HESI HEALTH ASSESSMENT TEST EXAM, STUDY GUIDE WITH COMPLETE QUESTIONS AND VERIFIED ANSWERS

HESI HEALTH ASSESSMENT TEST EXAM, STUDY GUIDE WITH COMPLETE QUESTIONS AND VERIFIED ANSWERS .*grading muscle strength (1-5 scale) - Answer-0 = no contraction 1 = barely detectable contraction 2 = active movement with gravity eliminated 3 = active movement against gravity 4 = active movement w/ some resistance 5 = active movement against full resistance w/ no evidence of fatigue .+ allis sing - Answer-- hip dislocation in an infant .+ tinels sign - Answer-- found in persons with carpel tunnel .1+ pitting edema - Answer-- mild pitting - 2 mm .2 point discrimination test - Answer-The patient is sitting with hand stabilized on a hard surface. The therapist, using a caliper, 2-point discriminator, or paper clip, applies the device to the palmar aspect of the fingers to assess the patients ability to distinguish between 2 points of the testing device. Record smallest difference that the patient can sense 2 seperate points. Normal = <6mm, Poor = 11-15mm, Handling precision tools = 12mm, Gross Tool Handling = 15mm. .2+ pitting edema - Answer-- modera edema - 4 mm pitting .24hrs after surgical gastric bypass. RN obserces large amounts of blood in NGT cannister. Which assessment finding should the RN report as early signs of hypovolemic shock - Answer-- lethargy .4+ response - Answer-- brisk, hyperactive response .5 segments of the breast - Answer-- Divided into 5 segments - 4 Quadrants 1) Upper Inner Quadrant 2) Lower Inner Quadrant 3) Upper Outer Quadrant 4) Lower Outer Quadrant - Axillary tail of Spence .A A chronic seasonal cough related to bronchitis is likely accompanied with phlegm production and wheezing (A). Although smoking can contribute to chronic cough, the typical seasonal cough is an inflammatory reaction to seasonal changes (B). Hemoptysis (C) or a "new" cough or changes in a persistent chronic cough is likely related to lung cancer (C). Night sweats (D) is a trend in fever that is often seen with tuberculosis. - Answer-The registered nurse (RN) is interviewing a female client who states she has a persistent cough during the winter caused by bronchitis. Which additional finding should the RN assess for bronchitis? A. Phlegm production and wheezing. B. Smoking history C. Hemoptysis D. Night sweats .A A chronic seasonal cough related to bronchitis is likely accompanied with phlegm production and wheezing (A). Although smoking can contribute to chronic cough, the typical seasonal cough is an inflammatory reaction to seasonal changes (B). Hemoptysis (C) or a "new" cough or changes in a persistent chronic cough is likely related to lung cancer (C). Night sweats (D) is a trend in fever that is often seen with tuberculosis. - Answer-The registered nurse (RN) is interviewing a female client who states she has a persistent cough during the winter caused by bronchitis. Which additional finding should the RN assess for bronchitis? A. Phlegm production and wheezing. B. Smoking history C. Hemoptysis D. Night sweats .A A contract with a psychiatric client should include the nurse's expectations and responsibilities as well as the client's. A description of the client's therapies, the length of hospitalization, and insurance and financial information wouldn't be included in a contract. - Answer-A 23-year-old client is admitted to an inpatient psychiatric unit with severe depression. To develop rapport with the client, the nurse initiates a contract. What should the contract include? A. Expectations and responsibilities for you and the client B. A description of the therapies the client will undergo C. A prediction of the length of hospitalization D. The client's insurance and financial information .A A contract with a psychiatric client should include the nurse's expectations and responsibilities as well as the client's. A description of the client's therapies, the length of hospitalization, and insurance and financial information wouldn't be included in a contract. - Answer-A 23-year-old client is admitted to an inpatient psychiatric unit with severe depression. To develop rapport with the client, the nurse initiates a contract. What should the contract include? A. Expectations and responsibilities for you and the client B. A description of the therapies the client will undergo C. A prediction of the length of hospitalization D. The