HESI HEALTH ASSESSMENT NURSING RN V1 100-questions-with-answers

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• A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not four unrelated words . Recall; af... ter a 30-minute delay • During a mental status assessment, which question by the nurse would best assess a person’s judgment? “Tell me what you plan to do once you are discharged from the hospital.” • Which of these individuals would the nurse consider at highest risk for a suicide attempt? Older adult man who tells the nurse that he is going to “join his wife in heaven” tomorrow and plans to use a gun • When reviewing the use of alcohol by older adults, the nurse notes that older adults have several characteristics that can increase the risk of alcohol use. Which would increase the bioavailability of alcohol in the blood for longer periods in the older adult? Decreased liver and kidney functioning • During an assessment, the nurse asks a female patient, “How many alcoholic drinks do you have a week?” Which answer by the patient would indicate at-risk drinking? “I have seven or eight drinks a week, but I never get drunk.” • The nurse is asking an adolescent about illicit substance abuse. The adolescent answers, “Yes, I’ve used marijuana at parties with my friends.” What is the next question the nurse should ask? “When was the last time you used marijuana?” • The nurse has completed an assessment on a patient who came to the clinic for a leg injury. As a result of the assessment, the nurse has determined that the patient has at-risk alcohol use. Which action by the nurse is most appropriate at this time? State, “You are drinking more than is medically safe. I strongly recommend that you quit drinking, and I’m willing to help you.” • A patient is brought to the emergency department. He is restless, has dilated pupils, is sweating, has a runny nose and tearing eyes, and complains of muscle and joint pains. His girlfriend thinks he has influenza, but she became concerned when his temperature went up to 39.4° C. She admits that he has been a heavy drug user, but he has been trying to stop on his own. The nurse suspects that the patient is experiencing withdrawal symptoms from which substance? Heroin • Patient taking ipratropium reports nausea, blurred vision, has, insomnia after using the inhaler. RN action to implement - withhold med and report symptoms • A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient? Bilaterally percuss the thorax, noting any differences in percussion tones. • The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? Although the stethoscope does not magnify sound, it does block out extraneous room noise. • The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: Is used to listen for high-pitched sounds. • Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should: Check the temperature of the room, and offer blankets to the patient if he or she feels cold. • While measuring a patient’s blood pressure, the nurse recalls that certain factors, such as , help determine blood pressure. Peripheral vascular resistance • A nurse is helping at a health fair at a local mall. When taking blood pressures on a variety of people, the nurse keeps in mind that: The blood pressure of a Black adult is usually higher than that of a White adult of the same age. 8. The nurse notices a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading to: Yield a falsely high blood pressure. • A student is late for his appointment and has rushed across campus to the health clinic. The nurse should: Allow 5 minutes for him to relax and rest before checking his vital signs. • Hypoptysis (new cough) or changes in persistent cough tuberculosis s/sx • The nurse is assessing a patient’s pain. The nurse knows that the most reliable indicator of pain would be the: Subjective report. • A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is “bad this morning” and rates it at an 8 on a 1-to-10 scale. What does the nurse suspect? The patient: Has experienced chronic pain for years and has adapted to it. • The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system? Neuropathic • The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4year-old child. The nurse should: Consider this finding as normal for a child this age, and proceed with the examination. • When assessing the quality of a patient’s pain, the nurse should ask which question? “What does your pain feel like?” • When assessing a patient’s pain, the nurse knows that an example of visceral pain would be: Cholecystitis. • A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because: The woman could be at increased risk for infection and lesions because of her chronic disease. • The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a person’s: Circulatory status. • A patient comes in for a physical examination and complains of “freezing to death” while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: Peripheral vasoconstriction. • A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find: Caused by the complete absence of melanin pigment [Show More]

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