BSN 246 HESI HEALTH ASSESSMENT
128 Questions and Answers | 2025
Update | 100% Correct.
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
The nurse is assessing a client who has experienced a sudden onset of hearing loss
in the right ear. Which finding should alert the nurse to a potentially serious medical
condition that requires further evaluation? - ANSWER-There is no sign of associated
infection.
Which information should the nurse obtain to identify the client's self-perception of
health status? - ANSWER-Health history
During the initial assessment, the nurse notes that a client has blurred vision with
cloudy lenses. Which condition should the nurse document? - ANSWER-Cataracts.
Which condition is indicated by a fluorescent, yellow-green color when the nurse
uses a Wood's lamp toexamine a client's skin lesions? - ANSWER-Fungal infection.
A client with dark skin is reporting a painful and itching area on the lower left leg.
What should the nurse look for when assessing this client's skin for inflammation? -
ANSWER-Change in consistency.
A client reports pain when taking a deep breath. Which lung auscultation sound
should the nurse anticipate hearing? - ANSWER-Pleural friction rub
A nurse is completing a nutritional assessment with a client. What is the easiest
method for the nurse to use to get information about the client's nutritional intake? -
ANSWER-24-hour dietary recall
The nurse palpates a weak pedal pulse in the client's right foot. Which assessment
findings should the RN document that are consistent with diminished peripheral
circulation? (Select all that apply.) - ANSWER-Diminished hair on legs.
Skin cool to touch.
The nurse is completing a physical assessment of a client who feel from a tree. The
client's abdomen is soft with hyperactive bowel sounds in all four quadrants. Which
assessment technique should the nurse implement when evaluating the client's
spleen? - ANSWER-Percuss the splenic area as the client takes a deep breath.
,The nurse enters an examination room to conduct a routine health assessment on
an adolescent female client, who is accompanied by her mother. Which action by the
nurse is likely to facilitate accurate responses to personal and social history
questions? - ANSWER-Request that the mother leave the exam room.
While performing a mental status exam (MSE), the nurse asks a client to remember
three unrelated words and repeat them later. The client was able to repeat the words
as directed. Which computer documentation is accurate? - ANSWER-"Short-term
memory is intact."
Which technique should the nurse implement when performing a Weber test? -
ANSWER-Place a vibrating tuning fork midline on top of the head
Which technique should the nurse use to assess a client for scoliosis? - ANSWER-
Observe spine while the client is erect and bent forward
Which term should the nurse use to document in the client's medical record for a
high-pitched scratchy sound during auscultation of the heart? - ANSWER-Friction
rub
While performing a head-to-toe assessment, the nurse assesses the client's pupillary
accommodation. During the second portion of the test, the nurse notes that the
client's pupils constrict and there is convergence of the axes of the eyes. What action
should the nurse implement next? - ANSWER-Document a normal finding.
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
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.
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."
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.
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?
*CAGE is the acronym for Cut down, Annoyed, Guilty, and Eye-opener. Nurse can
use it to assess for possible alcohol abuse.
, The nurse is examining the hip joint of a client who reports hip pain. Which other
assessment is most helpful in determining the cause of the client's pain? - ANSWER-
Knee joint evaluation.
The nurse performs a series of cranial nerve tests on a client with a head injury.
Which test should the nurse use to assess damage to the first cranial nerve? -
ANSWER-Occlude one nostril and have the client identify various odors.
The client reports to the nurse a recent exposure to the mumps. Which assessment
finding suggests the client has contracted the mumps? - ANSWER-Swelling anterior
to the ear lobe on one side of the face
A nurse is working in a healthcare facility that serves a diverse population. What
action(s) by the nurse will allow the nurse to empathize with and understand this
population? (Select all that apply.) - ANSWER-Be open to people who are different.
Have a curiosity about people.
Become culturally competent.
Which findings can the nurse determine by palpating a client's skin? (Select all that
apply.) - ANSWER-Diaphoresis.
Scaling.
Which question should the nurse ask in order to test a client's remote memory? -
ANSWER-What is your date of birth?
While assessing level of consciousness, the nurse finds that a client localizes to
pain, is confused during conversation, and opens the eyes to sound. How should the
nurse document the Glasgow score of this client? - ANSWER-12.
