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BSN HESI 246 Health Assessment V2 Exam –
Nightingale College
Comprehensive Study Guide – 250 Questions with
verified answers
1. A client presents with a blood pressure of 148/92 mmHg on two separate occasions during a routine clinic
visit. What is the most appropriate nursing action based on this finding?
A. Recheck the blood pressure in the contralateral arm after five minutes of rest
B. Immediately notify the healthcare provider for prescription of antihypertensive medication
C. Document the finding as expected for the client's age and reassure the client
D. Instruct the client to return in one month for a follow-up blood pressure assessment
Correct Answer: A. Recheck the blood pressure in the contralateral arm after five minutes of rest
2. The nurse is assessing an older adult client's skin turgor and notes that the skin remains tented after being
pinched on the sternum. Which additional assessment finding would support the suspicion of dehydration?
A. Moist mucous membranes and adequate urine output
B. Dry mucous membranes and decreased urine output
C. Bounding peripheral pulses and warm extremities
D. Increased skin elasticity and normal capillary refill
Correct Answer: B. Dry mucous membranes and decreased urine output
3. A client recovering from abdominal surgery reports sudden sharp pain in the right calf and shortness of
breath. Which action should the nurse implement first?
A. Administer prescribed analgesic medication for the calf pain
B. Elevate the client's legs to reduce swelling in the calves
C. Apply warm compresses to the affected calf to improve circulation
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D. Assess vital signs and oxygen saturation while notifying the provider immediately
Correct Answer: D. Assess vital signs and oxygen saturation while notifying the provider immediately
4. During a neurological assessment, the nurse asks the client to close their eyes and identify a familiar object
placed in their hand. Which cranial nerve is primarily being evaluated through this technique?
A. Cranial nerve V (Trigeminal)
B. Cranial nerve VII (Facial)
C. Cranial nerve VIII (Acoustic)
D. Cranial nerve IX (Glossopharyngeal)
Correct Answer: A. Cranial nerve V (Trigeminal)
5. The nurse is performing a respiratory assessment on a client with chronic obstructive pulmonary disease
and notes a barrel-shaped chest configuration. What underlying pathophysiological change most likely
accounts for this physical finding?
A. Collapse of the alveoli with decreased lung compliance
B. Increased lung compliance with air trapping and hyperinflation
C. Accumulation of fluid in the pleural space with lung compression
D. Fibrotic changes in lung tissue with reduced elasticity
Correct Answer: B. Increased lung compliance with air trapping and hyperinflation
6. A female client reports experiencing urinary incontinence whenever she coughs or sneezes. Which type of
incontinence is the client most likely describing to the nurse?
A. Urge incontinence due to overactive bladder muscle contractions
B. Overflow incontinence caused by bladder outlet obstruction
C. Stress incontinence resulting from weakened pelvic floor muscles
D. Functional incontinence related to cognitive or physical impairment
Correct Answer: C. Stress incontinence resulting from weakened pelvic floor muscles
7. When assessing the client's abdomen, the nurse notes a visible pulsation in the epigastric region. Which
action should the nurse implement to appropriately evaluate this finding?
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A. Palpate the pulsation deeply to assess its characteristics and diameter
B. Auscultate the area with the bell of the stethoscope to detect a bruit
C. Percuss the area to determine if the pulsation is dull or tympanic
D. Document the finding and reassess the client in 30 minutes
Correct Answer: B. Auscultate the area with the bell of the stethoscope to detect a bruit
8. A client with a history of diabetes mellitus presents with diminished sensation in both feet. Which
assessment technique should the nurse use to evaluate the client's protective sensation?
A. Test the client's ability to distinguish hot and cold temperatures on the feet
B. Assess the client's deep tendon reflexes in the lower extremities
C. Use a monofilament to test light touch perception on various foot areas
D. Evaluate the client's ability to feel vibration using a tuning fork on the toes
Correct Answer: C. Use a monofilament to test light touch perception on various foot areas
9. During a cardiovascular assessment, the nurse detects a thrill while palpating the client's chest over the
second intercostal space at the left sternal border. What does this physical finding most likely indicate to the
nurse?
