HESI PREP - HEALTH ASSESSMENT PRACTICE QUESTIONS AND ANSWERS 100% CORRECT!!, Exams of Nursing

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HESI PREP - HEALTH ASSESSMENT

PRACTICE QUESTIONS AND ANSWERS 100%

CORRECT!!

1. In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking?

A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors. B) Note-taking allows the patient to continue at his or her own pace as the nurse records what is said. C) Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. D) Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort. - ANSWER A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors.

Page: 31 Some use of history forms and note-taking may be unavoidable. But be aware that note-taking during the interview has disadvantages. It breaks eye contact too often, and it shifts attention away from the patient, which diminishes his or her sense of importance. It also may interrupt the patient's narrative flow, and it impedes the observation of the patient's nonverbal behavior.

2. During an interview, the nurse states, "You mentioned shortness of breath. Tell me more about that." Which verbal skill is used with this statement?

A) Reflection B) Facilitation C) Direct question D) Open-ended question - ANSWER D) Open-ended question

Page: 32 The open-ended question asks for narrative information. It states the topic to be discussed but only in general terms. The nurse should use it to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic.

3. A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, "You don't smoke, drink, or take drugs, do you?" This question is an example of:

A) talking too much.

Page: 46 In a situation where there is a language barrier and no interpreter available, use simple words avoiding medical jargon. Avoid using contractions and pronouns. Use nouns repeatedly and discuss one topic at a time.

7. A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice?

A) A trained interpreter B) A male family member C) A female family member D) A volunteer college student from the foreign language studies department - ANSWER A) A trained interpreter

Page: 46 whenever possible, the nurse should use a trained interpreter, preferably one who knows medical terminology. In general, an older, more mature interpreter is preferred to a younger, less experienced one, and the same gender is preferred when possible.

8. The nurse is conducting an interview. Which of these statements is true regarding open-ended questions? Select all that apply.

A) They elicit cold facts. B) They allow for self-expression. C) They build and enhance rapport. D) They leave interactions neutral. E) They call for short one- to two-word answers. F) They are used when narrative information is needed. - ANSWER B) They allow for self-expression. C) They build and enhance rapport. F) They are used when narrative information

Page: 32 Open-ended questions allow for self-expression, build rapport, and obtain narrative information. These features enhance communication during an interview. The other statements are appropriate for closed or direct questions.

9. The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which is the best use of the computer in this situation? Select all that apply.

A) Collect the patient's data in a direct, face-to-face manner. B) Enter all the data as the patient states it.

C) Ask the patient to wait as the nurse enters data. D) Type the data into the computer after the narrative is fully explored. E) Allow the patient to see the monitor during typing. - ANSWER A) Collect the patient's data in a direct, face-to-face manner. D) Type the data into the computer after the narrative is fully explored. E) Allow the patient to see the monitor during typing.

Page: 32 The use of a computer can become a barrier. The nurse should begin the interview as usual by greeting the patient, establishing rapport, and collecting the patient's narrative story in a direct face-to-face manner. Only after the narrative is fully explored should the nurse type data into the computer. When typing, the nurse should position the monitor so that the patient can see it.

10. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate?

A) Ask the patient about the item and its significance. B) Ask the patient to lock the item with other valuables in the hospital's safe. C) Tell the patient that a family member should take valuables home. D) No action is necessary. - ANSWER A) Ask the patient about the item and its significance.

Page: 21 The nurse should inquire about the amulet's meaning. Amulets, such as charms, are often seen as an important means of protection from "evil spirits" by some cultures.

11. In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this is true, probably because Mexican-Americans:

A) have less efficient immune systems and are often ill. B) consider these symptoms a part of normal living, not symptoms of ill health. C) come from Mexico and coughing is normal and healthy there. D) are usually in a lower socioeconomic group and are more likely to be sick. - ANSWER B) consider these symptoms a part of normal living, not symptoms of ill health.

Page: 37 Note the person's position. An open position with the extension of large muscle groups shows relaxation, physical comfort, and a willingness to share information. A closed position with the arms and legs crossed tends to look defensive and anxious. Note any change in posture. If a person in a relaxed position suddenly tenses, it suggests possible discomfort with the new topic.

