BSN246 HESIHealthAssessmentV2
Exam with NGN CORRECT
ANSWERS AND EXPLANATIONS
### Question 1
A 29-year-old male client informs the nurse that he came to the clinic
to see if, "Maybe I have lung cancer or something," and wants to get
checked out since, "I can't seem to get rid of this body-wracking dry
cough that has been hanging around for the last six weeks." Which
computer documentation of this client's concerns should the nurse
enter?
A) "Patient reports a persistent cough accompanied by wheezing."
B) "Client describes having a 'body-wracking dry cough' of 6 weeks
duration."
C) "The client expresses concern about possible lung cancer
symptoms."
D) "Client presents with a cough lasting more than a month."
ANSWER:B) "Client describes having a 'body-wracking dry cough' of
6
weeks duration."
Expert Rationale:The documentation should reflect the client's own
description of their symptoms. Using the client's words captures the
severity and character of the cough, providing clear information for
future assessments.
### Question 2
A male client arrives at the clinic for a follow-up health
assessment after recent antibiotic treatment for pneumonia without
hospitalization. Which technique should the nurse implement to
assess for adventitious lung sounds?
A) Place the stethoscope's diaphragm lightly on the skin.
B) Press the stethoscope's diaphragm firmly on the skin over
each lung
field.
C) Ask the client to breathe normally while using the bell of the
stethoscope.
, D) Use the diaphragm lightly over each lung field and listen for
changes.
ANSWER:B) Press the stethoscope's diaphragm firmly on the
skin over each lung field.
Expert Rationale:Applying the diaphragm firmly enhances the
transmission of breath sounds and allows the nurse to detect any
adventitious sounds such as wheezes or crackles effectively.
### Question 3
The nurse examines a client's abdomen. Which finding
indicates an abnormal response when palpating the spleen?
- A) No palpable mass noted.
- B) Tenderness reported upon deep palpation.
- C) Firm mass palpated at bottom of left rib cage.
- D) Softness in the lateral aspect of the abdomen.
ANSWER:C) Firm mass palpated at bottom of left rib cage.
Expert Rationale:The spleen is usually not palpable
unless it is enlarged. A firm mass in this area may indicate
splenomegaly, which is abnormal.
Question 4
In auscultating for the presence of a carotid artery
bruit, the nurse places the bell of the stethoscope at
which location?
, lOMoARcPSD|27916040
- A) Over the left subclavian artery.
- B) Over the aortic arch.
- C) Over the carotid artery.
- D) Over the temporal artery.
ANSWER:C) Over the carotid artery.
Expert Rationale:The bell of the stethoscope is applied
directly over the carotid artery to listen for bruits, which are
abnormal sounds indicating turbulent blood flow, possibly
due to stenosis.
---
### Question 5
A 75-year-old client with a recent history of a
cerebrovascular accident (CVA) presents with right
, hemiparesis. The nurse tests the deep tendon reflexes
on the right side and elicits a brisk 4+ response.
Which interpretation of this finding is accurate?
- A) Normal response suggesting healthy neuromuscular
function.
- B) Hypoactive response consistent with a lower motor neuron
disorder.
- C) Hyperactive response consistent with an upper motor
neuron disorder.
- D) Reflexes indicate potential peripheral nerve damage.
ANSWER:C) Hyperactive response consistent with an
upper motor
neuron disorder.
Exam with NGN CORRECT
ANSWERS AND EXPLANATIONS
### Question 1
A 29-year-old male client informs the nurse that he came to the clinic
to see if, "Maybe I have lung cancer or something," and wants to get
checked out since, "I can't seem to get rid of this body-wracking dry
cough that has been hanging around for the last six weeks." Which
computer documentation of this client's concerns should the nurse
enter?
A) "Patient reports a persistent cough accompanied by wheezing."
B) "Client describes having a 'body-wracking dry cough' of 6 weeks
duration."
C) "The client expresses concern about possible lung cancer
symptoms."
D) "Client presents with a cough lasting more than a month."
ANSWER:B) "Client describes having a 'body-wracking dry cough' of
6
weeks duration."
Expert Rationale:The documentation should reflect the client's own
description of their symptoms. Using the client's words captures the
severity and character of the cough, providing clear information for
future assessments.
### Question 2
A male client arrives at the clinic for a follow-up health
assessment after recent antibiotic treatment for pneumonia without
hospitalization. Which technique should the nurse implement to
assess for adventitious lung sounds?
A) Place the stethoscope's diaphragm lightly on the skin.
B) Press the stethoscope's diaphragm firmly on the skin over
each lung
field.
C) Ask the client to breathe normally while using the bell of the
stethoscope.
, D) Use the diaphragm lightly over each lung field and listen for
changes.
ANSWER:B) Press the stethoscope's diaphragm firmly on the
skin over each lung field.
Expert Rationale:Applying the diaphragm firmly enhances the
transmission of breath sounds and allows the nurse to detect any
adventitious sounds such as wheezes or crackles effectively.
### Question 3
The nurse examines a client's abdomen. Which finding
indicates an abnormal response when palpating the spleen?
- A) No palpable mass noted.
- B) Tenderness reported upon deep palpation.
- C) Firm mass palpated at bottom of left rib cage.
- D) Softness in the lateral aspect of the abdomen.
ANSWER:C) Firm mass palpated at bottom of left rib cage.
Expert Rationale:The spleen is usually not palpable
unless it is enlarged. A firm mass in this area may indicate
splenomegaly, which is abnormal.
Question 4
In auscultating for the presence of a carotid artery
bruit, the nurse places the bell of the stethoscope at
which location?
, lOMoARcPSD|27916040
- A) Over the left subclavian artery.
- B) Over the aortic arch.
- C) Over the carotid artery.
- D) Over the temporal artery.
ANSWER:C) Over the carotid artery.
Expert Rationale:The bell of the stethoscope is applied
directly over the carotid artery to listen for bruits, which are
abnormal sounds indicating turbulent blood flow, possibly
due to stenosis.
---
### Question 5
A 75-year-old client with a recent history of a
cerebrovascular accident (CVA) presents with right
, hemiparesis. The nurse tests the deep tendon reflexes
on the right side and elicits a brisk 4+ response.
Which interpretation of this finding is accurate?
- A) Normal response suggesting healthy neuromuscular
function.
- B) Hypoactive response consistent with a lower motor neuron
disorder.
- C) Hyperactive response consistent with an upper motor
neuron disorder.
- D) Reflexes indicate potential peripheral nerve damage.
ANSWER:C) Hyperactive response consistent with an
upper motor
neuron disorder.
