BSN 246 HESI HEALTH ASSESSMENT EXAM 2026/2027 |
Complete Exam | Nightingale College | Pass Guaranteed - A+
Graded
SECTION 1: Health History & Interview (Q1-Q20)
Q1: A 58-year-old patient presents to the clinic with complaints of chest discomfort.
Using the OLDCARTS mnemonic, which question best assesses the "A" component?
A. "Does the discomfort radiate to your arm or jaw?" [CORRECT]
B. "When did the discomfort first start?"
C. "What does the discomfort feel like?"
D. "What makes the discomfort better or worse?"
Correct Answer: A
Rationale: The "A" in OLDCARTS stands for Associated symptoms, which includes
radiation and accompanying symptoms. "When did it start" assesses Onset, "What does
it feel like" assesses Character, and "What makes it better" assesses
Relieving/Aggravating factors.
Q2: A nurse is assessing a patient with abdominal pain using the PQRST method. Which
question addresses the "Q" component?
A. "Can you rate your pain on a scale of 0 to 10?"
B. "Does the pain come and go or is it constant?"
C. "What were you doing when the pain started?"
D. "Does the pain radiate to your back?"
Correct Answer: A
Rationale: The "Q" in PQRST stands for Quality/Quantity, which includes pain intensity
rating. "Does it come and go" addresses Time, "What were you doing" addresses
Provocation, and "Does it radiate" addresses Region/Radiation.
Q3: After providing discharge instructions to a patient with low health literacy, what is
the nurse's next best step to ensure understanding?
A. Ask the patient to teach back the instructions in their own words [CORRECT]
B. Provide written instructions only and ask the patient to read them at home
,C. Ask the patient if they understand and accept a verbal "yes"
D. Repeat the instructions more quickly to save time
Correct Answer: A
Rationale: The teach-back method is the gold standard for confirming health literacy
and comprehension. A verbal "yes" does not confirm understanding, written-only
instructions are insufficient for low literacy, and speaking faster reduces
comprehension.
Q4: A Spanish-speaking patient arrives for a health history interview and speaks limited
English. The patient's teenage son offers to translate. What is the nurse's most
appropriate action?
A. Accept the son's offer to translate to maintain family involvement
B. Use a professional medical interpreter and request the son wait in the lobby
[CORRECT]
C. Use simple English words and speak loudly to the patient
D. Ask another nursing student who took Spanish in high school to interpret
Correct Answer: B
Rationale: Professional medical interpreters are required for accurate, confidential, and
unbiased communication. Family members should not interpret due to privacy
concerns, potential omission of sensitive information, and risk of misinterpretation.
Q5: A patient is admitted to the emergency department with multiple traumatic injuries.
The nurse performs a health history focusing only on the presenting problem and
relevant systems. This is an example of which type of health history?
A. Comprehensive health history
B. Focused health history [CORRECT]
C. Emergency health history
D. Follow-up health history
Correct Answer: B
Rationale: A focused health history addresses the presenting problem and relevant
systems only, appropriate for emergency or urgent care settings. A comprehensive
health history covers all body systems, past history, and family history.
,Q6: During the review of systems (ROS), a patient reports frequent nocturia, orthopnea,
and ankle swelling. Which body system should the nurse document these findings
under?
A. Respiratory system
B. Cardiovascular system [CORRECT]
C. Genitourinary system
D. Musculoskeletal system
Correct Answer: B
Rationale: Nocturia, orthopnea, and peripheral edema are classic symptoms of heart
failure and cardiovascular compromise. While nocturia involves the genitourinary
system, the cluster of symptoms indicates cardiovascular dysfunction.
Q7: A 45-year-old patient reports that his father died of a myocardial infarction at age 50
and his mother has type 2 diabetes. How should the nurse best document this
information?
A. In the social history section
B. In the family history section using a genogram [CORRECT]
C. In the past medical history section
D. In the chief complaint section
Correct Answer: B
Rationale: Family history is best documented using a genogram, which graphically
represents family relationships, medical conditions, and ages at onset or death. This
provides a clear visual of hereditary risk factors.
Q8: During a routine health history, a patient admits to drinking 6-8 beers daily. Which
screening tool is most appropriate for the nurse to use next?
