BSN 246 HESI HEALTH ASSESSMENT
EXAM V2 | 2026–2027
1. A 29-year-old male client states he wants to see if, "Maybe
I have lung cancer or something," due to a "body-wracking
dry cough" for six weeks. What is the best computer
documentation?
Answer: "Client describes having a 'body-wracking dry cough' of
6 weeks duration."
Rationale: The nurse should document the client's own words in
the chief complaint, as it provides an objective account of the
client's reason for seeking care, without adding interpretation or a
diagnosis.
2. A 75-year-old client with right hemiparesis post-CVA has a
brisk 4+ deep tendon reflex. What does this indicate?
Answer: Hyperactive response consistent with an upper motor
neuron disorder.
Rationale: A brisk 4+ reflex indicates hyperreflexia, which is a sign
of an upper motor neuron lesion, such as a stroke.
3. The nurse examines a client's abdomen. Which finding
indicates an abnormal response when palpating the spleen?
Answer: Firm mass palpated at the bottom of the left rib cage.
Rationale: A palpable mass at the left rib cage suggests
splenomegaly or other splenic pathology and is an abnormal
finding.
, 4. Where should the nurse place the bell of the stethoscope
when auscultating for a carotid artery bruit?
Answer: Lateral neck, just under the mandible towards lymph
nodes.
Rationale: The carotid artery runs laterally beside the trachea,
under the mandible. Using the bell here allows detection of low-
pitched bruits, indicating turbulent blood flow.
5. For assessing adventitious lung sounds after pneumonia
treatment, which technique should the nurse use?
Answer: Press the stethoscope's diaphragm firmly on the skin
over each lung field.
Rationale: The diaphragm is best for transmitting high-pitched
sounds like breath sounds. Firm pressure ensures good skin
contact to reduce extraneous noise.
6. A client with strep pharyngitis reports high fever, difficulty
swallowing, and a muffled voice. Which complication should
the nurse suspect?
Answer: Peritonsillar abscess.
Rationale: High fever, dysphagia, and a muffled voice are classic
signs of a peritonsillar abscess, a complication of bacterial
pharyngitis.
7. When asking about a client's use of illegal drugs and
alcohol, what is the best approach?
Answer: Ask specifically about alcohol, marijuana, cocaine, and
heroin use.
, Rationale: Clear, specific, and nonjudgmental questions
encourage honest disclosure and improve accuracy.
8. A client reports pain upon release of pressure in the lower
abdomen (rebound tenderness). What action should the nurse
take?
Answer: Notify the healthcare provider immediately.
Rationale: Rebound tenderness suggests peritoneal irritation,
such as from appendicitis, and requires urgent notification and
further evaluation.
9. How should the nurse differentiate an ulcer caused by
venous insufficiency from one caused by arterial
insufficiency?
Answer: Observe the specific location and appearance of the
ulceration.
Rationale: Venous ulcers typically occur around the medial
malleolus with irregular margins, while arterial ulcers are on toes
or pressure points with well-demarcated edges.
10. Which clinical finding best indicates nutritional status in a
young adult?
Answer: Condition of hair, nails, and skin.
Rationale: Hair, nail, and skin condition reflect long-term
nutritional health and are the most important physical indicators
of nutritional status.
11. The nurse auscultates the abdomen and hears gurgling
sounds every ten seconds. What action should the nurse take?
, Answer: Document this normal bowel sound activity in the
record.
Rationale: Normal bowel sounds consist of clicks and gurgles and
occur 5-30 times per minute.
12. In observing a client's face, which finding requires the
most immediate intervention?
Answer: Oral mucosa is cyanotic.
Rationale: Cyanosis of the oral mucosa indicates hypoxemia, a
life-threatening condition requiring immediate action.
13. A male client reports occasional shortness of breath, but
his respiratory rate is 14/min and regular. What is the best
nursing action?
Answer: Ask the client to describe the episodes of dyspnea in
more detail.
Rationale: Since vital signs are normal, further assessment is
needed to understand the nature of the dyspnea.
14. Which technique should the nurse use to assess anterior-
posterior (AP) chest diameter?
Answer: Observation.
Rationale: The AP diameter is assessed visually by comparing the
anterior and posterior chest dimensions.
15. Which finding supports a client's statement, "My feet
swell all the time?"
Answer: 2+ pitting edema of ankles bilaterally.
