2024 HESI Exit Health Assessment Exam 1 – 4 + Test Bank | Guaranteed A+ Actual Questions and Answers,Complete 100%

2024 HESI Exit Health Assessment Exam 1 – 4 + Test Bank | Guaranteed A+ Actual Questions and Answers,Complete 100%

2024 Health Assessment Hesi Exam
Guaranteed A+ Actual Questions and Answers, Complete 100%

1. Which of the following statements from a patient’s history is it most
   important to investigate further?
   a. “I have an allergy to peanuts.”
   b. “I have lost 30 pounds over the last 4 months.”
   c. “I don’t like many vegetables so I take multivitamins.”
   d. “I drink 2 cups of coffee each morning.”:
   Answer:
   ANS: B
   The statement in option “b is most important to investigate further because any
   significant weight loss may indicate a serious problem. The statement about an
   allergy to peanuts is not the most important piece of information, although the
   nurse would want to investigate and document any food allergies. Option “c” is not
   the most significant statement; however, the nurse should investigate the types
   and amounts of vegetables the patient eats. Two cups of coffee is considered fairly
   typical and the patient is not consuming an excessive amount of caffeine.
2. Your patient complains of pruritus. You should examine the patient for
   which of the following associated signs and symptoms?
   a. rash and edema
   b. coolness and pallor
   c. cyanosis and coolness
   d. ecchymosis and purpura:
   Answer:
   ANS: A
   Pruritus or itching of the skin is associated with the following manifestations:
   rashes, lesions, edema, angioedema, anaphylaxis, excoriation or ulcers as a result
   of scratching, lichenification or thickening of the skin, and systemic disease. As a
   result of scratching the skin due to pruritus, the skin would most likely be warm
   and red, not pale, cool, or cyanotic. Ecchymosis is a violaceous discoloration, also
   called a black-and-blue mark. Purpura is a condition characterized by the presence
   of confluent petechiae or confluent ecchymosis. Neither of these is associated with
   pruritus.
3. 3. Your patient asks you about the small, reddish purple discolorations
   of the skin, less than 0.5 cm in diameter. You inform the patient that this is known
   as which of the following?
   a. ecchymoses c. purpura
   b. petechiae d. spider telangiectasia:

Answer:
ANS: B
Petechiae are violaceous (red-purple) discolorations of less than 0.5 cm in
diameter.
Petechiae do not blanch. They can indicate an increased bleeding tendency
or embolism; causes include intravascular defects and infections. Ecchymosis is
a violaceous discoloration of varying size, also called a black-and-blue mark. It is
caused by extravasation of blood into the skin as a result of trauma; heparin or
Coumadin use; or liver dysfunction. Purpura is a condition characterized by the
presence of confluent petechiae or confluent ecchymosis over any part of the body.
Purpura is caused by hemorrhage into the skin and can be the result of decreased
platelet formation. Spider angiomas, a type of telangiectasia, are bright red and
star-shaped. Most often these lesions are found on the face, neck, and chest. There
is often a central pulsation noted with pressure, and this results in blanching in the
extensions.

4. Your patient expresses concern about a mole on her right leg that has
   recently started itching. Which accompanying finding most likely indicates
   a developing cancerous lesion?
   a. regular and distinct border c. edema in both feet
   b. multiple colorations d. inflammation of periungual tissue:
   Answer:
   ANS: B
   Developing cancerous lesions may have multiple colorations such as brownish,
   tan, red, white, blue, pink, purple, or gray. Other signs in potentially cancerous
   lesions include the following: 1) rapid change in size; 2) change in coloration; 3)
   irregular or butterfly-shaped border; 4) elevation in a previously flat mole; 5)
   multiple colorations in a lesion; 6) change in surface characteristics, such as
   oozing; 7) change in sensation, such as pain, itching, or tenderness; 8) change in
   surrounding skin, such as inflammation or induration; and 9) bleeding or ulcerative
   appearance in a mole. These lesions are not associated with edema or inflammation
   of the area around the fingernails or the toenails.
5. After releasing the pressure of your thumb on your patient’s lower legs,
   ankles, and feet, you observe a 4 mm depression of the skin that disappears
   in 10 to 15 seconds. You would report this finding as which of the following?
   a. 1+ pitting edema c. 3+ pitting edema
   b. 2+ pitting edema d. 4+ pitting edema:
   Answer:
   ANS: B

