BSN 246 HESI Health Assessment V1 Complete
Exam Study Guide (Questions and Verified
Answers) | Brand New Version
1. The nurse is performing a thoracic assessment on a client with chronic
asthma and hyperinflation of the lungs. Which finding should be expected
for this client? - ANSWER Barrel chest
2. The nurse is assessing bowel sounds for a hospitalized client. The nurse has
heard bowel sounds in the right upper quadrant. What action should the
nurse take next? - ANSWER Note the character and frequency of bowel
sounds
3. The nurse is testing the client's shoulders for range of motion. What should
the nurse document to record normal internal rotation? - ANSWER Range
of 90 degrees when the hands are placed at the small of the back.
4. A client presents with a rash along the occipital area of the hairline and
reports intense itching. How should the nurse begin the objective part of the
examination? - ANSWER Inspect the scalp looking for nits.
5. The nurse is assessing a client's range of motion as the client bends the right
knee up to the chest while keeping the left leg straight, but is unable to keep
the left thigh on the table. The assessment is repeated for the left knee, and
the client is unable to keep the right thigh on the table. How should the nurse
document this finding? - ANSWER A flexion deformity referred to as a
positive Thomas test.
6. During a skin asssessment, the nurse notes, round and discrete lesions that
are dark red in color and will not blanch. The lesions range from 1 to 3 mm
, in size. What is the first question the nurse should ask the client? -
ANSWER Have you notice any irregular bleeding
7. A client with progressive hearing loss appears distressed when the registered
nurse (RN) asks open-ended questions about the client's health history.
Which forms of communication should the RN use? - ANSWER Face the
client so the client can see the RN's mouth.
Check if the client's hearing aides are working properly.
Reduce environmental noise surrounding the client.
8. A client states that she had a mastectomy of her left breast last year and now
experiences lymphedema. What should the nurse expect to find when
examining the client? - ANSWER Swelling of the left arm and non-pitting
edema.
9. A client has just returned from the recovery room and asks to get out of bed
to go to the bathroom. The nurse decides to obtain orthostatic vital signs
first. How will the nurse position the client to begin this procedure? -
ANSWER Lying.
10.A postmenopausal female client is undergoing a routine physical
examination. She has reported nothing out of the ordinary. When performing
the examination of the genitourinary system, the nurse finds an irregularly
enlarged uterus with firm, mobile, painless nodules in the uterine wall. How
should the nurse explain this finding to the client? - ANSWER You have
benign fibroid tumors, a common occurrence in women your age.
11.A client is reporting chest pain. What statement made by the client, helps the
nurse to understand this client has a naturalistic belief in the cause of illness?
- ANSWER "My life is really out of balance."
,12.The nurse is preparing to assess the hearing of a client with a history of
prolonged exposure to occupational noise. Which hearing test provides the
most reliable assessment of hearing status? - ANSWER Audiometry.
13.The nurse is performing a routine physical examination on an adult client.
When gathering a health history, which question is included in the CAGE
questionnaire? - ANSWER Have you ever felt guilty about your drinking?
14.During inspection of a client's mouth and pharynx, the nurse places a tongue
blade on the back of the tongue which causes the client to gag. After
removing the tongue blade, what action should the nurse take? - ANSWER
Document an intact gag reflex.
15.When teaching a client how to perform a monthly breast self-assessment, the
nurse should tell the client that it is most important to assess which part of
the breast more closely for changes? - ANSWER Upper outer quadrant.
16.The nurse is assessing a postmenopausal client who has a BMI of 32. The
client has a chest measurement of 42 inches, waist measurement of 45
inches, and hip measurement of 50 inches. What important message should
the nurse explain to the client to promote health promotion? - ANSWER A
waist circumference is greater than 35 inches in women puts you at higher
risk for type 2 diabetes and heart disease."
17.The nurse performs a physical assessment on an older female client. Which
change from the prior exam may be an indication of osteoporosis? -
ANSWER Height reduction of 1.5 inches.
18.While conducting an interview to obtain a health history, the nurse notices
that the client pauses frequently and looks at the nurse expectantly. Which
, response is best for the nurse to provide? - ANSWER Sit quietly to allow
the client to respond comfortably.
19.A client is in the clinical for a yearly physical examination. Which action
should the nurse take when preparing to examine the client's abdomen? -
ANSWER Ask the client to urinate before beginning the examination.
20.Which respiratory condition should the nurse document after measuring a
respiratory rate of 8 breaths/minute? - ANSWER Bradypnea.
21.Which procedure should the nurse use to assessfor a pulse deficit? -
ANSWER Measure the apical pulse and compare it to the peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point
of maximal impulse and the radial pulse palpated at the wrist.
22.A client has been diagnosed with bilateral lower lobe atelectasis. What
percussion sound should the nurse expect to hear when percussing over the
client's lower lobes? - ANSWER Dull, thud-like.
23.A client is being assessed upon admission to the medical-surgical unit. The
nurse is preparing to complete a head-to-toe assessment and will begin at the
head of the client. Which technique should the nurse use to begin the
assessment? - ANSWER Inspect the hair and skin.
24.The nurse is assessing a healthy young adult during an annual physical
examination. Which assessment technique should the nurse implement when
palpating the abdominal aorta? - ANSWER Deep palpation above and to the
left of the umbilicus.
