BSN 246 HESI HEALTH ASSESSMENT EXAM V1
NIGHTINGALE COLLEGE TEST BANK 2026
COMPLETE QUESTIONS AND ANSWERS
GRADED A+
◉ 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.
◉ 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.
◉ 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.
◉ Which respiratory condition should the nurse document after
measuring a respiratory rate of 8 breaths/minute? Answer:
Bradypnea.
◉ 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.
◉ 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.
◉ 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.
◉ 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.
◉ The nurse is conducting a family history as part of the assessment
interview. Which action should the nurse take to ensure that
sufficient information about the client's blood relatives is obtained?
Answer: Document at least 3 generations of the client's family
medical history.
, ◉ 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.
◉ 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.
◉ 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.
◉ 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
◉ A client with progressive hearing loss appears distressed when
the registered nurse (RN) asks open-ended questions about the
NIGHTINGALE COLLEGE TEST BANK 2026
COMPLETE QUESTIONS AND ANSWERS
GRADED A+
◉ 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.
◉ 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.
◉ 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.
◉ Which respiratory condition should the nurse document after
measuring a respiratory rate of 8 breaths/minute? Answer:
Bradypnea.
◉ 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.
◉ 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.
◉ 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.
◉ 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.
◉ The nurse is conducting a family history as part of the assessment
interview. Which action should the nurse take to ensure that
sufficient information about the client's blood relatives is obtained?
Answer: Document at least 3 generations of the client's family
medical history.
, ◉ 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.
◉ 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.
◉ 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.
◉ 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
◉ A client with progressive hearing loss appears distressed when
the registered nurse (RN) asks open-ended questions about the
