BSN 246 HESI Health Assessment
questions answered correctly
The vnurse vis vperforming va vthoracic vassessment von va vclient vwith vchronic
vasthma vand vhyperinflation vof vthe vlungs. vWhich vfinding vshould vbe vexpected
vfor vthis vclient? v- vANSWER-Barrel vchest
The vnurse vis vassessing vbowel vsounds vfor va vhospitalized vclient. vThe vnurse
vhas vheard vbowel vsounds vin vthe vright vupper vquadrant. vWhat vaction vshould
vthe vnurse vtake vnext? v- vANSWER-Note vthe vcharacter vand vfrequency vof
vbowel vsounds
During vinspection vof va vclient's vmouth vand vpharynx, vthe vnurse vplaces va
vtongue vblade von vthe vback vof vthe vtongue vwhich vcauses vthe vclient vto vgag.
vAfter vremoving vthe vtongue vblade, vwhat vaction vshould vthe vnurse vtake? v-
vANSWER-Document van vintact vgag vreflex.
When vteaching va vclient vhow vto vperform va vmonthly vbreast vself-assessment,
vthe vnurse vshould vtell vthe vclient vthat vit vis vmost vimportant vto vassess vwhich
vpart vof vthe vbreast vmore vclosely vfor vchanges? v- vANSWER-Upper vouter
vquadrant.
The vnurse vis vassessing va vpostmenopausal vclient vwho vhas va vBMI vof v32.
vThe vclient vhas va vchest vmeasurement vof v42 vinches, vwaist vmeasurement vof
v45 vinches, vand vhip vmeasurement vof v50 vinches. vWhat vimportant vmessage
vshould vthe vnurse vexplain vto vthe vclient vto vpromote vhealth vpromotion? v-
vANSWER-A vwaist vcircumference vis vgreater vthan v35 vinches vin vwomen vputs
vyou vat vhigher vrisk vfor vtype v2 vdiabetes vand vheart vdisease."
The vnurse vperforms va vphysical vassessment von van volder vfemale vclient. vWhich
vchange vfrom vthe vprior vexam vmay vbe van vindication vof vosteoporosis? v-
vANSWER-Height vreduction vof v1.5 vinches.
, While vconducting van vinterview vto vobtain va vhealth vhistory, vthe vnurse vnotices
vthat vthe vclient vpauses vfrequently vand vlooks vat vthe vnurse vexpectantly. vWhich
vresponse vis vbest vfor vthe vnurse vto vprovide? v- vANSWER-Sit vquietly vto vallow
vthe vclient vto vrespond vcomfortably.
A vclient vis vin vthe vclinical vfor va vyearly vphysical vexamination. vWhich vaction
vshould vthe vnurse vtake vwhen vpreparing vto vexamine vthe vclient's vabdomen? v-
vANSWER-Ask vthe vclient vto vurinate vbefore vbeginning vthe vexamination.
Which vrespiratory vcondition vshould vthe vnurse vdocument vafter vmeasuring va
vrespiratory vrate vof v8 vbreaths/minute? v- vANSWER-Bradypnea.
Which vprocedure vshould vthe vnurse vuse vto vassessfor va vpulse vdeficit? v-
vANSWER-Measure vthe vapical vpulse vand vcompare vit vto vthe vperipheral vpulse.
*A vpulse vdeficit vis va vpalpable vdifference vbetween vthe vapical vpulse vat vthe
vpoint vof vmaximal vimpulse vand vthe vradial vpulse vpalpated vat vthe vwrist.
A vclient vhas vbeen vdiagnosed vwith vbilateral vlower vlobe vatelectasis. vWhat
vpercussion vsound vshould vthe vnurse vexpect vto vhear vwhen vpercussing vover
vthe vclient's vlower vlobes? v- vANSWER-Dull, vthud-like.
A vclient vis vbeing vassessed vupon vadmission vto vthe vmedical-surgical vunit. vThe
vnurse vis vpreparing vto vcomplete va vhead-to-toe vassessment vand vwill vbegin vat
vthe vhead vof vthe vclient. vWhich vtechnique vshould vthe vnurse vuse vto vbegin vthe
vassessment? v- vANSWER-Inspect vthe vhair vand vskin.
The vnurse vis vassessing va vhealthy vyoung vadult vduring van vannual vphysical
vexamination. vWhich vassessment vtechnique vshould vthe vnurse vimplement vwhen
vpalpating vthe vabdominal vaorta? v- vANSWER-Deep vpalpation vabove vand vto
vthe vleft vof vthe vumbilicus.
The vnurse vis vconducting va vfamily vhistory vas vpart vof vthe vassessment
vinterview. vWhich vaction vshould vthe vnurse vtake vto vensure vthat vsufficient
vinformation vabout vthe vclient's vblood vrelatives vis vobtained? v- vANSWER-
Document vat vleast v3 vgenerations vof vthe vclient's vfamily vmedical vhistory.
The vnurse vis vtesting vthe vclient's vshoulders vfor vrange vof vmotion. vWhat vshould
vthe vnurse vdocument vto vrecord vnormal vinternal vrotation? v- vANSWER-Range
vof v90 vdegrees vwhen vthe vhands vare vplaced vat vthe vsmall vof vthe vback.
