BSN 246 HESI HEALTH ASSESSMENT
EXAM V1 STUDY GUIDE
1. When performing a physical assessment on a client with a suspected abdominal aortic
aneurysm, which assessment technique should the nurse avoid?
A. Auscultation of the midline
B. Inspection of the umbilical area
C. Deep palpation of the abdomen
D. Percussion of the lower quadrants
Answer: C
Conceptual Explanation: Deep palpation should be avoided because it may cause the
aneurysm to rupture. Auscultation for bruits and inspection for pulsations are appropriate.
2. Which assessment finding is considered the most reliable indicator of a client’s fluid
volume status?
A. Skin turgor over the sternum
B. Presence of peripheral edema
C. Intake and output records
,D. Daily weight measurements
Answer: D
Conceptual Explanation: Daily weight is the most accurate and reliable indicator of fluid
volume changes, as 1 kg of weight change equates to approximately 1 liter of fluid.
3. The nurse is assessing a client’s cranial nerves. To test Cranial Nerve XII (Hypoglossal), what
should the nurse ask the client to do?
A. Shrug their shoulders against resistance
B. Smile and frown
C. Follow a moving finger with their eyes
D. Stick out their tongue
Answer: D
Conceptual Explanation: Cranial Nerve XII (Hypoglossal) controls the muscles of the
tongue. CN XI is shoulder shrugging, CN VII is facial expressions, and CN III, IV, and VI are
eye movements.
4. During a cardiac assessment, the nurse notes a blowing, swishing sound auscultated over
the left second intercostal space. This should be documented as:
A. A friction rub
B. An S3 gallop
C. A murmur
, D. A normal S2
Answer: C
Conceptual Explanation: A blowing, swishing sound caused by turbulent blood flow
through heart valves is a murmur. Friction rubs are scratchy; S3 is a low-pitched extra
sound.
5. Which technique is correct for assessing the thyroid gland using a posterior approach?
A. Have the client flex the neck forward and to the side being examined
B. Ask the client to hyper-extend the neck while swallowing
C. Apply firm pressure with the thumb on the cricoid cartilage
D. Palpate the gland while the client holds their breath
Answer: A
Conceptual Explanation: To palpate the thyroid posteriorly, the client should tilt the head
slightly forward and toward the side being examined to relax the sternocleidomastoid
muscle.
6. When assessing a client’s lungs, the nurse hears high-pitched, musical sounds primarily
during expiration. These are identified as:
A. Wheezes
B. Pleural friction rubs
C. Coarse crackles
EXAM V1 STUDY GUIDE
1. When performing a physical assessment on a client with a suspected abdominal aortic
aneurysm, which assessment technique should the nurse avoid?
A. Auscultation of the midline
B. Inspection of the umbilical area
C. Deep palpation of the abdomen
D. Percussion of the lower quadrants
Answer: C
Conceptual Explanation: Deep palpation should be avoided because it may cause the
aneurysm to rupture. Auscultation for bruits and inspection for pulsations are appropriate.
2. Which assessment finding is considered the most reliable indicator of a client’s fluid
volume status?
A. Skin turgor over the sternum
B. Presence of peripheral edema
C. Intake and output records
,D. Daily weight measurements
Answer: D
Conceptual Explanation: Daily weight is the most accurate and reliable indicator of fluid
volume changes, as 1 kg of weight change equates to approximately 1 liter of fluid.
3. The nurse is assessing a client’s cranial nerves. To test Cranial Nerve XII (Hypoglossal), what
should the nurse ask the client to do?
A. Shrug their shoulders against resistance
B. Smile and frown
C. Follow a moving finger with their eyes
D. Stick out their tongue
Answer: D
Conceptual Explanation: Cranial Nerve XII (Hypoglossal) controls the muscles of the
tongue. CN XI is shoulder shrugging, CN VII is facial expressions, and CN III, IV, and VI are
eye movements.
4. During a cardiac assessment, the nurse notes a blowing, swishing sound auscultated over
the left second intercostal space. This should be documented as:
A. A friction rub
B. An S3 gallop
C. A murmur
, D. A normal S2
Answer: C
Conceptual Explanation: A blowing, swishing sound caused by turbulent blood flow
through heart valves is a murmur. Friction rubs are scratchy; S3 is a low-pitched extra
sound.
5. Which technique is correct for assessing the thyroid gland using a posterior approach?
A. Have the client flex the neck forward and to the side being examined
B. Ask the client to hyper-extend the neck while swallowing
C. Apply firm pressure with the thumb on the cricoid cartilage
D. Palpate the gland while the client holds their breath
Answer: A
Conceptual Explanation: To palpate the thyroid posteriorly, the client should tilt the head
slightly forward and toward the side being examined to relax the sternocleidomastoid
muscle.
6. When assessing a client’s lungs, the nurse hears high-pitched, musical sounds primarily
during expiration. These are identified as:
A. Wheezes
B. Pleural friction rubs
C. Coarse crackles
