BSN 246 HESI HEALTH ASSESSMENT EXAM V2| QUESTIONS WITH VERIFIED
ANSWERS | 2026
1. In observing a client's face, which assessment finding requires the most
immediate intervention by the nurse?
A. Oral mucosa is cyanotic.
B. Nasolabial folds present bilaterally
C. Smooth and even skin tone
D. Absence of facial drooping ANS: A. Oral mucosa is cyanotic.
2. While obtaining a health history, a male client tells the nurse that he sometimes
experiences shortness of breath. The nurse determines that the client's respirators are
regular and deep, and his respiratory rate is 14 breaths/minutes. What is the best nursing
action? A. Administer oxygen immediately.
B. Ask the client to describe the episodes of dyspnea in more detail.
C. Notify the healthcare provider about the client's condition.
D. Place the client in a prone position to ease breathing. ANS: B. Ask the client to describe
the episodes of dyspnea in more detail.
3. When assessing a male client's respiratory status, which technique should the nurse
use to assess his anterior-posterior (AP) chest diameter? A. Intervention.
B. Assessment.
C. Documentation.
D. Observation. ANS: D. Observation.
4. Which assessment finding supports the client's statement, "My feet swell all the time?"
A. No edema present.
B. 2+ pitting edema of ankles bilaterally.
C. Non-pitting edema of the lower extremities.
,D. Redness and warmth in the ankles.ANS: B. 2+ pitting edema of ankles bilaterally.
5. The nurse is performing a cranial nerve exam on an 87-yearold client. The nurse
notes that the client has a reduced upward gaze, a decreased corneal reflex, a high-
frequency hearing loss, and a reduced gag reflex. What action should the nurse take
next?
A. Repeat the cranial nerve test to confirm the findings.
B. Document the findings and notify the healthcare provider.
C. Ask the client if they are experiencing any unusual symptoms.
D. Continue the assessment to the next pairs of cranial nerves. .ANS: D. Continue the
assessment to the next pairs of cranial nerves.
6. When performing a neurologic assessment on an alert client, the nurse observes that
the client's pupils are both round, 3 mm in size, and respond briskly to light. Which
notation should the nurse use when documenting the assessment
A. PERRL
B. Dilated pupils
C. Unequal pupil size
D. Sluggish pupillary reaction? .ANS: A. PERRL
7. The nurse is assessing a female client who states that her hemorrhoids are
inflamed and hurt constantly. Which intervention is best for the nurse to complete a
focused assessment?
A. Position the client in the left lateral position to inspect the perianal area for fissures or
sacs.
B. Palpate the perianal area with both hands to assess skin elasticity.
C. Ask the client to stand and bend forward to assess the sacrum.
D. Apply deep palpation to the lower abdomen to detect tenderness. .ANS: A. Position
the client in the left lateral position to inspect the perianal area for fissures or sacs.
, 9. The nurse is performing an initial assessment of a client who has an expressionless facial
affect, slurred speech, and red conjunctivae. What question should the nurse ask first? A.
"Have you been sleeping well?"
B. "What did you eat for breakfast today?"
C. "Do you experience any changes in your vision?"
D. "How often do you exercise during the week?" .ANS: A. "Have you been sleeping
well?"
10. After checking a client's pupillary response to light, the practical nurse (PN) tells the
nurse that the client's pupils are constricted with minimal response to light. Before
verifying the PN's findings, which action should the nurse take?
A. Assess the client's visual fields
B. Check the client's blood pressure
C. Ask the client about recent headaches
D. Observe the client's facial symmetry .ANS: A. Assess the client's visual fields.
11. The nurse completes inspection of the abdomen on an adult client. Which finding is
considered normal for this client? A. Homogeneous color.
B. Redness with patches.
C. Uneven pigmentation.
D. Presence of lesions. .ANS: A. Homogeneous color.
12. Which skill should the nurse have an older client demonstrate to evaluate
performance of daily living activities? A. Reading a book aloud.