14. If an American Indian has come to the clinic to seek help with regulating her diabetes, the nurse can expect that she:

A) will comply with the treatment prescribed. B) has obviously given up her beliefs in naturalistic causes of disease. C) may also be seeking the assistance of a shaman or medicine man. D) will need extra help in dealing with her illness and may be experiencing a crisis of faith. - ANSWER C) may also be seeking the assistance of a shaman or medicine man.

Page: 23 When self-treatment is unsuccessful, the individual may turn to the lay or folk healing systems, to spiritual or religious healing, or to scientific biomedicine. In addition to seeking help from a biomedical or scientific health care provider, patients may also seek help from folk or religious healers.

16. The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain?

A) All patients will behave the same way when in pain. B) Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. C) Cultural norms have very little to do with pain tolerance, because pain tolerance is always biologically determined. D) A patient's expression of pain is largely dependent on the amount of tissue injury associated with the pain. - ANSWER B) Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain.

Page: 25 In addition to expecting variations in pain perception and tolerance, the nurse should expect variations in the expression of pain. It is well known that individuals turn to their social environment for validation and comparison. The other statements are incorrect.

17. The nurse recognizes that working with children with a different cultural perspective may be especially difficult because:

A) children have spiritual needs that are influenced by their stages of development. B) children have spiritual needs that are direct reflections of what is occurring in their homes. C) religious beliefs rarely affect the parents' perceptions of the illness. D) parents are often the decision makers, and they have no knowledge of their children's spiritual needs. - ANSWER A) children have spiritual needs that are influenced by their stages of development.

Page: 20. Illness during childhood may be an especially difficult clinical situation. Children, as well as adults, have spiritual needs that vary according to the child's developmental level and the religious climate that exists in the family. The other statements are not correct.

18. When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an elderly American Indian patient?

A) "Are you of the Christian faith?" B) "Do you want to see a medicine man?" C) "How often do you seek help from medical providers?" D) "What cultural or spiritual beliefs are important to you?" - ANSWER D) "What cultural or spiritual beliefs are important to you?"

Page: 17. The nurse needs to assess the cultural beliefs and practices of the patient. American Indians may seek assistance from a medicine man or shaman, but the nurse should not assume this. An open-ended question regarding cultural and spiritual beliefs is best used initially when performing a cultural assessment.

19. When planning a cultural assessment, the nurse should include which component?

A) Family history B) Chief complaint C) Medical history D) Health-related beliefs - ANSWER D) Health-related beliefs

questioning whether the child is really having pain do not explore the symptoms, which should be done before a physical examination.

15. An elderly Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally-sensitive nurse would:

A) contact the hospital administrator about the best course of action. B) automatically get a curandero for her because it is not culturally appropriate for her to request one. C) further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. D) ask the family what they would like to do because Mexican-Americans traditionally give control of decisions to their families. - ANSWER C) further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires.

Pages: 22-23 In addition to seeking help from the biomedical/scientific health care provider, patients may also seek help from folk or religious healers. Some people, such as those of Mexican-American or American Indian origins, may believe that the cure is incomplete unless the body, mind, and spirit are also healed (although the division of the person into parts is a Western concept).

25. The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask?

A. "Do you wear glasses?" B. "Are you able to dress yourself?" C. "Do you have any thyroid problems?" D. "How many times a day do you have a bowel movement?" - ANSWER B. "Are you able to dress yourself?"

Page: 67. Functional assessment measures how a person manages day-to-day activities. For the older person, the meaning of health becomes those activities that they can or cannot do. The other responses do not relate to functional assessment.

26. The nurse is conducting a developmental history on a 5-year-old child. Which questions are appropriate to ask the parents for this part of the assessment? Select all that apply.

A. "How much junk food does your child eat?"

B. "How many teeth has he lost, and when did he lose them?" C. "Is he able to tie his shoelaces?" D. "Does he take a children's vitamin?" E. "Can he tell time?" F. "Does he have any food allergies?" - ANSWER B. "How many teeth has he lost, and when did he lose them?" C. "Is he able to tie his shoelaces?" E. "Can he tell time?"

Page: 61. Questions about tooth loss, ability to tell time, and ability to tie shoelaces are appropriate questions for a developmental assessment. Questions about junk food intake and vitamins are part of a nutritional history. Questions about food allergies are not part of a developmental history.