Edema is the accumulation of fluid in the intercellular spaces. Pitting edema is
rated on a 4-point scale:
0+ = no pitting edema.
1+ = mild pitting edema; 2 mm depression that disappears rapidly.
2+ = moderate pitting edema; 4 mm depression that disappears in 10 to 15
seconds.
3+ = moderately severe pitting edema; 6 mm depression that can last more than
1 minute.
4+ = severe pitting edema; 8 mm depression that can last more than 2 minutes.

6. The nurse checks the capillary refill of a new patient. The amount of time
   for the nail color to return after the pressure is released on the patient’s nail
   should not exceed which of the following?
   a. 1-2 seconds c. 3-4 seconds
   b. 2-3 seconds d. 4-5 seconds:
   Answer:
   ANS: B
   Capillary refill time is a measure used to examine arterial flow to the extremities
   and is an indicator of peripheral circulation. Normal capillary refill varies with age,
   but color should return to normal within 2-3 seconds. Options “c” and “d” indicate
   prolonged capillary refill time and may indicate cardiovascular or respiratory
   dysfunction.
   Option “a” would be considered within normal limits.
7. To locate the temporomandibular joint, the nurse would palpate with both
   index and middle fingers on both sides of the face
   a. anterior to the tragus of the ear. c. over the temporalis muscles.
   b. inferior to the external meatus of the ear. d. posterior to the tragus of the
   ear.:
   Answer:
   ANS: A
   The temporomandibular joint is just below the temporal artery and anterior to the
   tragus of the ear. The tragus is a small extension of the auricular cartilage of the
   ear, anterior to the external meatus of the ear. The temporomandibular joint is not
   over the temporalis muscles. The nurse can examine this joint by palpating it as the
   patient opens and closes the mouth and notes normally smooth movement with
   no limitation or tenderness. Crepitation, limited range of motion, or tenderness are
   abnormal findings.
8. To perform auscultation of a patient’s thyroid gland, you would place the
   bell of your stethoscope over the
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2024 HESI Exam Health Assessment Exam
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Answer:

1. pt taking ipratropium reports nausea, blurred vision, has, insominia after
   using the inhaler. RN action to implement:
   Answer:
   withhold med and report symptoms
2. primary reason for teahing pt pursed lip breathing:
   Answer:
   promote CO2 elimination
3. additional finding that RN should assess for bronchitis:
   Answer:
   phlegm production and wheezing
4. lung cancer s/sx:
   Answer:
   hypoptysis (new cough) or changes in persistent cough
5. tuberculosis s/sx:
   Answer:
   night sweats
6. s/sx of PUD:
   Answer:

• hematemesis
• gastric pain on an empty stomach
• intolerance to spicy foods

1. which finding should RN assess for a pt for a risk of DI (diabetes insipidus)-:

Answer:
polydipsia

8. forms of communication of RN to a hearing impaired pt:
   Answer:

• face pt
• rephrase information if pt misunderstood
• check if pts hearing aids are working
• reduce env noise surrounding the pt

8. RN reviews new prx of MAOI for a pt w/ depression. Which info is most imp
   for RN to assess:
   Answer:

• consumption of any alcohol or tyramine rich foods

8. young pt having an oral tolerance tests (OGTT). which lab result should
   RN assess as normal value for the two hour postprandial result:
   Answer:

• 140 mg/dl

8. pt dx with acute pancreatitis. what lab value should the RN anticipate
   being elevated w/ dx:
   Answer:

