1|Pag e
HESI HEALTH ASSESSMENT EXAM LATEST
UPDATE HESI HEALTH ASSESSMENT EXAM/ ALL
QUESTIONS AND CORRECT AND ANSWERS BEST
GRADED A+
What is the most important assessment for the nurse to conduct following the
administration of epidural anesthesia to a client who is at 40-weeks gestation?
A. Maternal blood pressure
B. Level of pain sensation
C. Station of preseneting part
D. Variability of fetal heart rate - ANSWER: A. Maternal blood pressure
The nurse observes that a client is experiencing melena. What serum laboratory
test should the nurse monitor in response to this finding?
A. White blood cell count WBC
B. Blood urea nitrogen BUN
C. Glucose
D. Hematocrit - ANSWER: A. White blood cell count
The nurse is performing a cranial nerve exam on an 87-year-old client. The nurse
notes that the client has a reduced upward gaze, a decreased corneal reflex, a high
frequency hearing loss, and a reduced gag reflex. What action should the nurse
take next?
A. Continue the assessment of the next pairs of cranial nerves
B. Assess the spinal reflexes for demyelination symptoms
C. Implement neural vital signs every 2 hours to detect Cushing's Triad
D. Review past history for any episodes of a cerebral cortex lesion - ANSWER: C.
Implement neural vital signs every 2 hours to detect Cushing's Triad
,2|Pag e
The nurse assesses a male client who is brought to the ED by his family who
believe he is having a heart attack. Which finding is the best indicator that a client
is experiencing an acute coronary syndrome (ACS)?
A. Chest pain that intensifies upon chest excursion
B. Localized sternal border pain intensified by palpation
C. Pain in the neck, jaw, or medial side of the left arm
D. Anterior thorax pain that radiates between the scapulae - ANSWER: C. Pain in
the neck, jaw, or medial side of the left arm
The nurse is reviewing the health history of a client who had osteoarthritis. During
the physical assessment, the nurse identifies the presence of Heberden's nodes.
Which finding should the nurse document in the client's medical record?
A. A firm ganglion mass that is fluid filled over the dorsum of the wrist
B. Swollen nodes at the middle proximal interphalangeal joints
C. Palpable nodes at the distal interphalangeal joints with joint deviation
D. Weakness of hand muscle strength and poor grip when picking up a cup -
ANSWER: C. Palpable nodes at the distal interphalangeal joints with joint
deviation
During an abdominal assessment, a client with a temp of 103F experiences pain
and abruptly stops inhaling during deep palpation. Which prescription is most
important for the nurse to implement.
A. Nothing by mouth
B. Complete bed rest
C. Monitor urinary output
D. Electrocardiogram - ANSWER: A. Nothing by mouth
,3|Pag e
A 29-year-old male client informs the nurse that he came to the clinic to see if,
"maybe I have lung cancer or something," and wants to get checked out since, "I
can't seem to get rid of this body-wracking dry cough that has been hanging around
for the last six weeks." Which computer documentation of this client's concerns
should the nurse enter?
A. Expresses concern of "lung cancer" symptoms for last 6 weeks
B. Presents with a hacking non-productive cough of 6 weeks duration
C. Describes having a "body-wracking dry cough" of 6 weeks duration
D. Young adult male presents with fears that he has "lung cancer" - ANSWER: C.
Describes having a "body-wracking dry cough" of 6 weeks duration
When assessing a client's skin, which finding should the nurse report to the
healthcare provider?
A. Bluish discoloration of the nail beds
B. Multiple yellow lesions with a grainy surface
C. Multiple silver striae on the abdomen
D. Large, flat, dark red irregular area on the neck - ANSWER: A. Bluish
discoloration of the nail beds
The nurse is assessing a client who has a history of kidney stones and returns to the
clinic with flank pain. Which intervention should the nurse implement first?
A. Ask the client if he took any pain medication at home
B. Observe for nonverbal signs to measure pain intensity
C. Use a standard pain assessment questionnaire and scale
D. Collect a urine sample and strain for granules of calculi - ANSWER: D. Collect
a urine sample and strain for granules of calculi
, 4|Pag e
The nurse enters a client's room and notes that the formerly alert client is now
lethargic and only mutters incomprehensible sounds. In gathering additional data
related to these findings, which tool should the nurse use?
A. SBAR format
B. Braden scale
C. Mini-mental status exam
D. Glasgow coma scale - ANSWER: D. Glasgow come scale
A client who recently underwent a routine surgical procedure made a clinic
appointment. To elicit the most information, which question is best for the nurse to
ask this client?
A. "When did your surgery take place?"
B. "What type of surgery did you have?"
C. "Are you having any pain?"
D. "What brought you to the clinic?" - ANSWER: D. "What brought you to the
clinic?"
While completing an admission assessment for a client with rectal bleeding, the
nurse observes dried, dark red blood on surface of a purple, shiny tissue mass that
extrudes from the anal opening. When documenting in client's electronic medical
record, which finding should the nurse enter in the client's physical assessment?
