HESI Health Assessment Fortis
Prioritize the nursing actions - Question and answersABC rule:
Airway
Breathing
Circulation
two point discrimination: Fingers - Question and answers2-3 mm
two point discrimination: Palm - Question and answers10 mm
two point discrimination: Forearm - Question and answers35 mm
Two point discrimination: Upper arm - Question and answers39
Cranial Nerves - Question and answers12 pairs of nerves that carry messages to and
from the brain
Nerve I - Question and answersOlfactory
Nerve II - Question and answersOptic
Nerve III - Question and answersOculomotor
Nerve IV - Question and answersTrochlear
Nerve V - Question and answersTrigeminal
Nerve VI - Question and answersAbducens
Nerve VII - Question and answersFacial
Nerve VIII - Question and answersAcoustic
Nerve IX - Question and answersGlossopharyngeal
Nerve X - Question and answersVagus
Nerve XI - Question and answersspinal accessory
Nerve XII - Question and answersHypoglossal
, Hips ROM Osteoarthritis - Question and answersPain increases at night, movement
increases pain
Reasons for enlarged spleen - Question and answerstraumatic injury
acute infection (mono)
referred chest pain, back, mid/upper R section of abd.
Hemorrhoids - Question and answerspainless, flabby pa-pules, are cause by varicose
veins. Thrombosed, contains clotted blood and becomes painful, swollen, shiny blue
mass that itches and bleeds with deification. Occur with straining stool, chronic
constipation, pregnancy, obesity, chronic liver disease, low fiber diet.
ascites assessment - Question and answerspathologic increase in fluid in peritoneal
cavity- percuss for dullness and resonance, shifting dullness, fluid wave
breast exam - Question and answersearly detection is important. Every woman should
preform exam monthly, as soon as menstrual bleeding has ceased or if
postmenopausal same date every month.
S1 - Question and answersthe first heart sound, heard when the atrioventricular (mitral
and tricuspid) valves close, beginning of systole, loudest at APEX
S2 - Question and answerssecond heart sound,heard when the semilunar valves close,
signals the end of systole, loudest at the BASE
chronic ear infection inspection - Question and answersuse an otoscope, for adults pull
up and back, for children pull down. Eardrum is yellow amber color, scarring and
denting may be present.
Cardiovascular - Question and answerspalpate cold feet, check pulses in both feet. May
indicate arterial deficiency or oxygen deficit. deep muscle pain in calf, lower leg or foot;
intermittent claudication feels like cramps, numbness, and tingling.
Chronic ear infection inspection - Question and answersinspect with otoscope. Pull up
and back for adults, down for children. Eardrum is yellow amber color, scarring may be
present
Seizure documentation - Question and answers*Course and duration-when a seizure
starts, do you have any warning signs? What type of sign?
*Motor activity-Where in your body doe the seizures begin? Do they travel through your
body? On one side or both? Does your muscle tone seem tense or limp
Any associated sign-color change in face or lips, loss of consciousness (for how long),
automatism, incontinence
Prioritize the nursing actions - Question and answersABC rule:
Airway
Breathing
Circulation
two point discrimination: Fingers - Question and answers2-3 mm
two point discrimination: Palm - Question and answers10 mm
two point discrimination: Forearm - Question and answers35 mm
Two point discrimination: Upper arm - Question and answers39
Cranial Nerves - Question and answers12 pairs of nerves that carry messages to and
from the brain
Nerve I - Question and answersOlfactory
Nerve II - Question and answersOptic
Nerve III - Question and answersOculomotor
Nerve IV - Question and answersTrochlear
Nerve V - Question and answersTrigeminal
Nerve VI - Question and answersAbducens
Nerve VII - Question and answersFacial
Nerve VIII - Question and answersAcoustic
Nerve IX - Question and answersGlossopharyngeal
Nerve X - Question and answersVagus
Nerve XI - Question and answersspinal accessory
Nerve XII - Question and answersHypoglossal
, Hips ROM Osteoarthritis - Question and answersPain increases at night, movement
increases pain
Reasons for enlarged spleen - Question and answerstraumatic injury
acute infection (mono)
referred chest pain, back, mid/upper R section of abd.
Hemorrhoids - Question and answerspainless, flabby pa-pules, are cause by varicose
veins. Thrombosed, contains clotted blood and becomes painful, swollen, shiny blue
mass that itches and bleeds with deification. Occur with straining stool, chronic
constipation, pregnancy, obesity, chronic liver disease, low fiber diet.
ascites assessment - Question and answerspathologic increase in fluid in peritoneal
cavity- percuss for dullness and resonance, shifting dullness, fluid wave
breast exam - Question and answersearly detection is important. Every woman should
preform exam monthly, as soon as menstrual bleeding has ceased or if
postmenopausal same date every month.
S1 - Question and answersthe first heart sound, heard when the atrioventricular (mitral
and tricuspid) valves close, beginning of systole, loudest at APEX
S2 - Question and answerssecond heart sound,heard when the semilunar valves close,
signals the end of systole, loudest at the BASE
chronic ear infection inspection - Question and answersuse an otoscope, for adults pull
up and back, for children pull down. Eardrum is yellow amber color, scarring and
denting may be present.
Cardiovascular - Question and answerspalpate cold feet, check pulses in both feet. May
indicate arterial deficiency or oxygen deficit. deep muscle pain in calf, lower leg or foot;
intermittent claudication feels like cramps, numbness, and tingling.
Chronic ear infection inspection - Question and answersinspect with otoscope. Pull up
and back for adults, down for children. Eardrum is yellow amber color, scarring may be
present
Seizure documentation - Question and answers*Course and duration-when a seizure
starts, do you have any warning signs? What type of sign?
*Motor activity-Where in your body doe the seizures begin? Do they travel through your
body? On one side or both? Does your muscle tone seem tense or limp
Any associated sign-color change in face or lips, loss of consciousness (for how long),
automatism, incontinence