27. During an examination, the nurse can assess mental status by which activity?

A) Examining the patient's electroencephalogram B) Observing the patient as he or she performs an IQ test C) Observing the patient and inferring health or dysfunction D) Examining the patient's response to a specific set of questions - ANSWER C) Observing the patient and inferring health or dysfunction

Page: 71. Mental status cannot be scrutinized directly like the characteristics of skin or heart sounds. Its functioning is inferred through assessment of an individual's behaviors, such as consciousness, language, mood and affect, and other aspects.

28. The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient:

A) will have no decrease in any of his abilities, including response time. B) will have difficulty on tests of remote memory because this typically decreases with age. C) may take a little longer to respond, but his general knowledge and abilities should not have declined. D) will have had a decrease in his response time because of language loss and a decrease in general knowledge. - ANSWER C) may take a little longer to respond, but his general knowledge and abilities should not have declined.

Page: 72. The aging process leaves the parameters of mental status mostly intact. There is no decrease in general knowledge and little or no loss in vocabulary. Response

C) "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?" D) "What would you do if you found a stamped, addressed envelope lying on the sidewalk?" - ANSWER B) "Tell me about what you plan to do once you are discharged from the hospital."

Pages: 76-77. A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action. Rather than testing the person's response to a hypothetical situation (as illustrated in the option with the envelope), the nurse should be more interested in the person's judgment about daily or long-term goals, the likelihood of acting in response to delusions or hallucinations and the capacity for violent or suicidal behavior.

23. A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure?

A. The child's birth weight B. The age at which he crawled C. Whether he has had the measles D. Reactions to previous hospitalizations - ANSWER D. Reactions to previous hospitalizations

Assess how the child reacted to hospitalization and any complications. If the child reacted poorly, he or she may be afraid now and will need special preparation for the examination that is to follow. The other items are not significant for the procedure.

24. The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment?

A. It assesses how the individual is coping with life at home. B. It determines how children are meeting developmental milestones. C. It can identify any problems with memory the individual may be experiencing. D. It helps to determine how a person is managing day-to-day activities. - ANSWER D. It helps to determine how a person is managing day-to-day activities.

Page: 67. The functional assessment measures how a person manages day-to-day activities. The other answers do not reflect the purpose of a functional assessment.

34. The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess the patient's skin temperature? Use the:

A) fingertips because they're more sensitive to small changes in temperature. B) dorsal surface of the hand because the skin is thinner than on the palms. C) ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity. D) palmar surface of the hand because it is most sensitive to temperature variations because of increased nerve supply in this area. - ANSWER B) dorsal surface of the hand because the skin is thinner than on the palms.

The dorsa (backs) of hands and fingers are best for determining temperature because the skin there is thinner than on the palms. Fingertips are best for fine, tactile discrimination; the other responses are not useful for palpation.

35. The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed?

A) Avoid palpation of reported "tender" areas because this may cause the patient pain. B) Quickly palpate a tender area to avoid any discomfort that the patient may experience. C) Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths. D) Start with light palpation to detect surface characteristics and to accustom the patient to being touched. - ANSWER D) Start with light palpation to detect surface characteristics and to accustom the patient to being touched.

Pages: 115-116. Light palpation is performed initially to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first.

36. The nurse would use bimanual palpation technique in which situation?

A) Palpating the thorax of an infant B) Palpating the kidneys and uterus C) Assessing pulsations and vibrations D) Assessing the presence of tenderness and pain - ANSWER B) Palpating the kidneys and uterus

Pages: 115-116. Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa. The other situations are not appropriate for bimanual palpation.

Page: 120. The nurse should wash his or her hands before and after every physical patient encounter; after contact with blood, body fluids, secretions, and excretions; after contact with any equipment contaminated with body fluids; and after removing gloves. Hands should be washed after gloves have been removed, even if the gloves appear to be intact. Gloves should be worn when there is potential contact with any body fluids.

40. The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination?

A) When the infant is sleeping B) At the end of the examination C) Before auscultation of the thorax D) Halfway through the examination - ANSWER B) At the end of the examination

Page: 123. Elicit the Moro or "startle" reflex at the end of the examination because it may cause the infant to cry.

41. A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination?

A) Auscultate the lungs and heart while the infant is still sleeping. B) Examine the infant's hips because this procedure is uncomfortable. C) Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach. D) Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems. - ANSWER A) Auscultate the lungs and heart while the infant is still sleeping.