Exam Study Guide (Questions and Verified
Answers) | Brand New Version
1. The nurse is performing a thoracic assessment on a client with chronic
asthma and hyperinflation of the lungs. Which finding should be expected
for this client? - ANSWER Barrel chest
2. The nurse is assessing bowel sounds for a hospitalized client. The nurse has
heard bowel sounds in the right upper quadrant. What action should the
nurse take next? - ANSWER Note the character and frequency of bowel
sounds
3. The nurse is testing the client's shoulders for range of motion. What should
the nurse document to record normal internal rotation? - ANSWER Range
of 90 degrees when the hands are placed at the small of the back.
4. A client presents with a rash along the occipital area of the hairline and
reports intense itching. How should the nurse begin the objective part of the
examination? - ANSWER Inspect the scalp looking for nits.
5. The nurse is assessing a client's range of motion as the client bends the right
knee up to the chest while keeping the left leg straight, but is unable to keep
the left thigh on the table. The assessment is repeated for the left knee, and
the client is unable to keep the right thigh on the table. How should the nurse
document this finding? - ANSWER A flexion deformity referred to as a
positive Thomas test.
6. During a skin asssessment, the nurse notes, round and discrete lesions that
are dark red in color and will not blanch. The lesions range from 1 to 3 mm
, in size. What is the first question the nurse should ask the client? -
ANSWER Have you notice any irregular bleeding
7. A client with progressive hearing loss appears distressed when the registered
nurse (RN) asks open-ended questions about the client's health history.
Which forms of communication should the RN use? - ANSWER Face the
client so the client can see the RN's mouth.
Check if the client's hearing aides are working properly.
Reduce environmental noise surrounding the client.
8. A client states that she had a mastectomy of her left breast last year and now
experiences lymphedema. What should the nurse expect to find when
examining the client? - ANSWER Swelling of the left arm and non-pitting
edema.
9. A client has just returned from the recovery room and asks to get out of bed
to go to the bathroom. The nurse decides to obtain orthostatic vital signs
first. How will the nurse position the client to begin this procedure? -
ANSWER Lying.
10.A postmenopausal female client is undergoing a routine physical
examination. She has reported nothing out of the ordinary. When performing
the examination of the genitourinary system, the nurse finds an irregularly
enlarged uterus with firm, mobile, painless nodules in the uterine wall. How
should the nurse explain this finding to the client? - ANSWER You have
benign fibroid tumors, a common occurrence in women your age.
11.A client is reporting chest pain. What statement made by the client, helps the
nurse to understand this client has a naturalistic belief in the cause of illness?
- ANSWER "My life is really out of balance."
,12.The nurse is preparing to assess the hearing of a client with a history of
prolonged exposure to occupational noise. Which hearing test provides the
most reliable assessment of hearing status? - ANSWER Audiometry.
13.The nurse is performing a routine physical examination on an adult client.
When gathering a health history, which question is included in the CAGE
questionnaire? - ANSWER Have you ever felt guilty about your drinking?
14.During inspection of a client's mouth and pharynx, the nurse places a tongue
blade on the back of the tongue which causes the client to gag. After
removing the tongue blade, what action should the nurse take? - ANSWER
Document an intact gag reflex.
15.When teaching a client how to perform a monthly breast self-assessment, the
nurse should tell the client that it is most important to assess which part of
the breast more closely for changes? - ANSWER Upper outer quadrant.
16.The nurse is assessing a postmenopausal client who has a BMI of 32. The
client has a chest measurement of 42 inches, waist measurement of 45
inches, and hip measurement of 50 inches. What important message should
the nurse explain to the client to promote health promotion? - ANSWER A
waist circumference is greater than 35 inches in women puts you at higher
risk for type 2 diabetes and heart disease."
17.The nurse performs a physical assessment on an older female client. Which
change from the prior exam may be an indication of osteoporosis? -
ANSWER Height reduction of 1.5 inches.
18.While conducting an interview to obtain a health history, the nurse notices
that the client pauses frequently and looks at the nurse expectantly. Which
, response is best for the nurse to provide? - ANSWER Sit quietly to allow
the client to respond comfortably.
19.A client is in the clinical for a yearly physical examination. Which action
should the nurse take when preparing to examine the client's abdomen? -
ANSWER Ask the client to urinate before beginning the examination.
20.Which respiratory condition should the nurse document after measuring a
respiratory rate of 8 breaths/minute? - ANSWER Bradypnea.
21.Which procedure should the nurse use to assessfor a pulse deficit? -
ANSWER Measure the apical pulse and compare it to the peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point
of maximal impulse and the radial pulse palpated at the wrist.
22.A client has been diagnosed with bilateral lower lobe atelectasis. What
percussion sound should the nurse expect to hear when percussing over the
client's lower lobes? - ANSWER Dull, thud-like.
23.A client is being assessed upon admission to the medical-surgical unit. The
nurse is preparing to complete a head-to-toe assessment and will begin at the
head of the client. Which technique should the nurse use to begin the
assessment? - ANSWER Inspect the hair and skin.
24.The nurse is assessing a healthy young adult during an annual physical
examination. Which assessment technique should the nurse implement when
palpating the abdominal aorta? - ANSWER Deep palpation above and to the
left of the umbilicus.