• amylase

8. RN is teaching a pt being dx after treatment of TB. which cultural issues
   should the RN assess when preparing the pat:
   Answer:

• native language
• education level
• type of lifestyle
• financial resources

8. incomplete fracture of the humerus:

Answer:

• fracture that bends or splinter part of the bone

1. RN intervention w/ highest priority that should be anticipated by RN after
   removal of chest tube:
   Answer:
   prepare pt for chest xray at the bedside
2. assessment findings to document that are consistent with diminished
   peripheral circulation:
   Answer:

• diminished hair on legs
• skin cool to touch

1. muslim male pt refuses to let female RN listen to breath sounds. How
   should the RN respond:
   Answer:

• request a male RN or HCP to perform exam

1. RN assesss pt who is at risk for interaction w/ OTC decongestant. Which
   pt health history should the RN report to the HCP:
   Answer:

• closed angle glaucoma
• chronic hypertension

1. OTC decongestants:
   Answer:

• can increase IOP
• can Increase HR and BP

1. RN assessing pt who was discharged after management of chronic HTN.
   Which equipment should the RN instruct pt to use at home:
   Answer:
   get pdf at https://learnexams.com/search/study?query=hesi

2024 HESI Exit Test Bank Health Assessment
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1. The nurse is caring for a patient with chronic lower back pain. The nurse
   knows that the most reliable indicator of pain in this client is:
   The patient is reporting “6/10” pain.
   The patient is refusing to get out of bed.
   The patient is refusing to eat breakfast.
   The patient’s heart rate is 90 beats per minute.:
   Answer:
   A
2. Which of the following actions should the nurse take to ensure an accurate
   blood pressure (BP) reading?
   Ensure the width of the BP cuff is equal to 80% of the arm circumference.
   Ensure the client’s back is supported and feet are flat on the ground.
   Take two BP readings 20 seconds apart.
   Ensure that the patient’s arm is above heart level.:
   Answer:
   B
   The patient’s arm should be supported at heart level. Separate BP readings may
   need to be taken, but not one right after the other. The length of the BP bladder
   should equal 80% of the arm circumferen
3. The nurse obtains which piece of data during the general survey?
   Client is alert and calm.
   Client’s heart rate is 80 beats per minute.
   Client’s body mass index (BMI) is 30.
   Client’s lung sounds are “clear” to auscultation.:
   Answer:
   A
4. A man is at the clinic for a complete physical exam. He states that he is
   “very anxious”. What steps can the nurse take to make him more comfortable?
   Appear confident and unhurried during the exam.
   Measure vital signs at the end to allow the patient sufficient time to relax.
   Let him leave his clothes on during the examination.
   Obtain another nurse to examine the patient.:

Answer:
A

5. A father brings his 13 month-old child in for “fever” and he reports that
   the child has been “pulling on his left ear”. Upon entering the exam room,
   the child is asleep in the father’s arms. The nurse should perform which
   assessment first?
   Use the otoscope to look inside the ear.
   Use a penlight to check the eyes and nose.
   Auscultate the lungs, heart, and abdomen.
   Assess gross motor skills using the Denver II screening tool.:
   Answer:
   C
6. An 18 year-old presents to the emergency department with “headache.”
   Which of these assessment findings alerts the nurse to recent opioid use?
   Pupillary constriction
   Hallucinations.
   Fever.
   Tachypnea.:
   Answer:
   A- constricted pupils are a sign of recent opioid use, the rest are withdrawals
7. While collecting the pulse on a 26 year-old client, the nurse notes that
   the heart rate seems to speed up and then slow down in accordance with
   respirations. The pulse is counted at 80 beats per minute. What should the
   nurse do next?
   Obtain orthostatic vital signs.
   Notify the physician.
   Document “sinus arrhythmia.”
   Use a doppler to confirm the finding.:
   Answer:
   C
8. An elderly client with pneumonia is being treated in the intensive care unit
   (ICU). He is acutely agitated, restless, and disoriented. The nurse documents
   his level of consciousness as:
   Manic.

