HESI HEALTH ASSESSMENT
NIGHTINGALE COLLEGE FALL 2026/2027 QUESTIONS
AND 100% VERIFIED ANSWERS WITH RATIONALES
GRADED A+ LATEST
1. A nurse is preparing to assess cranial nerve II. Which action is most
appropriate?
A. Assess facial symmetry
B. Test visual acuity
C. Observe tongue movement
D. Assess shoulder shrug
Correct Answer: B
Rationale: Cranial nerve II (optic nerve) is responsible for vision; visual acuity
testing directly evaluates its function.
2. When auscultating bowel sounds, the nurse should:
A. Palpate the abdomen first
B. Auscultate before percussion
C. Use the diaphragm only
D. Listen for 1 minute in each quadrant
Correct Answer: B
Rationale: Auscultation is performed before percussion or palpation to avoid
altering bowel sounds.
3. A blood pressure reading of 88/56 mmHg in an adult is best interpreted as:
A. Normal
B. Elevated
C. Hypotension
D. Hypertension
,Correct Answer: C
Rationale: Adult hypotension is typically defined as systolic BP below 90 mmHg.
4. Which finding is expected in a healthy older adult?
A. Absent deep tendon reflexes
B. Decreased skin elasticity
C. Fixed pupils
D. Severe memory loss
Correct Answer: B
Rationale: Decreased skin turgor and elasticity are normal age-related changes.
5. During assessment of the lungs, crackles are best described as:
A. Continuous musical sounds
B. High-pitched wheezes
C. Discontinuous popping sounds
D. Low-pitched snoring sounds
Correct Answer: C
Rationale: Crackles are discontinuous, nonmusical sounds often associated with
fluid in alveoli.
6. The nurse notes unequal pupil size. This finding is documented as:
A. Diplopia
B. Strabismus
C. Anisocoria
D. Ptosis
Correct Answer: C
Rationale: Anisocoria refers to unequal pupil sizes.
,7. A patient reports sharp chest pain that worsens with deep inspiration. This
finding suggests:
A. Angina
B. Musculoskeletal pain
C. Pleural irritation
D. Gastroesophageal reflux
Correct Answer: C
Rationale: Pain that increases with inspiration is characteristic of pleural
involvement.
8. Which assessment finding requires immediate follow-up?
A. Heart rate of 58 bpm in an athlete
B. Capillary refill of 5 seconds
C. BMI of 29
D. Mild ankle edema at the end of the day
Correct Answer: B
Rationale: Capillary refill greater than 3 seconds may indicate impaired perfusion.
9. The best position to assess jugular venous distention is:
A. Supine
B. High Fowler’s
C. Prone
D. Semi-Fowler’s at 30–45°
Correct Answer: D
Rationale: JVD is best visualized with the patient semi-reclined at 30–45 degrees.
10. A nurse assessing a newborn’s reflexes would expect to find which reflex?
A. Babinski absent
B. Moro present
C. Triceps reflex present
D. Plantar reflex absent
, Correct Answer: B
Rationale: The Moro (startle) reflex is normal in newborns.
11. When assessing pain, the most reliable indicator is:
A. Facial expression
B. Vital signs
C. Patient self-report
D. Nurse observation
Correct Answer: C
Rationale: Pain is subjective; the patient’s report is the most accurate indicator.
12. Which percussion sound is expected over healthy lung tissue?
A. Dull
B. Flat
C. Resonant
D. Tympanic
Correct Answer: C
Rationale: Resonance indicates air-filled lung tissue.
13. The Romberg test assesses:
A. Muscle strength
B. Cerebellar function
C. Balance and proprioception
D. Reflex activity
Correct Answer: C
Rationale: The Romberg test evaluates balance and proprioceptive function.
NIGHTINGALE COLLEGE FALL 2026/2027 QUESTIONS
AND 100% VERIFIED ANSWERS WITH RATIONALES
GRADED A+ LATEST
1. A nurse is preparing to assess cranial nerve II. Which action is most
appropriate?
A. Assess facial symmetry
B. Test visual acuity
C. Observe tongue movement
D. Assess shoulder shrug
Correct Answer: B
Rationale: Cranial nerve II (optic nerve) is responsible for vision; visual acuity
testing directly evaluates its function.
2. When auscultating bowel sounds, the nurse should:
A. Palpate the abdomen first
B. Auscultate before percussion
C. Use the diaphragm only
D. Listen for 1 minute in each quadrant
Correct Answer: B
Rationale: Auscultation is performed before percussion or palpation to avoid
altering bowel sounds.
3. A blood pressure reading of 88/56 mmHg in an adult is best interpreted as:
A. Normal
B. Elevated
C. Hypotension
D. Hypertension
,Correct Answer: C
Rationale: Adult hypotension is typically defined as systolic BP below 90 mmHg.
4. Which finding is expected in a healthy older adult?
A. Absent deep tendon reflexes
B. Decreased skin elasticity
C. Fixed pupils
D. Severe memory loss
Correct Answer: B
Rationale: Decreased skin turgor and elasticity are normal age-related changes.
5. During assessment of the lungs, crackles are best described as:
A. Continuous musical sounds
B. High-pitched wheezes
C. Discontinuous popping sounds
D. Low-pitched snoring sounds
Correct Answer: C
Rationale: Crackles are discontinuous, nonmusical sounds often associated with
fluid in alveoli.
6. The nurse notes unequal pupil size. This finding is documented as:
A. Diplopia
B. Strabismus
C. Anisocoria
D. Ptosis
Correct Answer: C
Rationale: Anisocoria refers to unequal pupil sizes.
,7. A patient reports sharp chest pain that worsens with deep inspiration. This
finding suggests:
A. Angina
B. Musculoskeletal pain
C. Pleural irritation
D. Gastroesophageal reflux
Correct Answer: C
Rationale: Pain that increases with inspiration is characteristic of pleural
involvement.
8. Which assessment finding requires immediate follow-up?
A. Heart rate of 58 bpm in an athlete
B. Capillary refill of 5 seconds
C. BMI of 29
D. Mild ankle edema at the end of the day
Correct Answer: B
Rationale: Capillary refill greater than 3 seconds may indicate impaired perfusion.
9. The best position to assess jugular venous distention is:
A. Supine
B. High Fowler’s
C. Prone
D. Semi-Fowler’s at 30–45°
Correct Answer: D
Rationale: JVD is best visualized with the patient semi-reclined at 30–45 degrees.
10. A nurse assessing a newborn’s reflexes would expect to find which reflex?
A. Babinski absent
B. Moro present
C. Triceps reflex present
D. Plantar reflex absent
, Correct Answer: B
Rationale: The Moro (startle) reflex is normal in newborns.
11. When assessing pain, the most reliable indicator is:
A. Facial expression
B. Vital signs
C. Patient self-report
D. Nurse observation
Correct Answer: C
Rationale: Pain is subjective; the patient’s report is the most accurate indicator.
12. Which percussion sound is expected over healthy lung tissue?
A. Dull
B. Flat
C. Resonant
D. Tympanic
Correct Answer: C
Rationale: Resonance indicates air-filled lung tissue.
13. The Romberg test assesses:
A. Muscle strength
B. Cerebellar function
C. Balance and proprioception
D. Reflex activity
Correct Answer: C
Rationale: The Romberg test evaluates balance and proprioceptive function.
