BSN 246 HESI Health Assessment V1/ACTUAL EXAM –
NIGHTINGALE COLLEGE
1. Describe the purpose of the CAGE questionnaire in nursing assessments.
The CAGE questionnaire evaluates neurological status.
The CAGE questionnaire assesses respiratory function in patients.
The CAGE questionnaire is a tool for measuring blood pressure.
The CAGE questionnaire is used to identify potential alcohol abuse
by asking specific questions about drinking habits.
2. If a client appears anxious during a mini-mental state examination, which
strategy should the RN prioritize to help the client feel more comfortable?
Use complex medical terminology to explain the process.
Conduct the examination in a busy environment.
Rush through the examination to save time.
Ask questions one at a time to decrease confusion.
3. What is the primary role of an interpreter during a nursing assessment?
To document the assessment findings.
To conduct the physical examination.
To provide medical advice to the client.
To facilitate communication between the nurse and the client.
4. What is the term used to describe the ability to recall information during a
mental status exam?
Perception
, Judgment
Memory
Attention
5. What is the primary function of the facial nerve that should be assessed in a
client?
Facial muscle movement
Taste sensation
Vision clarity
Hearing ability
6. What is the primary purpose of the Weber test in nursing assessments?
To measure blood pressure.
To assess hearing loss.
To check for neurological deficits.
To evaluate lung function.
7. A nurse notices that a client has dry mucous membranes and decreased skin
turgor. What should the nurse infer about the client's hydration status?
The client is well-hydrated.
The client has a respiratory condition.
The client is likely dehydrated.
The client is experiencing an allergic reaction.
8. A patient had a left radical mastectomy last year. The nurse assesses for
painless and nonpitting swelling of the arm on that side. Which complication
, of a mastectomy is the nurse assessing for?
Infection
Lymphoma
Lymphedema
Inflammation
9. If a nurse encounters a patient from a different cultural background, what
should they do to ensure effective communication and understanding?
Engage in active listening and ask open-ended questions about the
patient's cultural practices.
Limit the conversation to medical history only.
Assume the patient has the same beliefs as the nurse.
Use medical jargon to explain conditions.
10. Which states the naturalistic view of what causes illness?
Illness is a natural part of life and therefore unavoidable.
Only natural agents are effective in treating illness.
Illness is caused by cold, heat, wind, and dampness.
Outside agents, such as evil spirits, upset the body's natural balance.
11. What is one technique that can be used to reduce anxiety during a mini-
mental state examination?
Use simple sentences during the examination.
Ask multiple questions at once.
Avoid eye contact with the client.
, Increase environmental distractions.
12. What is the primary purpose of obtaining a family history during a nursing
assessment?
To identify potential genetic or hereditary health risks.
To evaluate the client's lifestyle choices.
To determine the client's medication history.
To assess the client's current health status.
13. If a nurse hears a pleural friction rub while auscultating a patient with chest
pain, what should be the next step in the nursing assessment?
Administer bronchodilators immediately.
Further assess for signs of pleuritis or pneumonia.
Reassess lung sounds in 30 minutes.
Document the finding and continue with the assessment.
14. A client reports feeling increasingly fatigued for several months, and the
nurse observes that the client's lips are pale. Which additional data should
the nurse collect based on this presentation?
Current alcohol and tobacco use.
A 24-hour dietary recall.
Daily pattern of oral hygiene practices.
Use of vitamin and iron supplements.
15. If a nurse suspects a patient may have incontinence based on their age and
health history, what would be the most appropriate action to take during the
assessment?
NIGHTINGALE COLLEGE
1. Describe the purpose of the CAGE questionnaire in nursing assessments.
The CAGE questionnaire evaluates neurological status.
The CAGE questionnaire assesses respiratory function in patients.
The CAGE questionnaire is a tool for measuring blood pressure.
The CAGE questionnaire is used to identify potential alcohol abuse
by asking specific questions about drinking habits.
2. If a client appears anxious during a mini-mental state examination, which
strategy should the RN prioritize to help the client feel more comfortable?
Use complex medical terminology to explain the process.
Conduct the examination in a busy environment.
Rush through the examination to save time.
Ask questions one at a time to decrease confusion.
3. What is the primary role of an interpreter during a nursing assessment?
To document the assessment findings.
To conduct the physical examination.
To provide medical advice to the client.
To facilitate communication between the nurse and the client.
4. What is the term used to describe the ability to recall information during a
mental status exam?
Perception
, Judgment
Memory
Attention
5. What is the primary function of the facial nerve that should be assessed in a
client?
Facial muscle movement
Taste sensation
Vision clarity
Hearing ability
6. What is the primary purpose of the Weber test in nursing assessments?
To measure blood pressure.
To assess hearing loss.
To check for neurological deficits.
To evaluate lung function.
7. A nurse notices that a client has dry mucous membranes and decreased skin
turgor. What should the nurse infer about the client's hydration status?
The client is well-hydrated.
The client has a respiratory condition.
The client is likely dehydrated.
The client is experiencing an allergic reaction.
8. A patient had a left radical mastectomy last year. The nurse assesses for
painless and nonpitting swelling of the arm on that side. Which complication
, of a mastectomy is the nurse assessing for?
Infection
Lymphoma
Lymphedema
Inflammation
9. If a nurse encounters a patient from a different cultural background, what
should they do to ensure effective communication and understanding?
Engage in active listening and ask open-ended questions about the
patient's cultural practices.
Limit the conversation to medical history only.
Assume the patient has the same beliefs as the nurse.
Use medical jargon to explain conditions.
10. Which states the naturalistic view of what causes illness?
Illness is a natural part of life and therefore unavoidable.
Only natural agents are effective in treating illness.
Illness is caused by cold, heat, wind, and dampness.
Outside agents, such as evil spirits, upset the body's natural balance.
11. What is one technique that can be used to reduce anxiety during a mini-
mental state examination?
Use simple sentences during the examination.
Ask multiple questions at once.
Avoid eye contact with the client.
, Increase environmental distractions.
12. What is the primary purpose of obtaining a family history during a nursing
assessment?
To identify potential genetic or hereditary health risks.
To evaluate the client's lifestyle choices.
To determine the client's medication history.
To assess the client's current health status.
13. If a nurse hears a pleural friction rub while auscultating a patient with chest
pain, what should be the next step in the nursing assessment?
Administer bronchodilators immediately.
Further assess for signs of pleuritis or pneumonia.
Reassess lung sounds in 30 minutes.
Document the finding and continue with the assessment.
14. A client reports feeling increasingly fatigued for several months, and the
nurse observes that the client's lips are pale. Which additional data should
the nurse collect based on this presentation?
Current alcohol and tobacco use.
A 24-hour dietary recall.
Daily pattern of oral hygiene practices.
Use of vitamin and iron supplements.
15. If a nurse suspects a patient may have incontinence based on their age and
health history, what would be the most appropriate action to take during the
assessment?