A. CAGE questionnaire [CORRECT]
B. PHQ-9 questionnaire
C. Braden Scale
D. Mini-Mental State Examination
Correct Answer: A
Rationale: The CAGE questionnaire screens for alcohol misuse and dependence. PHQ-9
screens for depression, the Braden Scale assesses pressure injury risk, and the MMSE
assesses cognitive function.
, Q9: A patient discloses during a private interview that her partner has been physically
abusive. What is the nurse's immediate priority?
A. Document the disclosure in the medical record
B. Assess the patient's immediate safety and provide resources [CORRECT]
C. Contact the patient's partner to verify the story
D. Wait until the next visit to follow up on the disclosure
Correct Answer: B
Rationale: Patient safety is the highest priority when abuse is disclosed. The nurse must
assess immediate danger, provide safety planning, and offer resources. Documentation
is important but secondary to safety assessment.
Q10: A nurse is taking a sexual history using the PLISSIT model. Which statement
represents the "Permission" component?
A. "Many people have questions about their sexual health. Is it okay if I ask you some
questions?" [CORRECT]
B. "I recommend you use barrier protection to prevent STIs."
C. "It sounds like you are experiencing pain during intercourse."
D. "Would you like a referral to a sexual health counselor?"
Correct Answer: A
Rationale: The PLISSIT model includes Permission, Limited Information, Specific
Suggestions, and Intensive Therapy. Asking permission to discuss sexual health
represents the Permission component.
Q11: A 65-year-old patient asks the nurse which immunizations he needs. He received
Tdap 8 years ago and has never had shingles or pneumonia vaccines. What is the
nurse's best recommendation?
A. Tdap booster now, pneumococcal vaccine now, and shingles vaccine now [CORRECT]
B. Tdap booster in 2 years, pneumococcal at age 70, and shingles at age 70
C. No vaccines needed at this time
D. Only the shingles vaccine is needed
Correct Answer: A
Rationale: Adults need Tdap every 10 years (he is due), pneumococcal vaccine at age 65
or older, and recombinant zoster vaccine (shingles) at age 50 or older. All three are
indicated for this patient.
Complete Exam | Nightingale College | Pass Guaranteed - A+
Graded
SECTION 1: Health History & Interview (Q1-Q20)
Q1: A 58-year-old patient presents to the clinic with complaints of chest discomfort.
Using the OLDCARTS mnemonic, which question best assesses the "A" component?
A. "Does the discomfort radiate to your arm or jaw?" [CORRECT]
B. "When did the discomfort first start?"
C. "What does the discomfort feel like?"
D. "What makes the discomfort better or worse?"
Correct Answer: A
Rationale: The "A" in OLDCARTS stands for Associated symptoms, which includes
radiation and accompanying symptoms. "When did it start" assesses Onset, "What does
it feel like" assesses Character, and "What makes it better" assesses
Relieving/Aggravating factors.
Q2: A nurse is assessing a patient with abdominal pain using the PQRST method. Which
question addresses the "Q" component?
A. "Can you rate your pain on a scale of 0 to 10?"
B. "Does the pain come and go or is it constant?"
C. "What were you doing when the pain started?"
D. "Does the pain radiate to your back?"
Correct Answer: A
Rationale: The "Q" in PQRST stands for Quality/Quantity, which includes pain intensity
rating. "Does it come and go" addresses Time, "What were you doing" addresses
Provocation, and "Does it radiate" addresses Region/Radiation.
Q3: After providing discharge instructions to a patient with low health literacy, what is
the nurse's next best step to ensure understanding?
A. Ask the patient to teach back the instructions in their own words [CORRECT]
B. Provide written instructions only and ask the patient to read them at home
,C. Ask the patient if they understand and accept a verbal "yes"
D. Repeat the instructions more quickly to save time
Correct Answer: A
Rationale: The teach-back method is the gold standard for confirming health literacy
and comprehension. A verbal "yes" does not confirm understanding, written-only
instructions are insufficient for low literacy, and speaking faster reduces
comprehension.
Q4: A Spanish-speaking patient arrives for a health history interview and speaks limited
English. The patient's teenage son offers to translate. What is the nurse's most
appropriate action?
