NSG 121 Health Assessment HESI Final Exam
with correct answers
Open Ended Question - CORRECT ANSWERS ✔✔When obtaining a nursing
history, use the open-ended question technique to allow the patient a wide
range of possible responses.
Interpreter - CORRECT ANSWERS ✔✔Person who can translate between
languages.
For patients who do not speak English, use an interpreter whenever possible
Interrupting Client - CORRECT ANSWERS ✔✔Do not interrupt clients, in
health care settings, it is better to listen than to talk and to ask good questions
rather than have all of the right answers.
BMI Risk Assessment - CORRECT ANSWERS ✔✔An assessment of risk
factors includes questions about past medical and surgical histories,
medication and supplement use, family history, food and fluid intake patterns,
and the patient's psychosocial profile
Low BMI - CORRECT ANSWERS ✔✔Below 18.5
Normal BMI - CORRECT ANSWERS ✔✔18.5-24.9
,Nutritional Assessment - CORRECT ANSWERS ✔✔Risk factors to review in a
nutritional assessment include medical history, abnormal weight history,
appetite or taste changes, gastrointestinal symptoms, food allergies or
intolerances, changes in eating or fluid patterns, poor food habits, inability to
cook, social isolation, multiple medications, inappropriate supplements or lack
of supplements, and alcohol or drug use.
Consider a board range of influences on patient's food choices
Mental Orientation - CORRECT ANSWERS ✔✔Person, Place, Time, Situation
CAGE - CORRECT ANSWERS ✔✔CAGE is a self report questionnaire used as
an assessment tool for drugs and alcohol. Yes to two or more of the questions
indicate a potential problem
Cutdown,Annoyed,Guilty,Eye Opener
Abstract Thinking - CORRECT ANSWERS ✔✔Assessment of thought
processes:
Patient's thoughts are easy to follow, logical, coherent, relevant, goal directed,
consistent, and abstract
Abstract Thinking: Ability to understand concepts that are real
Referred Pain Appendicitis - CORRECT ANSWERS ✔✔Referred pain
originates from a specific site, but the person experiencing it feels the pain at
another site along the innervating spinal nerve
It will "refer" pain often to the mid upper abdomen, the epigastrum. Because
the appendix is a piece of intestine, it follows a similar referral pattern.
, Nail Ridges in Geriatric Patients - CORRECT ANSWERS ✔✔Longitudinal
ridging is common in aging patients
Skin Turger Assessment - CORRECT ANSWERS ✔✔Assess skin turgor. Gently
grasp a fold of the patient's skin between your fingers and pull up, then release.
Below clavicle
Tenting indicates dehydration, poor skin turgor is also associated with aging
Clubbing Oxygen Saturation - CORRECT ANSWERS ✔✔Clubbing of the nails
indicates chronic hypoxia. Clubbing is identified when the angle of the nail to
the finger is more than 160º
Emphysema or congestive heart failure
Pallor Dark Skin - CORRECT ANSWERS ✔✔Normal skin color is pink, noting
the usual undertones present with even dark skin. The tongue, lips, nail beds,
and buccal mucosa are less pigmented areas and may be the best indicators of
pallor or cyanosis. Patients with darker skin may normally have
hypopigmented skin on the palms and soles
Lesion Assessment & Primary vs. Secondary Lesion - CORRECT ANSWERS
✔✔Primary Lesion: arise from previously normal skin
Secondary Lesion: follow primary lesions (scare tissue)
If observed, note the shape and measure the length, width, and depth with a
ruler. If a wound is deep or tunneled, insert a cotton applicator to measure
depth.
with correct answers
Open Ended Question - CORRECT ANSWERS ✔✔When obtaining a nursing
history, use the open-ended question technique to allow the patient a wide
range of possible responses.
Interpreter - CORRECT ANSWERS ✔✔Person who can translate between
languages.
For patients who do not speak English, use an interpreter whenever possible
Interrupting Client - CORRECT ANSWERS ✔✔Do not interrupt clients, in
health care settings, it is better to listen than to talk and to ask good questions
rather than have all of the right answers.
BMI Risk Assessment - CORRECT ANSWERS ✔✔An assessment of risk
factors includes questions about past medical and surgical histories,
medication and supplement use, family history, food and fluid intake patterns,
and the patient's psychosocial profile
Low BMI - CORRECT ANSWERS ✔✔Below 18.5
Normal BMI - CORRECT ANSWERS ✔✔18.5-24.9
,Nutritional Assessment - CORRECT ANSWERS ✔✔Risk factors to review in a
nutritional assessment include medical history, abnormal weight history,
appetite or taste changes, gastrointestinal symptoms, food allergies or
intolerances, changes in eating or fluid patterns, poor food habits, inability to
cook, social isolation, multiple medications, inappropriate supplements or lack
of supplements, and alcohol or drug use.
Consider a board range of influences on patient's food choices
Mental Orientation - CORRECT ANSWERS ✔✔Person, Place, Time, Situation
CAGE - CORRECT ANSWERS ✔✔CAGE is a self report questionnaire used as
an assessment tool for drugs and alcohol. Yes to two or more of the questions
indicate a potential problem
Cutdown,Annoyed,Guilty,Eye Opener
Abstract Thinking - CORRECT ANSWERS ✔✔Assessment of thought
processes:
Patient's thoughts are easy to follow, logical, coherent, relevant, goal directed,
consistent, and abstract
Abstract Thinking: Ability to understand concepts that are real
Referred Pain Appendicitis - CORRECT ANSWERS ✔✔Referred pain
originates from a specific site, but the person experiencing it feels the pain at
another site along the innervating spinal nerve
It will "refer" pain often to the mid upper abdomen, the epigastrum. Because
the appendix is a piece of intestine, it follows a similar referral pattern.
, Nail Ridges in Geriatric Patients - CORRECT ANSWERS ✔✔Longitudinal
ridging is common in aging patients
Skin Turger Assessment - CORRECT ANSWERS ✔✔Assess skin turgor. Gently
grasp a fold of the patient's skin between your fingers and pull up, then release.
Below clavicle
Tenting indicates dehydration, poor skin turgor is also associated with aging
Clubbing Oxygen Saturation - CORRECT ANSWERS ✔✔Clubbing of the nails
indicates chronic hypoxia. Clubbing is identified when the angle of the nail to
the finger is more than 160º
Emphysema or congestive heart failure
Pallor Dark Skin - CORRECT ANSWERS ✔✔Normal skin color is pink, noting
the usual undertones present with even dark skin. The tongue, lips, nail beds,
and buccal mucosa are less pigmented areas and may be the best indicators of
pallor or cyanosis. Patients with darker skin may normally have
hypopigmented skin on the palms and soles
Lesion Assessment & Primary vs. Secondary Lesion - CORRECT ANSWERS
✔✔Primary Lesion: arise from previously normal skin
Secondary Lesion: follow primary lesions (scare tissue)
If observed, note the shape and measure the length, width, and depth with a
ruler. If a wound is deep or tunneled, insert a cotton applicator to measure
depth.
