BSN 246 HESI HEALTH ASSESSMENT
FINAL EXAM (LATEST 2026/ 2027)
1. During a physical examination, the nurse notes a client has a positive Romberg test. Which
of the following is the most appropriate interpretation of this finding?
A. The client has a loss of balance when the eyes are closed, indicating a vestibular or
proprioceptive problem.
B. The client has a loss of motor coordination or cerebellar function.
C. The client has an abnormal reflex response in the lower extremities.
D. The client is unable to identify objects placed in the hand.
Answer: A
Conceptual Explanation: A positive Romberg sign occurs when a patient loses balance
when closing the eyes. This indicates a problem with proprioception or vestibular function
rather than cerebellar ataxia (which would cause imbalance even with eyes open).
2. When assessing a client’s heart sounds, the nurse auscultates a low-pitched extra sound
during early diastole at the apex. How should the nurse document this finding?
A. S3 heart sound (ventricular gallop)
,B. Pericardial friction rub
C. S4 heart sound (atrial gallop)
D. Systolic murmur
Answer: A
Conceptual Explanation: An S3 heart sound occurs in early diastole during the rapid
ventricular filling phase. It is often called a ventricular gallop and is best heard at the apex
with the bell.
3. The nurse is performing an abdominal assessment. In which order should the nurse
perform the following steps?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Palpation, Inspection, Auscultation
Answer: A
Conceptual Explanation: For the abdomen, the sequence is Inspection, Auscultation,
Percussion, and then Palpation. This prevents false bowel sound readings that could be
triggered by manipulating the abdomen.
, 4. A client presents with a ‘crowing’ sound heard during inspiration without a stethoscope.
The nurse recognizes this as:
A. Wheezing
B. Rales
C. Stridor
D. Rhonchi
Answer: C
Conceptual Explanation: Stridor is a high-pitched, monophonic, inspiratory, crowing
sound heard without a stethoscope, indicating upper airway obstruction (e.g., croup or
foreign body).
5. Which cranial nerve is the nurse assessing when asking the client to shrug their shoulders
against resistance?
A. CN XI (Spinal Accessory)
B. CN IX (Glossopharyngeal)
C. CN X (Vagus)
D. CN XII (Hypoglossal)
Answer: A
FINAL EXAM (LATEST 2026/ 2027)
1. During a physical examination, the nurse notes a client has a positive Romberg test. Which
of the following is the most appropriate interpretation of this finding?
A. The client has a loss of balance when the eyes are closed, indicating a vestibular or
proprioceptive problem.
B. The client has a loss of motor coordination or cerebellar function.
C. The client has an abnormal reflex response in the lower extremities.
D. The client is unable to identify objects placed in the hand.
Answer: A
Conceptual Explanation: A positive Romberg sign occurs when a patient loses balance
when closing the eyes. This indicates a problem with proprioception or vestibular function
rather than cerebellar ataxia (which would cause imbalance even with eyes open).
2. When assessing a client’s heart sounds, the nurse auscultates a low-pitched extra sound
during early diastole at the apex. How should the nurse document this finding?
A. S3 heart sound (ventricular gallop)
,B. Pericardial friction rub
C. S4 heart sound (atrial gallop)
D. Systolic murmur
Answer: A
Conceptual Explanation: An S3 heart sound occurs in early diastole during the rapid
ventricular filling phase. It is often called a ventricular gallop and is best heard at the apex
with the bell.
3. The nurse is performing an abdominal assessment. In which order should the nurse
perform the following steps?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Palpation, Inspection, Auscultation
Answer: A
Conceptual Explanation: For the abdomen, the sequence is Inspection, Auscultation,
Percussion, and then Palpation. This prevents false bowel sound readings that could be
triggered by manipulating the abdomen.
, 4. A client presents with a ‘crowing’ sound heard during inspiration without a stethoscope.
The nurse recognizes this as:
A. Wheezing
B. Rales
C. Stridor
D. Rhonchi
Answer: C
Conceptual Explanation: Stridor is a high-pitched, monophonic, inspiratory, crowing
sound heard without a stethoscope, indicating upper airway obstruction (e.g., croup or
foreign body).
5. Which cranial nerve is the nurse assessing when asking the client to shrug their shoulders
against resistance?
A. CN XI (Spinal Accessory)
B. CN IX (Glossopharyngeal)
C. CN X (Vagus)
D. CN XII (Hypoglossal)
Answer: A