B. Sorting a collection of socks.
C. Writing a letter to a friend.
D. Watching a movie. .ANS: B. Sorting a collection of socks.
ANSWERS | 2026
1. In observing a client's face, which assessment finding requires the most
immediate intervention by the nurse?
A. Oral mucosa is cyanotic.
B. Nasolabial folds present bilaterally
C. Smooth and even skin tone
D. Absence of facial drooping ANS: A. Oral mucosa is cyanotic.
2. While obtaining a health history, a male client tells the nurse that he sometimes
experiences shortness of breath. The nurse determines that the client's respirators are
regular and deep, and his respiratory rate is 14 breaths/minutes. What is the best nursing
action? A. Administer oxygen immediately.
B. Ask the client to describe the episodes of dyspnea in more detail.
C. Notify the healthcare provider about the client's condition.
D. Place the client in a prone position to ease breathing. ANS: B. Ask the client to describe
the episodes of dyspnea in more detail.
3. When assessing a male client's respiratory status, which technique should the nurse
use to assess his anterior-posterior (AP) chest diameter? A. Intervention.
B. Assessment.
C. Documentation.
D. Observation. ANS: D. Observation.
4. Which assessment finding supports the client's statement, "My feet swell all the time?"
A. No edema present.
B. 2+ pitting edema of ankles bilaterally.
C. Non-pitting edema of the lower extremities.
,D. Redness and warmth in the ankles.ANS: B. 2+ pitting edema of ankles bilaterally.
5. The nurse is performing a cranial nerve exam on an 87-yearold client. The nurse
notes that the client has a reduced upward gaze, a decreased corneal reflex, a high-
frequency hearing loss, and a reduced gag reflex. What action should the nurse take
next?
A. Repeat the cranial nerve test to confirm the findings.
B. Document the findings and notify the healthcare provider.
C. Ask the client if they are experiencing any unusual symptoms.
D. Continue the assessment to the next pairs of cranial nerves. .ANS: D. Continue the
assessment to the next pairs of cranial nerves.
6. When performing a neurologic assessment on an alert client, the nurse observes that
the client's pupils are both round, 3 mm in size, and respond briskly to light. Which
notation should the nurse use when documenting the assessment
A. PERRL
B. Dilated pupils
C. Unequal pupil size
D. Sluggish pupillary reaction? .ANS: A. PERRL
7. The nurse is assessing a female client who states that her hemorrhoids are
inflamed and hurt constantly. Which intervention is best for the nurse to complete a
focused assessment?
A. Position the client in the left lateral position to inspect the perianal area for fissures or
sacs.
B. Palpate the perianal area with both hands to assess skin elasticity.
C. Ask the client to stand and bend forward to assess the sacrum.
D. Apply deep palpation to the lower abdomen to detect tenderness. .ANS: A. Position
the client in the left lateral position to inspect the perianal area for fissures or sacs.
, 9. The nurse is performing an initial assessment of a client who has an expressionless facial
affect, slurred speech, and red conjunctivae. What question should the nurse ask first? A.
"Have you been sleeping well?"
B. "What did you eat for breakfast today?"
C. "Do you experience any changes in your vision?"
D. "How often do you exercise during the week?" .ANS: A. "Have you been sleeping
well?"
10. After checking a client's pupillary response to light, the practical nurse (PN) tells the
nurse that the client's pupils are constricted with minimal response to light. Before
verifying the PN's findings, which action should the nurse take?
A. Assess the client's visual fields
B. Check the client's blood pressure
C. Ask the client about recent headaches
D. Observe the client's facial symmetry .ANS: A. Assess the client's visual fields.
11. The nurse completes inspection of the abdomen on an adult client. Which finding is
considered normal for this client? A. Homogeneous color.
B. Redness with patches.
C. Uneven pigmentation.
D. Presence of lesions. .ANS: A. Homogeneous color.
12. Which skill should the nurse have an older client demonstrate to evaluate
performance of daily living activities? A. Reading a book aloud.
B. Sorting a collection of socks.
C. Writing a letter to a friend.
D. Watching a movie. .ANS: B. Sorting a collection of socks.