A. Normal cardiac function without any abnormalities
B. Turbulent blood flow through a cardiac valve or vessel
C. Decreased cardiac output with reduced peripheral perfusion
D. Presence of pericardial friction rub from inflammation
Correct Answer: B. Turbulent blood flow through a cardiac valve or vessel
10. The nurse is preparing to assess the client's deep tendon reflexes and plans to test the biceps reflex. Which
technique should the nurse implement to elicit this reflex accurately?
A. Tap the brachioradialis tendon near the radius with a reflex hammer
B. Place the thumb over the biceps tendon and strike the thumb with the hammer
C. Tap the triceps tendon just above the olecranon process with a firm stroke
D. Strike the patellar tendon directly below the kneecap with the hammer
Correct Answer: B. Place the thumb over the biceps tendon and strike the thumb with the hammer
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11. A client reports experiencing chest pain that worsens with deep inspiration and improves when leaning
forward. Based on this description, which condition should the nurse suspect?
A. Myocardial infarction with ischemic chest pain
B. Pericarditis with inflammation of the pericardial sac
C. Pulmonary embolism with sudden onset of pleuritic pain
D. Costochondritis with localized chest wall tenderness
Correct Answer: B. Pericarditis with inflammation of the pericardial sac
12. The nurse is assessing a client's peripheral pulses and notes that the dorsalis pedis pulse is weak and
difficult to palpate. Which action should the nurse take to confirm the presence of peripheral circulation?
A. Document the pulse as absent and notify the healthcare provider
B. Use a Doppler ultrasound device to detect blood flow in the vessel
C. Apply firm pressure to the pulse site and palpate for 30 seconds
D. Compare the finding with the radial pulse on the same extremity
Correct Answer: B. Use a Doppler ultrasound device to detect blood flow in the vessel
13. During an eye examination, the nurse uses an ophthalmoscope to assess the client's fundus and notes that
the optic disc appears pale with sharp margins. Which condition should the nurse suspect based on this
finding?
A. Papilledema indicating increased intracranial pressure
B. Glaucoma with optic nerve damage and visual field loss
C. Optic atrophy with degeneration of the optic nerve fibers
D. Diabetic retinopathy with microvascular changes
Correct Answer: C. Optic atrophy with degeneration of the optic nerve fibers
14. A client with hypertension reports taking their prescribed medication inconsistently because of
bothersome side effects. Which nursing action is most appropriate to address this client's concern?
A. Instruct the client to stop taking the medication and schedule an immediate appointment
B. Advise the client to take the medication at bedtime to minimize the side effects
C. Explore the side effects and collaborate with the provider to adjust the treatment plan
BSN HESI 246 Health Assessment V2 Exam –
Nightingale College
Comprehensive Study Guide – 250 Questions with
verified answers
1. A client presents with a blood pressure of 148/92 mmHg on two separate occasions during a routine clinic
visit. What is the most appropriate nursing action based on this finding?
A. Recheck the blood pressure in the contralateral arm after five minutes of rest
B. Immediately notify the healthcare provider for prescription of antihypertensive medication
C. Document the finding as expected for the client's age and reassure the client
D. Instruct the client to return in one month for a follow-up blood pressure assessment
Correct Answer: A. Recheck the blood pressure in the contralateral arm after five minutes of rest
2. The nurse is assessing an older adult client's skin turgor and notes that the skin remains tented after being
pinched on the sternum. Which additional assessment finding would support the suspicion of dehydration?
A. Moist mucous membranes and adequate urine output
B. Dry mucous membranes and decreased urine output
C. Bounding peripheral pulses and warm extremities
D. Increased skin elasticity and normal capillary refill
Correct Answer: B. Dry mucous membranes and decreased urine output
3. A client recovering from abdominal surgery reports sudden sharp pain in the right calf and shortness of
breath. Which action should the nurse implement first?
