Health Assessment HESI Review Questions and Correct Answer

While measuring a patient's blood pressure, which set of Korotkoff sounds should be recorded as systolic and diastolic pressure? 1 Phase III/phase V 2 Phase I/phase V 3 Phase II/phase III 4 Phase I/phase IV 2 What should the nurse document as a normal finding when auscultating a toddler's chest for breath sounds? 1 Bronchovesicular breath sounds in the peripheral lung fields 2 Persistent peristaltic sounds with diminished breath sounds 3 Persistent fine crackles that are scattered all over the chest 4 Crackles that are auscultated only in the lower lung fields 1 What is the shape of the uterus of a patient who is 24 weeks pregnant? 1 Globular 2 Round 3 Oval 4 Pear 3 While assessing a child with knee injury, the nurse shows the child six photographs of a young boy with different expressions of pain. Then the nurse asks the child to select one photograph which matches the level of pain. Which pain-rating scale is the nurse using for the pain assessment? 1 Verbal descriptor scale 2 Visual analogue scale 3 Numeric rating scale 4 Oucher Scale 4 The nurse and health care provider are assessing the mental status of a patient. Which patient findings suggest early-onset Alzheimer-type dementia? Select all that apply. 1 The patient has difficulty in holding objects. 2 The patient has difficulty in naming objects. 3 The patient has difficulty with ambulation. 4 The patient has difficulty finding words. 5 The patient has difficulty with vision. 2, 4 The nurse is caring for a patient who is undergoing alcohol withdrawal therapy. The nurse assesses the patient on the Clinical Institute Withdrawal Assessment (CIWA) and decides to follow the prescribed scheduled drug for treating alcohol withdrawal. What could be the reason for such an intervention? 1 The patient has scored 16 on the CIWA scale. 2 The patient has scored 11 on the CIWA scale. 3 The patient has scored 9 on the CIWA scale. 4 The patient has scored 6 on the CIWA scale. 1 The nurse is planning the cardiac assessment of a patient. Which patient positions are necessary during this assessment? Select all that apply. 1 Sitting 2 Left lateral recumbent 3 Right lateral semi-Fowler 4 Prone 5 Supine 1, 2, 5 While examining the lower extremities of an infant, the nurse checks for abnormalities in the infant's toes. What could be the reason behind this nursing intervention? 1 To assess for the presence of the Babinski reflex 2 To assess for the presence of the Ortolani sign 3 To assess for the presence of the grasp reflex 4 To assess for the presence of syndactyly 4 Which finding during the abdominal assessment of a newborn needs further investigation? 1 Venous hum 2 Occasional peristalsis 3 Umbilical hernia 4 Diastasis recti 1 While assessing a patient in a health care facility, the nurse uses Brief RCOPE. What is the reason for this intervention? 1 To identify the cognitive development of the patient 2 To identify psychologic symptoms in the patient 3 To identify the intensity of pain in the patient 4 To identify religious coping in the patient 4 The nurse is caring for a patient with rheumatoid arthritis who is on corticosteroid therapy. The health care provider instructs the nurse to evaluate the effectiveness of the treatment during the patient interview. What question does the nurse ask the patient in this situation? 1 "What makes your pain better or worse?" 2 "Why do you think you are having pain?" 3 "What does this pain mean to you?" 4 "When did your pain start?" 1 Which test helps in screening a child's fine and gross motor skills? 1 Denver II test 2 Tinel sign test 3 Ortolani test 4 Allis test 1