A. Dried dark red blood on swollen external hemorrhoids
B. Serosanguineous and purple to exudate from anus
C. Anal mucosa prolapse and loose sphincter tone
D. Tears of the anal mucosa with old blood around anus - ANSWER: D. Tears of
the anal mucosa with old blood around anus
HESI HEALTH ASSESSMENT EXAM LATEST
UPDATE HESI HEALTH ASSESSMENT EXAM/ ALL
QUESTIONS AND CORRECT AND ANSWERS BEST
GRADED A+
What is the most important assessment for the nurse to conduct following the
administration of epidural anesthesia to a client who is at 40-weeks gestation?
A. Maternal blood pressure
B. Level of pain sensation
C. Station of preseneting part
D. Variability of fetal heart rate - ANSWER: A. Maternal blood pressure
The nurse observes that a client is experiencing melena. What serum laboratory
test should the nurse monitor in response to this finding?
A. White blood cell count WBC
B. Blood urea nitrogen BUN
C. Glucose
D. Hematocrit - ANSWER: A. White blood cell count
The nurse is performing a cranial nerve exam on an 87-year-old client. The nurse
notes that the client has a reduced upward gaze, a decreased corneal reflex, a high
frequency hearing loss, and a reduced gag reflex. What action should the nurse
take next?
A. Continue the assessment of the next pairs of cranial nerves
B. Assess the spinal reflexes for demyelination symptoms
C. Implement neural vital signs every 2 hours to detect Cushing's Triad
D. Review past history for any episodes of a cerebral cortex lesion - ANSWER: C.
Implement neural vital signs every 2 hours to detect Cushing's Triad
,2|Pag e
The nurse assesses a male client who is brought to the ED by his family who
believe he is having a heart attack. Which finding is the best indicator that a client
is experiencing an acute coronary syndrome (ACS)?
A. Chest pain that intensifies upon chest excursion
B. Localized sternal border pain intensified by palpation
C. Pain in the neck, jaw, or medial side of the left arm
D. Anterior thorax pain that radiates between the scapulae - ANSWER: C. Pain in
the neck, jaw, or medial side of the left arm
The nurse is reviewing the health history of a client who had osteoarthritis. During
the physical assessment, the nurse identifies the presence of Heberden's nodes.
Which finding should the nurse document in the client's medical record?
A. A firm ganglion mass that is fluid filled over the dorsum of the wrist
B. Swollen nodes at the middle proximal interphalangeal joints
C. Palpable nodes at the distal interphalangeal joints with joint deviation
D. Weakness of hand muscle strength and poor grip when picking up a cup -
ANSWER: C. Palpable nodes at the distal interphalangeal joints with joint
deviation
During an abdominal assessment, a client with a temp of 103F experiences pain
and abruptly stops inhaling during deep palpation. Which prescription is most
important for the nurse to implement.
A. Nothing by mouth
B. Complete bed rest
C. Monitor urinary output
D. Electrocardiogram - ANSWER: A. Nothing by mouth
,3|Pag e
A 29-year-old male client informs the nurse that he came to the clinic to see if,
"maybe I have lung cancer or something," and wants to get checked out since, "I
can't seem to get rid of this body-wracking dry cough that has been hanging around
for the last six weeks." Which computer documentation of this client's concerns
should the nurse enter?
A. Expresses concern of "lung cancer" symptoms for last 6 weeks
B. Presents with a hacking non-productive cough of 6 weeks duration
C. Describes having a "body-wracking dry cough" of 6 weeks duration
D. Young adult male presents with fears that he has "lung cancer" - ANSWER: C.
Describes having a "body-wracking dry cough" of 6 weeks duration
When assessing a client's skin, which finding should the nurse report to the
healthcare provider?
A. Bluish discoloration of the nail beds
B. Multiple yellow lesions with a grainy surface
C. Multiple silver striae on the abdomen
D. Large, flat, dark red irregular area on the neck - ANSWER: A. Bluish
discoloration of the nail beds
The nurse is assessing a client who has a history of kidney stones and returns to the
clinic with flank pain. Which intervention should the nurse implement first?
A. Ask the client if he took any pain medication at home
B. Observe for nonverbal signs to measure pain intensity
C. Use a standard pain assessment questionnaire and scale
D. Collect a urine sample and strain for granules of calculi - ANSWER: D. Collect
a urine sample and strain for granules of calculi
, 4|Pag e
The nurse enters a client's room and notes that the formerly alert client is now
lethargic and only mutters incomprehensible sounds. In gathering additional data
related to these findings, which tool should the nurse use?
A. SBAR format
B. Braden scale
C. Mini-mental status exam
D. Glasgow coma scale - ANSWER: D. Glasgow come scale
A client who recently underwent a routine surgical procedure made a clinic
appointment. To elicit the most information, which question is best for the nurse to
ask this client?
A. "When did your surgery take place?"
B. "What type of surgery did you have?"
C. "Are you having any pain?"
D. "What brought you to the clinic?" - ANSWER: D. "What brought you to the
clinic?"
While completing an admission assessment for a client with rectal bleeding, the
nurse observes dried, dark red blood on surface of a purple, shiny tissue mass that
extrudes from the anal opening. When documenting in client's electronic medical
record, which finding should the nurse enter in the client's physical assessment?
A. Dried dark red blood on swollen external hemorrhoids
B. Serosanguineous and purple to exudate from anus
C. Anal mucosa prolapse and loose sphincter tone
D. Tears of the anal mucosa with old blood around anus - ANSWER: D. Tears of
the anal mucosa with old blood around anus