client's insurance and financial information .A All alcohol (A) and any foods that contain tyramine should be avoided while taking an MAO inhibitor, which interact to cause a hypertensive crisis. (B and C) should be discussed, but are not as important as (A). Although assessing blood pressure and pulse may be indicated, it is not necessary prior to taking each dose (D). - Answer-The registered nurse (RN) reviews the new prescription, phenelzine, a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is most important for the RN to assess? A. Consumption of any alcohol or tyramine-rich foods. B. Complaints of nausea or vomiting. C. Therapeutic serum drug levels. D. Blood pressure and pulse prior to taking each dose. .A All alcohol (A) and any foods that contain tyramine should be avoided while taking an MAO inhibitor, which interact to cause a hypertensive crisis. (B and C) should be discussed, but are not as important as (A). Although assessing blood pressure and pulse may be indicated, it is not necessary prior to taking each dose (D). - Answer-The registered nurse (RN) reviews the new prescription, phenelzine, a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is most important for the RN to assess? A. Consumption of any alcohol or tyramine-rich foods. B. Complaints of nausea or vomiting. C. Therapeutic serum drug levels. D. Blood pressure and pulse prior to taking each dose. .A Although Babinkski's reflex is a normal finding in infants and children younger than age 2, it's always an abnormal finding in adults. It wouldn't be classified as hyperactive or diminished. - Answer-A 30-year-old client is brought to the emergency department with head injuries from a motorcycle accident. During the neurological assessment, the client displays Babinski's reflex. The nurse knows that this finding is: A. an abnormal response B. a normal response C. a hyperactive response D. a diminished response .A Although Babinkski's reflex is a normal finding in infants and children younger than age 2, it's always an abnormal finding in adults. It wouldn't be classified as hyperactive or diminished. - Answer-A 30-year-old client is brought to the emergency department with head injuries from a motorcycle accident. During the neurological assessment, the client displays Babinski's reflex. The nurse knows that this finding is: A. an abnormal response B. a normal response C. a hyperactive response D. a diminished response .A Anthropometric arm measurements help assess nutritional status. Less than 90% of the standard indicates caloric deprivation. This result doesn't indicate a normal measurement and doesn't show caloric excess. Protein malnutrition is determined by albumin levels. - Answer-A 73-year old female client with Alzheimer's disease is admitted to the hospital with dehydration. Her daughter, who has been caring for the client at home, verbalizes frustration that the client refuses to eat or drink. The nurse performs anthropometric arm measurements on the client, and the result is 85% if the standard. What does this result suggest? A. Caloric deprivation B. Normalcy C. Protein malnutrition D. Caloric excess .A Anthropometric arm measurements help assess nutritional status. Less than 90% of the standard indicates caloric deprivation. This result doesn't indicate a normal measurement and doesn't show caloric excess. Protein malnutrition is determined by albumin levels. - Answer-A 73-year old female client with Alzheimer's disease is admitted to the hospital with dehydration. Her daughter, who has been caring for the client at home, verbalizes frustration that the client refuses to eat or drink. The nurse performs anthropometric arm measurements on the client, and the result is 85% if the standard. What does this result suggest? A. Caloric deprivation B. Normalcy C. Protein malnutrition D. Caloric excess .A Checking the pH of the aspirate (A) is the best method to validate that the NGT is not displaced and should reveal an acidic pH of 1.5 to 3.5 due to presence of gastric acid. (B, C and D) are not reliable methods to ensure NGT placement in the stomach. - Answer-The registered nurse (RN) is caring for a client with a newly placed nasogastric tube (NGT). Once the placement of the NG tube is verified by x-ray, which technique should the RN use as a reliable method to ensure the NGT is not displaced? a. check the pH of aspirated