BSN 246 HESI -Health Assessment V1 Exam Guide
The nurse is performing a thoracic assessment on a client with chronic asthma and hyperinflation of the
lungs. Which finding should be expected for this client? - ANSWER✅✅- Barrel chest
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.
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, 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.
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The nurse is performing a thoracic assessment on a client with chronic asthma and hyperinflation of the
lungs. Which finding should be expected for this client? - ANSWER✅✅- Barrel chest
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.
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, 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.
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