EXAM V2 | 2026–2027
1. A 29-year-old male client states he wants to see if, "Maybe
I have lung cancer or something," due to a "body-wracking
dry cough" for six weeks. What is the best computer
documentation?
Answer: "Client describes having a 'body-wracking dry cough' of
6 weeks duration."
Rationale: The nurse should document the client's own words in
the chief complaint, as it provides an objective account of the
client's reason for seeking care, without adding interpretation or a
diagnosis.
2. A 75-year-old client with right hemiparesis post-CVA has a
brisk 4+ deep tendon reflex. What does this indicate?
Answer: Hyperactive response consistent with an upper motor
neuron disorder.
Rationale: A brisk 4+ reflex indicates hyperreflexia, which is a sign
of an upper motor neuron lesion, such as a stroke.
3. The nurse examines a client's abdomen. Which finding
indicates an abnormal response when palpating the spleen?
Answer: Firm mass palpated at the bottom of the left rib cage.
Rationale: A palpable mass at the left rib cage suggests
splenomegaly or other splenic pathology and is an abnormal
finding.
, 4. Where should the nurse place the bell of the stethoscope
when auscultating for a carotid artery bruit?
Answer: Lateral neck, just under the mandible towards lymph
nodes.
Rationale: The carotid artery runs laterally beside the trachea,
under the mandible. Using the bell here allows detection of low-
pitched bruits, indicating turbulent blood flow.
5. For assessing adventitious lung sounds after pneumonia
treatment, which technique should the nurse use?
Answer: Press the stethoscope's diaphragm firmly on the skin
over each lung field.
Rationale: The diaphragm is best for transmitting high-pitched
sounds like breath sounds. Firm pressure ensures good skin
contact to reduce extraneous noise.
6. A client with strep pharyngitis reports high fever, difficulty
swallowing, and a muffled voice. Which complication should
the nurse suspect?
Answer: Peritonsillar abscess.
Rationale: High fever, dysphagia, and a muffled voice are classic
signs of a peritonsillar abscess, a complication of bacterial
pharyngitis.
7. When asking about a client's use of illegal drugs and
alcohol, what is the best approach?
Answer: Ask specifically about alcohol, marijuana, cocaine, and
heroin use.
, Rationale: Clear, specific, and nonjudgmental questions
encourage honest disclosure and improve accuracy.
8. A client reports pain upon release of pressure in the lower
abdomen (rebound tenderness). What action should the nurse
take?
Answer: Notify the healthcare provider immediately.
Rationale: Rebound tenderness suggests peritoneal irritation,
such as from appendicitis, and requires urgent notification and
further evaluation.
9. How should the nurse differentiate an ulcer caused by
venous insufficiency from one caused by arterial
insufficiency?
Answer: Observe the specific location and appearance of the
ulceration.
Rationale: Venous ulcers typically occur around the medial
malleolus with irregular margins, while arterial ulcers are on toes
or pressure points with well-demarcated edges.
10. Which clinical finding best indicates nutritional status in a
young adult?
Answer: Condition of hair, nails, and skin.
Rationale: Hair, nail, and skin condition reflect long-term
nutritional health and are the most important physical indicators
of nutritional status.
11. The nurse auscultates the abdomen and hears gurgling
sounds every ten seconds. What action should the nurse take?
, Answer: Document this normal bowel sound activity in the
record.
Rationale: Normal bowel sounds consist of clicks and gurgles and
occur 5-30 times per minute.
12. In observing a client's face, which finding requires the
most immediate intervention?
Answer: Oral mucosa is cyanotic.
Rationale: Cyanosis of the oral mucosa indicates hypoxemia, a
life-threatening condition requiring immediate action.
13. A male client reports occasional shortness of breath, but
his respiratory rate is 14/min and regular. What is the best
nursing action?
Answer: Ask the client to describe the episodes of dyspnea in
more detail.
Rationale: Since vital signs are normal, further assessment is
needed to understand the nature of the dyspnea.
14. Which technique should the nurse use to assess anterior-
posterior (AP) chest diameter?
Answer: Observation.
Rationale: The AP diameter is assessed visually by comparing the
anterior and posterior chest dimensions.
15. Which finding supports a client's statement, "My feet
swell all the time?"
Answer: 2+ pitting edema of ankles bilaterally.