A vclient vpresents vwith va vrash valong vthe voccipital varea vof vthe vhairline vand
vreports vintense vitching. vHow vshould vthe vnurse vbegin vthe vobjective vpart vof
vthe vexamination? v- vANSWER-Inspect vthe vscalp vlooking vfor vnits.
questions answered correctly
The vnurse vis vperforming va vthoracic vassessment von va vclient vwith vchronic
vasthma vand vhyperinflation vof vthe vlungs. vWhich vfinding vshould vbe vexpected
vfor vthis vclient? v- vANSWER-Barrel vchest
The vnurse vis vassessing vbowel vsounds vfor va vhospitalized vclient. vThe vnurse
vhas vheard vbowel vsounds vin vthe vright vupper vquadrant. vWhat vaction vshould
vthe vnurse vtake vnext? v- vANSWER-Note vthe vcharacter vand vfrequency vof
vbowel vsounds
During vinspection vof va vclient's vmouth vand vpharynx, vthe vnurse vplaces va
vtongue vblade von vthe vback vof vthe vtongue vwhich vcauses vthe vclient vto vgag.
vAfter vremoving vthe vtongue vblade, vwhat vaction vshould vthe vnurse vtake? v-
vANSWER-Document van vintact vgag vreflex.
When vteaching va vclient vhow vto vperform va vmonthly vbreast vself-assessment,
vthe vnurse vshould vtell vthe vclient vthat vit vis vmost vimportant vto vassess vwhich
vpart vof vthe vbreast vmore vclosely vfor vchanges? v- vANSWER-Upper vouter
vquadrant.
The vnurse vis vassessing va vpostmenopausal vclient vwho vhas va vBMI vof v32.
vThe vclient vhas va vchest vmeasurement vof v42 vinches, vwaist vmeasurement vof
v45 vinches, vand vhip vmeasurement vof v50 vinches. vWhat vimportant vmessage
vshould vthe vnurse vexplain vto vthe vclient vto vpromote vhealth vpromotion? v-
vANSWER-A vwaist vcircumference vis vgreater vthan v35 vinches vin vwomen vputs
vyou vat vhigher vrisk vfor vtype v2 vdiabetes vand vheart vdisease."
The vnurse vperforms va vphysical vassessment von van volder vfemale vclient. vWhich
vchange vfrom vthe vprior vexam vmay vbe van vindication vof vosteoporosis? v-
vANSWER-Height vreduction vof v1.5 vinches.
, While vconducting van vinterview vto vobtain va vhealth vhistory, vthe vnurse vnotices
vthat vthe vclient vpauses vfrequently vand vlooks vat vthe vnurse vexpectantly. vWhich
vresponse vis vbest vfor vthe vnurse vto vprovide? v- vANSWER-Sit vquietly vto vallow
vthe vclient vto vrespond vcomfortably.
A vclient vis vin vthe vclinical vfor va vyearly vphysical vexamination. vWhich vaction
vshould vthe vnurse vtake vwhen vpreparing vto vexamine vthe vclient's vabdomen? v-
vANSWER-Ask vthe vclient vto vurinate vbefore vbeginning vthe vexamination.
Which vrespiratory vcondition vshould vthe vnurse vdocument vafter vmeasuring va
vrespiratory vrate vof v8 vbreaths/minute? v- vANSWER-Bradypnea.
Which vprocedure vshould vthe vnurse vuse vto vassessfor va vpulse vdeficit? v-
vANSWER-Measure vthe vapical vpulse vand vcompare vit vto vthe vperipheral vpulse.
*A vpulse vdeficit vis va vpalpable vdifference vbetween vthe vapical vpulse vat vthe
vpoint vof vmaximal vimpulse vand vthe vradial vpulse vpalpated vat vthe vwrist.
A vclient vhas vbeen vdiagnosed vwith vbilateral vlower vlobe vatelectasis. vWhat
vpercussion vsound vshould vthe vnurse vexpect vto vhear vwhen vpercussing vover
vthe vclient's vlower vlobes? v- vANSWER-Dull, vthud-like.
A vclient vis vbeing vassessed vupon vadmission vto vthe vmedical-surgical vunit. vThe
vnurse vis vpreparing vto vcomplete va vhead-to-toe vassessment vand vwill vbegin vat
vthe vhead vof vthe vclient. vWhich vtechnique vshould vthe vnurse vuse vto vbegin vthe
vassessment? v- vANSWER-Inspect vthe vhair vand vskin.
The vnurse vis vassessing va vhealthy vyoung vadult vduring van vannual vphysical
vexamination. vWhich vassessment vtechnique vshould vthe vnurse vimplement vwhen
vpalpating vthe vabdominal vaorta? v- vANSWER-Deep vpalpation vabove vand vto
vthe vleft vof vthe vumbilicus.
The vnurse vis vconducting va vfamily vhistory vas vpart vof vthe vassessment
vinterview. vWhich vaction vshould vthe vnurse vtake vto vensure vthat vsufficient
vinformation vabout vthe vclient's vblood vrelatives vis vobtained? v- vANSWER-
Document vat vleast v3 vgenerations vof vthe vclient's vfamily vmedical vhistory.
The vnurse vis vtesting vthe vclient's vshoulders vfor vrange vof vmotion. vWhat vshould
vthe vnurse vdocument vto vrecord vnormal vinternal vrotation? v- vANSWER-Range
vof v90 vdegrees vwhen vthe vhands vare vplaced vat vthe vsmall vof vthe vback.
A vclient vpresents vwith va vrash valong vthe voccipital varea vof vthe vhairline vand
vreports vintense vitching. vHow vshould vthe vnurse vbegin vthe vobjective vpart vof
vthe vexamination? v- vANSWER-Inspect vthe vscalp vlooking vfor vnits.
