnea - Correct Answer: Normal RR, rhythm and depth Normal SPO2 value - Correct Answer: 95-100% What level is poor oxygenation - Correct Answer: below 90% Systolic BP - Correct Answer: Maximum pressure on the artery during ventricular contraction Diastolic BP - Correct Answer: Resting pressure during ventricular filling Pulse pressure - Correct Answer: Difference between systolic and diastolic Stroke volume - Correct Answer: Amount of blood ejected with each beat How does age affect BP - Correct Answer: BP increases with age What BP is pre hypertensive? - Correct Answer: Sustained BP over 120/80 What extremities should you avoid taking a BP in - Correct Answer -Extremities with IV lines, invasive lines, history of mastectomy/lymph node issues Orthostatic hypertension - Correct Answer: - Decreased BP with change in position Drop in SBP of 25 mmHg or DBP of 10 mmHG Symptoms Dizziness Weakness Blurred vision Syncope Changes in BP/HR - Causes Hypovolemia Impaired vasoconstriction Medications Precautions in someone with orthostatic hypertension - Correct Answer: - change positions slowly falls risk assist back to bed if symptomatic What is the main objective of the health history - Correct Answer: - To gather accurate information to provide immediate care Establish rapport with the client What does establishing a positive patient relationship depend on - Correct Answer: 1) courtesy comfort connection confirmation confidentiality What questions should you begin with for a health history interview - Correct Answer: Open ended questions Approaching Sensitive Issues - Correct Answer: - Use language that is understandable. Do not apologize for broaching the issue. Ensure privacy. Be direct and firm. Do not preach. Do not push too hard. CAGE questionnaire - Correct Answer: Cutting down Annoyance Guilty feeling Eye-openers Helps diagnose alcoholism TACE questionnaire - Correct Answer: T - how many drinks does it TAKE to make you feel right A - Have people ANNOYED you by criticizing your drinking C - Have you felt you out to cut down on your drinking E - Have you had an EYE -OPENER first thing in the morning CRAFFT questionnaire - Correct Answer: - Screening tool for alcohol and substance abuse in adolescents Car Relax Alone Forget Friends Trouble What is the goal of a screening tool? - Correct Answer: To find out if the problem exists Three questions to detect partner violence - Correct Answer: - Have you ever been hit, kicked, punched, or otherwise hurt by someone within the past year? Do you feel safe in your current relationship? Is there a partner from a previous relationship who is making you feel unsafe now? HITS questionnaire - Correct Answer: The wording of the question is "In the last year how often did your partner: Hurt you physically?" Insult or talk down to you?" Threaten you with physical harm?" Scream or curse at you?" FICA - Correct Answer: Faith Importance and Influence Community Address/action in care Format of interview - Correct Answer: CC HPI PMH PSH FH SH ROS Is pain subjective or objective - Correct Answer: Subjective PMH - Correct Answer: 1) Allergies Childhood and adult illnesses Immunizations Diagnostic and lab results Symptom analysis tool - Correct Answer: OLDCARTS Complete history - Correct Answer: Most often recorded the first time you see the patient Inventory history - Correct Answer: - Related to but does not replace the complete history Touches on major points without complete detail Entire history will be completed in more than one session Problem (or focused) history - Correct Answer: Taken when a problem is acute so that only the need of the moment is given full attention Interim history - Correct Answer: - Designed to chronicle events that have occurred since your last meeting with the patient Substance determined by nature of problem and need of the moment Should always be complemented by the patient's previous medical record Transduction of pain - Correct Answer: Action potential moves to the spinal cord Transmission of pain - Correct Answer: Pain impulse moves from spinal cord to the brain Modulation of pain - Correct Answer: Neurons from the brain stem release neurotransmitters that block the pain impulse Steps in pain - Correct Answer: 1) Noxious stimuli and transduction Transmission Perception of pain Modulation Neuropathic pain - Correct Answer: - Pain within nervous system Abnormal processing of pain from nerve fibers Often chronic Visceral pain - Correct Answer: - Originates from larger internal organs Often described as crampy Physical pain based on site of organ Somatic pain - Correct Answer: Originates from MS system Referred pain - Correct Answer: Pain is felt from a different site other than where it originates Gallbladder referred pain - Correct Answer: The shoulder Kidney referred pain - Correct Answer: The lower back Acute pain - Correct Answer: - Less than 6 mos Chronic pain - Correct Answer: - pain lasting longer than 6 months Hard to treat Elderly and pain - Correct Answer: - No evidence exists to suggest that older individuals perceive pain to a lesser degree or that sensitivity is diminished Infants and pain - Correct Answer: - Do not have adequate number of inhibitory neurotransmitters, so thought to be more sensitive to pain (premies full-term) What is most reliable indicator of pain - Correct Answer: Subjective report Pain rating scale - Correct Answer: - scale 0 to 10 Pain rating scales can indicate a baseline intensity, track changes, and give some degree of evaluation to a treatment modality Reflect pain intensity Older adults may prefer the descriptor scale that asks patients to indicate their pain by using selected pain term words Verbal descriptor scales - Correct Answer: have the patient use words to describe pain Visual analog scales - Correct Answer: have the patient mark the intensity of the pain on a horizontal line from "no pain" to "worst pain" Should pain be discounted when objective, physical evidence is not found - Correct Answer: NO Epidermis - Correct Answer: - Protection Avascular Contains Keratin Top layer of the skin Dermis - Correct Answer: - Connective tissue collagen, elasticity Sensory nerve fibers Vascular Nourish the epidermis Middle layer Hypodermis - Correct Answer: - Connects dermis to organs Connective tissue and fat Acts as insulation and shock protection Bottom layer Lanugo - Correct Answer: - fine downy hair of newborn infant Vernix caseosa - Correct Answer: thick, cheesy substance on newborn infant Sebum - Correct Answer: holding water in the skin producing milia Children developmental considerations of skin - Correct Answer: - Epidermis thickens, darkens, and becomes lubricated Hair growth accelerates Adolescents - Correct Answer: - Secretions from apocrine sweat glands increase Subcutaneous fat deposits increase Secondary sex characteristics Linea nigra - Correct Answer: Increased pigmentation midline of abdomen that occurs in pregnant women Chloasma - Correct Answer: Discoloration changes on face representing the "mask of pregnancy" Striae gravidarum - Correct Answer: Stretch marks, which can develop over the abdomen, breast, and thighs after pregnancy Elasticity in the aging adult - Correct Answer: Loses elasticity; skin folds and sags Sweat and sebaceous glands in the aging adult - Correct Answer: Decrease in number and function, leaving skin dry Senile purpura in the aging adult - Correct Answer: Discoloration due to increasing capillary fragility Skin breakdown due to multiple factors in the aging adult - Correct Answer -Cell replacement is slower and wound healing is delayed Hair matrix in the aging adult - Correct Answer: Functioning melanocytes decrease, leading to gray fine hair Annular or circular lesions - Correct Answer: Round Confluent lesions - Correct Answer: Cant tell where one ends and the other begins Discrete lesions - Correct Answer: -distinct, individual lesions that remain seperate (eg acrochordon= skin tags, or acne) Gyrate lesions - Correct Answer: Worm like lesions Grouped lesions - Correct Answer: Discrete lesions grouped together Linear lesions - Correct Answer: Lesions in a straight line Target lesions - Correct Answer: Round lesions with a light outer ring and dark inner ring Zosteriform lesions - Correct Answer: Band like, unilateral lesion group Polycyclic lesions - Correct Answer: are lesions that are circular but united Examples: psoriasis Macule - Correct Answer: flat skin lesion with only a color change Patch skin lesion - Correct Answer: Larger macule Papule - Correct Answer: - A small, raised, solid pimple or swelling, often forming part of a rash on the skin and typically inflamed but not producing pus. Smaller than 1 cm