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.
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."
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.
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.
128 Questions and Answers | 2025
Update | 100% Correct.
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
The nurse is assessing a client who has experienced a sudden onset of hearing loss
in the right ear. Which finding should alert the nurse to a potentially serious medical
condition that requires further evaluation? - ANSWER-There is no sign of associated
infection.
Which information should the nurse obtain to identify the client's self-perception of
health status? - ANSWER-Health history
During the initial assessment, the nurse notes that a client has blurred vision with
cloudy lenses. Which condition should the nurse document? - ANSWER-Cataracts.
Which condition is indicated by a fluorescent, yellow-green color when the nurse
uses a Wood's lamp toexamine a client's skin lesions? - ANSWER-Fungal infection.
A client with dark skin is reporting a painful and itching area on the lower left leg.
What should the nurse look for when assessing this client's skin for inflammation? -
ANSWER-Change in consistency.
A client reports pain when taking a deep breath. Which lung auscultation sound
should the nurse anticipate hearing? - ANSWER-Pleural friction rub
A nurse is completing a nutritional assessment with a client. What is the easiest
method for the nurse to use to get information about the client's nutritional intake? -
ANSWER-24-hour dietary recall
The nurse palpates a weak pedal pulse in the client's right foot. Which assessment
findings should the RN document that are consistent with diminished peripheral
circulation? (Select all that apply.) - ANSWER-Diminished hair on legs.
Skin cool to touch.
The nurse is completing a physical assessment of a client who feel from a tree. The
client's abdomen is soft with hyperactive bowel sounds in all four quadrants. Which
assessment technique should the nurse implement when evaluating the client's
spleen? - ANSWER-Percuss the splenic area as the client takes a deep breath.
,The nurse enters an examination room to conduct a routine health assessment on
an adolescent female client, who is accompanied by her mother. Which action by the
nurse is likely to facilitate accurate responses to personal and social history
questions? - ANSWER-Request that the mother leave the exam room.
While performing a mental status exam (MSE), the nurse asks a client to remember
three unrelated words and repeat them later. The client was able to repeat the words
as directed. Which computer documentation is accurate? - ANSWER-"Short-term
memory is intact."
Which technique should the nurse implement when performing a Weber test? -
ANSWER-Place a vibrating tuning fork midline on top of the head
Which technique should the nurse use to assess a client for scoliosis? - ANSWER-
Observe spine while the client is erect and bent forward
Which term should the nurse use to document in the client's medical record for a
high-pitched scratchy sound during auscultation of the heart? - ANSWER-Friction
rub
While performing a head-to-toe assessment, the nurse assesses the client's pupillary
accommodation. During the second portion of the test, the nurse notes that the
client's pupils constrict and there is convergence of the axes of the eyes. What action
should the nurse implement next? - ANSWER-Document a normal finding.
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
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.
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."
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.
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?
*CAGE is the acronym for Cut down, Annoyed, Guilty, and Eye-opener. Nurse can
use it to assess for possible alcohol abuse.
, The nurse is examining the hip joint of a client who reports hip pain. Which other
assessment is most helpful in determining the cause of the client's pain? - ANSWER-
Knee joint evaluation.
The nurse performs a series of cranial nerve tests on a client with a head injury.
Which test should the nurse use to assess damage to the first cranial nerve? -
ANSWER-Occlude one nostril and have the client identify various odors.
The client reports to the nurse a recent exposure to the mumps. Which assessment
finding suggests the client has contracted the mumps? - ANSWER-Swelling anterior
to the ear lobe on one side of the face
A nurse is working in a healthcare facility that serves a diverse population. What
action(s) by the nurse will allow the nurse to empathize with and understand this
population? (Select all that apply.) - ANSWER-Be open to people who are different.
Have a curiosity about people.
Become culturally competent.
Which findings can the nurse determine by palpating a client's skin? (Select all that
apply.) - ANSWER-Diaphoresis.
Scaling.
Which question should the nurse ask in order to test a client's remote memory? -
ANSWER-What is your date of birth?
While assessing level of consciousness, the nurse finds that a client localizes to
pain, is confused during conversation, and opens the eyes to sound. How should the
nurse document the Glasgow score of this client? - ANSWER-12.
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.
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."
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.
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.
