, BSN HESI 246 Health Assessment V2 Exam
Actual Exam – Nightingale College
Question 1
A nursing student is performing a physical assessment. The instructor emphasizes that the
"assessment" phase of the nursing process involves:
A) Establishing goals for the patient
B) Performing nursing interventions
C) Collecting, validating, and organizing data
D) Determining the effectiveness of care
Answer: C
Rationale: Assessment is the first step of the nursing process; it involves gathering subjective
and objective data from various sources to form a comprehensive database .
Question 2
Which of the following represents subjective data?
A) Blood pressure 120/80 mmHg
B) Liver palpable 2 cm below costal margin
C) Patient states, "I feel like my heart is skipping beats."
D) Pupils equal, round, and reactive to light
Answer: C
Rationale: Subjective data are symptoms reported by the patient that cannot be verified by the
examiner. The patient's statement is subjective data; the other options are objective findings .
Question 3
A 29-year-old male client informs the nurse that he came to the clinic to see if, "Maybe I have
lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this
body-wracking dry cough that has been hanging around for the last six weeks." Which computer
documentation of this client's concerns should the nurse enter?
A) "Patient reports a persistent cough accompanied by wheezing."
B) "Client describes having a 'body-wracking dry cough' of 6 weeks duration."
,C) "The client expresses concern about possible lung cancer symptoms."
D) "Client presents with a cough lasting more than a month."
Answer: B
Rationale: The documentation should reflect the client's own description of their symptoms.
Using the client's words captures the severity and character of the cough, providing clear
information for future assessments .
Question 4
Which assessment finding requires the most immediate nursing intervention when observing a
client's face?
A) Pallor of the skin
B) Facial asymmetry
C) Oral mucosa is cyanotic
D) Dry lips
Answer: C
Rationale: Cyanosis of the oral mucosa indicates inadequate oxygenation and potential
respiratory failure. This is a life-threatening finding requiring immediate intervention, unlike
pallor or dryness which are less urgent .
Question 5
While obtaining a health history, a male client reports occasional shortness of breath. His
respirations are regular and deep at 14 breaths/min. What is the nurse's best action?
A) Notify the provider
B) Apply supplemental oxygen
C) Ask the client to describe the episodes in more detail
D) Document the finding as normal
Answer: C
Rationale: Normal respiratory rate and depth suggest stability. Further subjective data is
required to identify triggers, duration, and severity before intervening .
, Question 6
During an abdominal assessment, the nurse auscultates before palpating. What is the primary
rationale for this sequence?
A) To warm up the stethoscope diaphragm
B) To prevent altering the frequency of bowel sounds
C) To allow the patient to relax before palpation
D) To identify areas of tenderness before palpation
Answer: B
Rationale: Palpation can increase peristalsis or alter bowel sounds; auscultation must occur first
to get an accurate baseline .
Question 7
The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While
interviewing the client, which assessment technique should the nurse use when asking about
the client's use of illegal drugs and alcohol?
A) Ask about drug use in relation to the client's job
B) Inquire about general lifestyle habits
C) Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts
D) Assess family history of substance use disorders
Answer: C
Rationale: Specific questions about types and amounts of substance use provide a clearer
understanding of the client's habits and potential risks that could affect surgical outcomes .
Question 8
The nurse is conducting a physical assessment of a young adult. Which information provides the
best indication of the individual's nutritional status?
A) Condition of hair, nails, and skin
B) Body mass index (BMI)
C) History of weight fluctuations
D) Dietary recall over the past week
Answer: A
Actual Exam – Nightingale College
Question 1
A nursing student is performing a physical assessment. The instructor emphasizes that the
"assessment" phase of the nursing process involves:
A) Establishing goals for the patient
B) Performing nursing interventions
C) Collecting, validating, and organizing data
D) Determining the effectiveness of care
Answer: C
Rationale: Assessment is the first step of the nursing process; it involves gathering subjective
and objective data from various sources to form a comprehensive database .
Question 2
Which of the following represents subjective data?
A) Blood pressure 120/80 mmHg
B) Liver palpable 2 cm below costal margin
C) Patient states, "I feel like my heart is skipping beats."
D) Pupils equal, round, and reactive to light
Answer: C
Rationale: Subjective data are symptoms reported by the patient that cannot be verified by the
examiner. The patient's statement is subjective data; the other options are objective findings .
Question 3
A 29-year-old male client informs the nurse that he came to the clinic to see if, "Maybe I have
lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this
body-wracking dry cough that has been hanging around for the last six weeks." Which computer
documentation of this client's concerns should the nurse enter?
A) "Patient reports a persistent cough accompanied by wheezing."
B) "Client describes having a 'body-wracking dry cough' of 6 weeks duration."
,C) "The client expresses concern about possible lung cancer symptoms."
D) "Client presents with a cough lasting more than a month."
Answer: B
Rationale: The documentation should reflect the client's own description of their symptoms.
Using the client's words captures the severity and character of the cough, providing clear
information for future assessments .
Question 4
Which assessment finding requires the most immediate nursing intervention when observing a
client's face?
A) Pallor of the skin
B) Facial asymmetry
C) Oral mucosa is cyanotic
D) Dry lips
Answer: C
Rationale: Cyanosis of the oral mucosa indicates inadequate oxygenation and potential
respiratory failure. This is a life-threatening finding requiring immediate intervention, unlike
pallor or dryness which are less urgent .
Question 5
While obtaining a health history, a male client reports occasional shortness of breath. His
respirations are regular and deep at 14 breaths/min. What is the nurse's best action?
A) Notify the provider
B) Apply supplemental oxygen
C) Ask the client to describe the episodes in more detail
D) Document the finding as normal
Answer: C
Rationale: Normal respiratory rate and depth suggest stability. Further subjective data is
required to identify triggers, duration, and severity before intervening .
, Question 6
During an abdominal assessment, the nurse auscultates before palpating. What is the primary
rationale for this sequence?
A) To warm up the stethoscope diaphragm
B) To prevent altering the frequency of bowel sounds
C) To allow the patient to relax before palpation
D) To identify areas of tenderness before palpation
Answer: B
Rationale: Palpation can increase peristalsis or alter bowel sounds; auscultation must occur first
to get an accurate baseline .
Question 7
The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While
interviewing the client, which assessment technique should the nurse use when asking about
the client's use of illegal drugs and alcohol?
A) Ask about drug use in relation to the client's job
B) Inquire about general lifestyle habits
C) Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts
D) Assess family history of substance use disorders
Answer: C
Rationale: Specific questions about types and amounts of substance use provide a clearer
understanding of the client's habits and potential risks that could affect surgical outcomes .
Question 8
The nurse is conducting a physical assessment of a young adult. Which information provides the
best indication of the individual's nutritional status?
A) Condition of hair, nails, and skin
B) Body mass index (BMI)
C) History of weight fluctuations
D) Dietary recall over the past week
Answer: A
