HESI: BSN 246 Health Assessment V1
Actual Exam| Nightingale College|
Reviewed 2026/2027| 197 Real
Questions and Correct Accurate
Answers With Rationales
Guaranteed Pass 100%(Brand New!!)
1. The nurse is assessing a client for a hip flexion contracture. Which finding
indicates a negative Thomas test when the client's right knee is brought toward
the chest? - Answer✔️-the left leg remains on the table
*the Thomas test is performed by having the client bring one knee toward the chest
while the other leg remains extended on the table. A positive Thomas test is elicited
when the extended leg rises off the table when the opposite leg's knee is brought up
to the client's chest, indicating hip flexor contracture. If the extended leg (the left
leg, in this example) remains on the table, the test is negative.
2. 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
The Glasgow coma scale is used to establish baseline data based on eye opening,
motor response, and verbal response. The lowest possible score is 3 and the highest
is 15. This client's Glasgow coma scale (gcs) score is 12: opening eyes to sound is
a score of 3, localizing to pain is a 5, and confusion during a conversation is a 4 (3
+ 5 + 4 = 12).
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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.
10.During a skin assessment, 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
11.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.
12.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.
13.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.
14.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.
15.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."
16.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.
17.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.
18.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.
Actual Exam| Nightingale College|
Reviewed 2026/2027| 197 Real
Questions and Correct Accurate
Answers With Rationales
Guaranteed Pass 100%(Brand New!!)
1. The nurse is assessing a client for a hip flexion contracture. Which finding
indicates a negative Thomas test when the client's right knee is brought toward
the chest? - Answer✔️-the left leg remains on the table
*the Thomas test is performed by having the client bring one knee toward the chest
while the other leg remains extended on the table. A positive Thomas test is elicited
when the extended leg rises off the table when the opposite leg's knee is brought up
to the client's chest, indicating hip flexor contracture. If the extended leg (the left
leg, in this example) remains on the table, the test is negative.
2. 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
The Glasgow coma scale is used to establish baseline data based on eye opening,
motor response, and verbal response. The lowest possible score is 3 and the highest
is 15. This client's Glasgow coma scale (gcs) score is 12: opening eyes to sound is
a score of 3, localizing to pain is a 5, and confusion during a conversation is a 4 (3
+ 5 + 4 = 12).
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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.
10.During a skin assessment, 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
11.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.
12.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.
13.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.
14.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.
15.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."
16.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.
17.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.
18.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.
