“BSN 246 HESI HEALTH ASSESSMENT EXAM
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BSN 246 Practice HESI
In observing a client's face, which assessment finding requires the most
immediate intervention by the nurse?
A. Oral mucosa is cyanotic.
B. Nasolabial folds present bilaterally
C. Smooth and even skin tone
D. Absence of facial drooping
A. Oral mucosa is cyanotic.
While obtaining a health history, a male client tells the nurse that he
sometimes experiences shortness of breath. The nurse determines that the
client's respirators are regular and deep, and his respiratory rate is 14
breaths/minutes. What is the best nursing action?
A. Administer oxygen immediately.
B. Ask the client to describe the episodes of dyspnea in more detail.
C. Notify the healthcare provider about the client's condition.
D. Place the client in a prone position to ease breathing.
B. Ask the client to describe the episodes of dyspnea in more detail.
When assessing a male client's respiratory status, which technique should the
nurse use to assess his anterior-posterior (AP) chest diameter?
A. Intervention.
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B. Assessment.
C. Documentation.
D. Observation.
D. Observation.
Which assessment finding supports the client's statement, "My feet swell all
the time?"
A. No edema present.
B. 2+ pitting edema of ankles bilaterally.
C. Non-pitting edema of the lower extremities.
D. Redness and warmth in the ankles.
B. 2+ pitting edema of ankles bilaterally.
The nurse is performing a cranial nerve exam on an 87-year-
old client. The nurse notes that the client has a reduced upward gaze, a
decreased corneal reflex, a high-frequency hearing loss, and a reduced gag
reflex. What action should the nurse take next?
A. Repeat the cranial nerve test to confirm the findings.
B. Document the findings and notify the healthcare provider.
C. Ask the client if they are experiencing any unusual symptoms.
D. Continue the assessment to the next pairs of cranial nerves.
D. Continue the assessment to the next pairs of cranial nerves.
When performing a neurologic assessment on an alert client, the nurse
observes that the client's pupils are both round, 3 mm in size, and respond
briskly to light. Which notation should the nurse use when documenting the
assessment
A. PERRL
B. Dilated pupils
C. Unequal pupil size
D. Sluggish pupillary reaction?
A. PERRL
Which assessment technique provides the nurse with the best data related to
the client's level of peripheral perfusion?
.
The nurse is assessing a female client who states that her hemorrhoids are
inflamed and hurt constantly. Which intervention is best for the nurse to
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complete a focused assessment?
A. Position the client in the left lateral position to inspect the perianal area for
fissures or sacs.
B. Palpate the perianal area with both hands to assess skin elasticity.
C. Ask the client to stand and bend forward to assess the sacrum.
D. Apply deep palpation to the lower abdomen to detect tenderness.
A. Position the client in the left lateral position to inspect the perianal area for
fissures or sacs.
The nurse is performing an initial assessment of a client who has an
expressionless facial affect, slurred speech, and red conjunctivae. What
question should the nurse ask first?
A. "Have you been sleeping well?"
B. "What did you eat for breakfast today?"
C. "Do you experience any changes in your vision?"
D. "How often do you exercise during the week?"
A. "Have you been sleeping well?"
After checking a client's pupillary response to light, the practical nurse (PN)
tells the nurse that the client's pupils are constricted with minimal response to
light. Before verifying the PN's findings, which action should the nurse take?
A. Assess the client's visual fields
B. Check the client's blood pressure
C. Ask the client about recent headaches
D. Observe the client's facial symmetry
A. Assess the client's visual fields.
The nurse completes inspection of the abdomen on an adult client. Which
finding is considered normal for this client?
A. Homogeneous color.
B. Redness with patches.
C. Uneven pigmentation.
D. Presence of lesions.
A. Homogeneous color.
Which skill should the nurse have an older client demonstrate to evaluate
performance of daily living activities?
A. Reading a book aloud.
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B. Sorting a collection of socks.
C. Writing a letter to a friend.
D. Watching a movie.
B. Sorting a collection of socks.
A client sustained a subconjunctival hemorrhage. The presence of which set
of symptoms indicate that the client needs to be seen for further evaluation by
an ophthalmologist?
A. Difficulty seeing objects at a distance.
B. Diminished ability to focus on close work and excessive illumination
required.
C. Increased sensitivity to bright lights.
D. Frequent headaches when reading or using a computer.
B. Diminished ability to focus on close work and excessive illumination required.
To assess a female client for hirsutism, which action should the nurse take?
A. Ask the client to smile and observe any asymmetry.
B. Check for tenderness or swelling around the client's eyes.
C. Assess the appearance of the client's face.
D. Ask the client to perform facial movements and observe for weakness.
C. Assess the appearance of the client's face.
An older adult client is admitted to the medical unit because of loss of appetite
and generalized malaise. To analyze the client medical condition, which
laboratory value is most important for the nurse to review?
A. Red blood cell count.
B. Hematocrit.
C. White blood cell count.
D. Hemoglobin.
D. Hemoglobin.
A male client returns to the clinic for a follow-up visit after being treated for a
bladder infection. While examining the client, which finding indicated an
expected response to the treatment?
A. Pain score of 1 out of 10 with urination.
B. Clear, yellow urine with no foul odor.
C. Absence of urinary frequency or urgency.
D. Normal voiding pattern without discomfort.