A. Accept the son's offer to translate to maintain family involvement
B. Use a professional medical interpreter and request the son wait in the lobby
[CORRECT]
C. Use simple English words and speak loudly to the patient
D. Ask another nursing student who took Spanish in high school to interpret
Correct Answer: B
Rationale: Professional medical interpreters are required for accurate, confidential, and
unbiased communication. Family members should not interpret due to privacy
concerns, potential omission of sensitive information, and risk of misinterpretation.
Q5: A patient is admitted to the emergency department with multiple traumatic injuries.
The nurse performs a health history focusing only on the presenting problem and
relevant systems. This is an example of which type of health history?
A. Comprehensive health history
B. Focused health history [CORRECT]
C. Emergency health history
D. Follow-up health history
Correct Answer: B
Rationale: A focused health history addresses the presenting problem and relevant
systems only, appropriate for emergency or urgent care settings. A comprehensive
health history covers all body systems, past history, and family history.
,Q6: During the review of systems (ROS), a patient reports frequent nocturia, orthopnea,
and ankle swelling. Which body system should the nurse document these findings
under?
A. Respiratory system
B. Cardiovascular system [CORRECT]
C. Genitourinary system
D. Musculoskeletal system
Correct Answer: B
Rationale: Nocturia, orthopnea, and peripheral edema are classic symptoms of heart
failure and cardiovascular compromise. While nocturia involves the genitourinary
system, the cluster of symptoms indicates cardiovascular dysfunction.
Q7: A 45-year-old patient reports that his father died of a myocardial infarction at age 50
and his mother has type 2 diabetes. How should the nurse best document this
information?
A. In the social history section
B. In the family history section using a genogram [CORRECT]
C. In the past medical history section
D. In the chief complaint section
Correct Answer: B
Rationale: Family history is best documented using a genogram, which graphically
represents family relationships, medical conditions, and ages at onset or death. This
provides a clear visual of hereditary risk factors.
Q8: During a routine health history, a patient admits to drinking 6-8 beers daily. Which
screening tool is most appropriate for the nurse to use next?
A. CAGE questionnaire [CORRECT]
B. PHQ-9 questionnaire
C. Braden Scale
D. Mini-Mental State Examination
Correct Answer: A
Rationale: The CAGE questionnaire screens for alcohol misuse and dependence. PHQ-9
screens for depression, the Braden Scale assesses pressure injury risk, and the MMSE
assesses cognitive function.
, Q9: A patient discloses during a private interview that her partner has been physically
abusive. What is the nurse's immediate priority?
A. Document the disclosure in the medical record
B. Assess the patient's immediate safety and provide resources [CORRECT]
C. Contact the patient's partner to verify the story
D. Wait until the next visit to follow up on the disclosure
Correct Answer: B
Rationale: Patient safety is the highest priority when abuse is disclosed. The nurse must
assess immediate danger, provide safety planning, and offer resources. Documentation
is important but secondary to safety assessment.
Q10: A nurse is taking a sexual history using the PLISSIT model. Which statement
represents the "Permission" component?
A. "Many people have questions about their sexual health. Is it okay if I ask you some
questions?" [CORRECT]
B. "I recommend you use barrier protection to prevent STIs."
C. "It sounds like you are experiencing pain during intercourse."
D. "Would you like a referral to a sexual health counselor?"
Correct Answer: A
Rationale: The PLISSIT model includes Permission, Limited Information, Specific
Suggestions, and Intensive Therapy. Asking permission to discuss sexual health
represents the Permission component.
Q11: A 65-year-old patient asks the nurse which immunizations he needs. He received
Tdap 8 years ago and has never had shingles or pneumonia vaccines. What is the
nurse's best recommendation?
A. Tdap booster now, pneumococcal vaccine now, and shingles vaccine now [CORRECT]
B. Tdap booster in 2 years, pneumococcal at age 70, and shingles at age 70
C. No vaccines needed at this time
D. Only the shingles vaccine is needed
Correct Answer: A
Rationale: Adults need Tdap every 10 years (he is due), pneumococcal vaccine at age 65
or older, and recombinant zoster vaccine (shingles) at age 50 or older. All three are
indicated for this patient.
