HESI HEALTH ASSESSMENT AND PHYSICAL
EXAMINATION
List the five nursing purposes for performing a physical assessment. (5) - ANSWER-a. Gather baseline
data about the patient's health status
b. Support or refute subjective data obtained in the nursing history
c. Confirm and identify nursing diagnoses
d. Make clinical judgments about a patient's changing health status and management
e. Evaluate the outcomes of care
List the principles related to the nurse performing daily physical examinations. (4) - ANSWER-a. A
head-to-toe assessment is required daily
b. Reassessment is performed when the patient's condition changes as it improves or worsens
c. The environment, equipment, and patient are properly prepared
d. Safety for confused patients should be a priority
Proper preparation for examination should include: (5) - ANSWER-a. Infection control
b. Environment
c. Equipment
d. Physical preparation of the patient
e. Psychological preparation of the patient
List seven variations in the nurse's individual style that are appropriate when examining children. (7) -
ANSWER-a. Gather all or part of the histories of infants and children from parents
b. Perform the examination in a nonthreatening are and provide time for play
c. Offer support to the parents during the examination and do not pass judgment
d. Call children by their first names and address their parents as Mr. and Mrs.
e. Use open-ended questions to allow parents to share more information
f. Treat adolescents as adults
g. Provide confidentiality for adolescents; speak alone with them
List seven variations in the nurse's individual style that are appropriate wen examining older adults. (7)
- ANSWER-a. Do not stereotype about aging patients's level of cognition
b. Be sensitive to sensory or physical limitations (more time)
c. Adequate space is needed
d. use patience, allow for pauses, and observe for details
e. Certain types of information may be stressful to give
f. Perform the examination near bathroom facilities
g. Be alert for signs of increasing fatigue
Identify the principles to follow to keep an examination well organized. (7) - ANSWER-a. Compare
both sides for symmetry
b. If a patient is ill, first assess the systems of the body part most at risk
c. Offer rest periods if the patient becomes fatigued
d. Perform painful procedures near the end of the examination
e. Record assessments in specific terms in the record
f. Use common and accepted medical terms and abbreviations
g. Record quick notes during the examination to avoid delays
, Define inspection. - ANSWER-Looking, listening, and smelling to distinguish normal from abnormal
findings
Identify the guidelines to achieve the best results during inspection. (6) - ANSWER-a. Adequate
lighting is available
b. Use direct light source
c. Inspect each area for size, shape, color, symmetry, position, and abnormality
d. Position and expose body parts as needed, maintaining privacy
e. Check for side-to-side symmetry
f. Validate findings with the patient
Define palpation - ANSWER-Using the hands to touch body parts.
Light palpation - ANSWER-Pressing inward 1 cm (surperficial)
Deep palpation - ANSWER-Depressing the area 4 cm to assess the conditions of organs.
Define auscultation - ANSWER-Listening to the internal sounds the body makes.
Auscultating sounds: Frequency - ANSWER-Frequency indicates the number of sound wave cycles
generated per second by a vibrating object
Auscultating sounds: Amplitude - ANSWER-Loudness, soft to loud
Auscultating sounds: Quality - ANSWER-Sounds of similar frequency and loudness
Auscultating sounds: Duration - ANSWER-Length of time that sound vibrations last
List at least 12 specific observations of the patient's general appearance and behavior that should be
reviewed. (12) - ANSWER-a. Gender and race
b. Age
c. Signs of distress
d. Body type
e. Posture
f. Gait
g. Body movements
h. Hygiene and grooming
i. Dress
j. Body odor
k. Affect and mood
l. Speech
Identify some signs of patient abuse. - ANSWER-Physical injury or neglect are signs of possible abuse
(evidence of malnutrition or presence of bruising). Also watch for fear of the spouse or partner,
caregiver, or parent.
Identify the questions related to the following acronym.
CAGE - ANSWER-C: Have you ever felt the need to cut down on your use?
A: Have people annoyed you by criticizing your use?
G: Have you ever felt bad or guilty about your use?
E: Have you ever used or had a drink first thing in the morning as an "eye opener" to steady your
nerves or feel normal?