Demented.
Drowsy.
Delirious.:
Answer:
D

9. The nurse is assessing a newborn infant. How should the nurse measure
   the heart rate (HR)?
   Palpate the radial pulse for 15 seconds and multiply by four.
   Palpate the brachial pulse for 30 seconds and multiply by two.
   Auscultate the apical site for 60 seconds.
   Apply a pulse oximeter to obtain both the HR and SpO2.:
   Answer:
   C
10. A 28 year-old is brought to the emergency department. He is disoriented
    and hallucinating, and vital signs are elevated. The nurse suspects that the
    patient is experiencing withdrawal symptoms from which substance?
    Alcohol.
    Cocaine.
    Cannabis.
    Opiates.:
    Answer:
    A- hallucinations and delirium are commonly seen w alcohol withdrawal
11. When evaluating the temperature of older adults, the nurse should remember
    which aspect about an older adult’s body temperature?
    Fever is a reliable sign of infection in older adults.
    The older adult’s body temperature varies widely because of the thinner
    subcutaneous layer.
    There are no differences in temperature between a young and old adult.
    Older adults body temperature runs lower than that of an adult.:
    Answer:
    D
12. Which error may result in a falsely low blood pressure (BP) reading?
    The patient has a full bladder.

The arm is held above the level of the heart.
The cuff size is too small for the client.
The BP cuff is wrapped loosely around the arm.:
Answer:
B- at heart level

13. During a general survey of a post-operative patient, the nurse notes that
    the patient’s eyes are closed but they temporarily open with loud verbal
    stimulus and a gentle shake to the shoulder. The nurse documents his level
    of consciousness as:
    Alert.
    Somnolent.
    Stuporous.
    Obtunded.:
    Answer:
    D
14. A 46-year-old male presents to the Emergency Department with syncope.
    He says his cardiologist recently placed him on a new medication for his
    blood pressure (BP). What should the nurse do first?
    Obtain orthostatic vital signs.
    Educate the patient on homeopathic methods to control his BP.
    Administer a fluid bolus.
    Advise the patient to stop taking this medication.:
    Answer:
    A
15. As a mandatory reporter, the nurse notifies the authorities with which of
    the following?
    Suspicion of child or elder abuse/neglect.
    Proof of substance abuse in minors.
    Any bruising on a child or older adult.
    Proof of intimate partner violence.:
    Answer:
    A
16. A 50 year-old patient is in the intensive care unit (ICU) with septic shock.
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2024 HESI Health Assessment Exam
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1. SOAP modified format:
   Answer:
   Subjective
   Objective
   Assessment
   Plan
2. What color ink should be used when documenting on paper:
   Answer:
   Permanent black ink
3. What is the correct order for vital signs:
   Answer:
   T, P, RR, BP, extremity, pt position, SPO2
4. What should be at the top of every page of documentation:
   Answer:
   Patient initials and date and time of entry
5. What should be at the end of every documentation entry:
   Answer:
   Interviewers signature
6. How do you correct a mistake in documentation:
   Answer:
   1) Draw a single line through the incorrect documentation
   2) Write error above the entry
   3) Initial and date the crossed out entry
7. Documentation tips:

Answer:
1) Avoid complete sentences
2) Do not use A, an, the
3) Do not put opinion in notes
4) Avoid use of normal or within normal limits

8. Normal oral temp range:
   Answer:
   96.4 – 99.1 F
9. Febrile:
   Answer:
   With fever
10. Afebrile:
    Answer:
    Without fever
11. Hyperthermia symptoms:
    Answer:
    1) Cessation of shivering
    2) Bradycardia
    3) Decrease in respiratory minute volume
12. Most common and easy method of assessing temperature:
    Answer:
    Oral
13. What methods of assessing temperature reflects core temperature:
    Answer:
    1) Oral
    2) Rectal