Pages: 122-124. When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat are invasive procedures and should be performed at the end of the examination.

42. The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal?

A) An increase in body weight from younger years B) Additional deposits of fat on the thighs and lower legs C) The presence of kyphosis and flexion in the knees and hips

D) A change in overall body proportion, a longer trunk, and shorter extremities - ANSWER C) The presence of kyphosis and flexion in the knees and hips

Page: 149. Changes that occur in the aging person include more prominent bony landmarks, decreased body weight (especially in males), a decrease in subcutaneous fat from the face and periphery, and additional fat deposited on the abdomen and hips. Postural changes of kyphosis and slight flexion in the knees and hips also occur.

43. When assessing the force, or strength, of a pulse, the nurse recalls that it:

A) is usually recorded on a 0- to 2-point scale. B) demonstrates elasticity of the vessel wall. C) is a reflection of the heart's stroke volume. D) reflects the blood volume in the arteries during diastole. - ANSWER C) is a reflection of the heart's stroke volume.

Page: 134. The heart pumps an amount of blood (the stroke volume) into the aorta. The force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse.

44. When assessing the quality of a patient's pain, the nurse should ask which question?

A) "When did the pain start?" B) "Is the pain a stabbing pain?" C) "Is it a sharp pain or dull pain?" D) "What does your pain feel like?" - ANSWER D) "What does your pain feel like?"

Page: 164. To assess the quality of a person's pain, have the patient describe the pain in his or her own words.

45. The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status?

A) The absorption of nutrients may be impaired. B) The constipation may represent a food allergy. C) She may need emergency surgery for the problem. D) The gastrointestinal problem will increase her caloric demand. - ANSWER A) The absorption of nutrients may be impaired.

Page: 183 Analgesics, antacids, anticonvulsants, antibiotics, diuretics, laxatives, antineoplastic drugs, steroids, and oral contraceptives are drugs that can interact with nutrients, impairing their digestion, absorption, metabolism, or use. The other responses are not correct.

49. The nurse needs to perform anthropometric measures of an 80-year-old man who is confined to a wheelchair. Which of the following is true in this situation?

A) Changes in fat distribution will affect the waist-to-hip ratio. B) Height measurements may not be accurate because of changes in bone. C) Declining muscle mass will affect the triceps skinfold measure. D) Mid-arm circumference is difficult to obtain because of loss of skin elasticity. - ANSWER B) Height measurements may not be accurate because of changes in bone.

Page: 191. Height measures may not be accurate in individuals confined to a bed or wheelchair or those over 60 years of age because of osteoporotic changes.

50. The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiological changes that directly affect the nutritional status of the elderly include:

A) slowed gastrointestinal motility. B) hyperstimulation of the salivary glands. C) an increased sensitivity to spicy and aromatic foods. D) decreased gastrointestinal absorption causing esophageal reflux. - ANSWER A) slowed gastrointestinal motility.

Page: 176. Normal physiological changes in aging adults that affect nutritional status include slowed gastrointestinal motility, decreased gastrointestinal absorption, diminished olfactory and taste sensitivity, decreased saliva production, decreased visual acuity, and poor dentition.

51. The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person's:

A) support systems. B) circulatory status. C) socioeconomic status. D) psychological wellness. - ANSWER B) circulatory status.

Page: 211. The skin holds information about the body's circulation, nutritional status, and signs of systemic diseases as well as topical data on the integument itself.

52. A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse would pay special attention to the danger signs for pigmented lesions and would be concerned with which additional finding?

A) Color variation B) Border regularity C) Symmetry of lesions D) Diameter less than 6 mm - ANSWER A) Color variation

Pages: 212-213. Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.

53. An elderly woman is brought to the emergency department after being found lying on the kitchen floor 2 days, and she is extremely dehydrated. What would the nurse expect to see upon examination?

A) Smooth mucous membranes and lips B) Dry mucous membranes and cracked lips C) Pale mucous membranes D) White patches on the mucous membranes - ANSWER B) Dry mucous membranes and cracked lips

Page: 215. With dehydration, mucous membranes look dry and lips look parched and cracked. The other responses are not found in dehydration.

54. A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which assessment finding?

A) Anasarca B) Scleroderma C) Pedal erythema D) Clubbing of the nails - ANSWER D) Clubbing of the nails