List three actions that should be taken to ensure accurate weight measurement of a hospitalized
patient. (3) - ANSWER-a. Weigh patients at the same time of day
b. Weigh patients on the same scale
c. Weigh patients in the same clothes
EXAMINATION
List the five nursing purposes for performing a physical assessment. (5) - ANSWER-a. Gather baseline
data about the patient's health status
b. Support or refute subjective data obtained in the nursing history
c. Confirm and identify nursing diagnoses
d. Make clinical judgments about a patient's changing health status and management
e. Evaluate the outcomes of care
List the principles related to the nurse performing daily physical examinations. (4) - ANSWER-a. A
head-to-toe assessment is required daily
b. Reassessment is performed when the patient's condition changes as it improves or worsens
c. The environment, equipment, and patient are properly prepared
d. Safety for confused patients should be a priority
Proper preparation for examination should include: (5) - ANSWER-a. Infection control
b. Environment
c. Equipment
d. Physical preparation of the patient
e. Psychological preparation of the patient
List seven variations in the nurse's individual style that are appropriate when examining children. (7) -
ANSWER-a. Gather all or part of the histories of infants and children from parents
b. Perform the examination in a nonthreatening are and provide time for play
c. Offer support to the parents during the examination and do not pass judgment
d. Call children by their first names and address their parents as Mr. and Mrs.
e. Use open-ended questions to allow parents to share more information
f. Treat adolescents as adults
g. Provide confidentiality for adolescents; speak alone with them
List seven variations in the nurse's individual style that are appropriate wen examining older adults. (7)
- ANSWER-a. Do not stereotype about aging patients's level of cognition
b. Be sensitive to sensory or physical limitations (more time)
c. Adequate space is needed
d. use patience, allow for pauses, and observe for details
e. Certain types of information may be stressful to give
f. Perform the examination near bathroom facilities
g. Be alert for signs of increasing fatigue
Identify the principles to follow to keep an examination well organized. (7) - ANSWER-a. Compare
both sides for symmetry
b. If a patient is ill, first assess the systems of the body part most at risk
c. Offer rest periods if the patient becomes fatigued
d. Perform painful procedures near the end of the examination
e. Record assessments in specific terms in the record
f. Use common and accepted medical terms and abbreviations
g. Record quick notes during the examination to avoid delays
, Define inspection. - ANSWER-Looking, listening, and smelling to distinguish normal from abnormal
findings
Identify the guidelines to achieve the best results during inspection. (6) - ANSWER-a. Adequate
lighting is available
b. Use direct light source
c. Inspect each area for size, shape, color, symmetry, position, and abnormality
d. Position and expose body parts as needed, maintaining privacy
e. Check for side-to-side symmetry
f. Validate findings with the patient
Define palpation - ANSWER-Using the hands to touch body parts.
Light palpation - ANSWER-Pressing inward 1 cm (surperficial)
Deep palpation - ANSWER-Depressing the area 4 cm to assess the conditions of organs.
Define auscultation - ANSWER-Listening to the internal sounds the body makes.
Auscultating sounds: Frequency - ANSWER-Frequency indicates the number of sound wave cycles
generated per second by a vibrating object
Auscultating sounds: Amplitude - ANSWER-Loudness, soft to loud
Auscultating sounds: Quality - ANSWER-Sounds of similar frequency and loudness
Auscultating sounds: Duration - ANSWER-Length of time that sound vibrations last
List at least 12 specific observations of the patient's general appearance and behavior that should be
reviewed. (12) - ANSWER-a. Gender and race
b. Age
c. Signs of distress
d. Body type
e. Posture
f. Gait
g. Body movements
h. Hygiene and grooming
i. Dress
j. Body odor
k. Affect and mood
l. Speech
Identify some signs of patient abuse. - ANSWER-Physical injury or neglect are signs of possible abuse
(evidence of malnutrition or presence of bruising). Also watch for fear of the spouse or partner,
caregiver, or parent.
Identify the questions related to the following acronym.
CAGE - ANSWER-C: Have you ever felt the need to cut down on your use?
A: Have people annoyed you by criticizing your use?
G: Have you ever felt bad or guilty about your use?
E: Have you ever used or had a drink first thing in the morning as an "eye opener" to steady your
nerves or feel normal?
List three actions that should be taken to ensure accurate weight measurement of a hospitalized
patient. (3) - ANSWER-a. Weigh patients at the same time of day
b. Weigh patients on the same scale
c. Weigh patients in the same clothes