3) Tympanic
4) Temporal Artery

14. What is the least accurate method of assessing temperature:
    Answer:
    axillary
15. Which patients are contraindicated for rectal temperature readings:
    Answer:
    Patients with increased HR
16. Preferred method of taking infants and small children’s temperatures: –
    Answer:
    Rectal
17. Pulse deficit:
    Answer:

• Difference between apical peripheral pulse

14. Pulse amplitude scale:
    Answer:
    0 = no pulse
    1 = diminished, weak
    2 = normal and expected
    3 = full or strong
    4 = bounding
15. Which pulses are assessed during a routine physical assessment?:
    Answer:
    1) Apical
    2) Radial
    3) Dorsalis pedis
    4) Posterior tibialis
16. Normal heart rate in resting adult:
    Answer:
    60 to 100 bpm
17. Well trained athletes heart rate:
    Answer:
    Heart rate less than 60 bpm
18. When is it normal for someone to have a rapid heart rate over 100
    bpm:
    Answer:
    Someone with anxiety and right after exercise
19. Eupnea:
    Answer:
    Normal RR, rhythm and depth
20. Normal SPO2 value:
    Answer:
    95-100%
21. What level is poor oxygenation:
    Answer:
    below 90%
22. Systolic BP:
    Answer:
    Maximum pressure on the artery during ventricular contraction
23. Diastolic BP:
    get pdf at https://learnexams.com/search/study?query=hesi

Answer:
2024 HESI Health Assessment Exam
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1. “My life is really out of balance.”:
   Answer:
   A client is reporting chest pain. What statement made by the client, helps the nurse
   to understand this client has a naturalistic belief in the cause of illness?
2. Be open to people who are different
   Have a curiosity about people.
   Become culturally competent.:
   Answer:
3. A nurse is working in a healthcare facility that
   serves a diverse population. What action(s) by the nurse will allow the nurse to
   empathize with and understand this population? (Select all that apply.)
4. It must be enlarged at least three times normal size for it to be palpable.: –
   Answer:
   Which statement is accurate about assessing the spleen?
5. Posterior chest below the 3rd intercostalspace.:
   Answer:
   What is the best place for the nurse to hear lower lobe lung sounds with a
   stethoscope?
6. Place the bell on the 5th intercostal space, left midclavicular line.:
   Answer:
   The nurse is assessing a client who has a history of mitral stenosis. How should the
   nurse assess this client with a stethoscope to listen for this condition?
7. 2nd intercostal space along the right sternal border.:

Answer:
The nurse is assessing a client who has a history of aortic regurgitation. Where
should the nurse place the stethoscope diaphragm to listen for this condition?

7. The client works in a daycare setting that has had a scabies outbreak.:
   Answer:
   The client is experiencing severe pruritus and small papules and burrows on areas
   over one hand and the inner thighs. Which assessment data best explains the
   condition the client is experiencing?
8. Level of consciousness.:
   Answer:
   A client comes to the clinic with a report of fever and a recent exposure to
   someone who was diagnosed with meningitis. Which nursing assessment should be
   completed during the initial examination of this client?
9. Use of vitamin and iron supplements.:
   Answer:
   A client reports feeling increasingly fatigued for several months, and the nurse
   observes that the client’s lips are pale.
   Which additional data should the nurse collect based on this presentation?
10. There is no sign of associated infection.:
    Answer:
    The nurse is assessing a client who has experienced a sudden onset of hearing loss
    in the right ear. Which finding should alert the nurse to a potentially serious
    medical condition that requires further evaluation?
11. Swelling anterior to the ear lobe on one side of the face.:
    Answer:
    The client reports to the nurse a recent exposure to the mumps. Which assessment
    finding suggests the client has contracted the mumps?
12. Swelling of the left arm and non-pitting edema.:
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