A. Administer prescribed analgesic medication for the calf pain
B. Elevate the client's legs to reduce swelling in the calves
C. Apply warm compresses to the affected calf to improve circulation
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D. Assess vital signs and oxygen saturation while notifying the provider immediately
Correct Answer: D. Assess vital signs and oxygen saturation while notifying the provider immediately
4. During a neurological assessment, the nurse asks the client to close their eyes and identify a familiar object
placed in their hand. Which cranial nerve is primarily being evaluated through this technique?
A. Cranial nerve V (Trigeminal)
B. Cranial nerve VII (Facial)
C. Cranial nerve VIII (Acoustic)
D. Cranial nerve IX (Glossopharyngeal)
Correct Answer: A. Cranial nerve V (Trigeminal)
5. The nurse is performing a respiratory assessment on a client with chronic obstructive pulmonary disease
and notes a barrel-shaped chest configuration. What underlying pathophysiological change most likely
accounts for this physical finding?
A. Collapse of the alveoli with decreased lung compliance
B. Increased lung compliance with air trapping and hyperinflation
C. Accumulation of fluid in the pleural space with lung compression
D. Fibrotic changes in lung tissue with reduced elasticity
Correct Answer: B. Increased lung compliance with air trapping and hyperinflation
6. A female client reports experiencing urinary incontinence whenever she coughs or sneezes. Which type of
incontinence is the client most likely describing to the nurse?
A. Urge incontinence due to overactive bladder muscle contractions
B. Overflow incontinence caused by bladder outlet obstruction
C. Stress incontinence resulting from weakened pelvic floor muscles
D. Functional incontinence related to cognitive or physical impairment
Correct Answer: C. Stress incontinence resulting from weakened pelvic floor muscles
7. When assessing the client's abdomen, the nurse notes a visible pulsation in the epigastric region. Which
action should the nurse implement to appropriately evaluate this finding?
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A. Palpate the pulsation deeply to assess its characteristics and diameter
B. Auscultate the area with the bell of the stethoscope to detect a bruit
C. Percuss the area to determine if the pulsation is dull or tympanic
D. Document the finding and reassess the client in 30 minutes
Correct Answer: B. Auscultate the area with the bell of the stethoscope to detect a bruit
8. A client with a history of diabetes mellitus presents with diminished sensation in both feet. Which
assessment technique should the nurse use to evaluate the client's protective sensation?
A. Test the client's ability to distinguish hot and cold temperatures on the feet
B. Assess the client's deep tendon reflexes in the lower extremities
C. Use a monofilament to test light touch perception on various foot areas
D. Evaluate the client's ability to feel vibration using a tuning fork on the toes
Correct Answer: C. Use a monofilament to test light touch perception on various foot areas
9. During a cardiovascular assessment, the nurse detects a thrill while palpating the client's chest over the
second intercostal space at the left sternal border. What does this physical finding most likely indicate to the
nurse?
A. Normal cardiac function without any abnormalities
B. Turbulent blood flow through a cardiac valve or vessel
C. Decreased cardiac output with reduced peripheral perfusion
D. Presence of pericardial friction rub from inflammation
Correct Answer: B. Turbulent blood flow through a cardiac valve or vessel
10. The nurse is preparing to assess the client's deep tendon reflexes and plans to test the biceps reflex. Which
technique should the nurse implement to elicit this reflex accurately?
A. Tap the brachioradialis tendon near the radius with a reflex hammer
B. Place the thumb over the biceps tendon and strike the thumb with the hammer
C. Tap the triceps tendon just above the olecranon process with a firm stroke
D. Strike the patellar tendon directly below the kneecap with the hammer
Correct Answer: B. Place the thumb over the biceps tendon and strike the thumb with the hammer
, Page 4 of 70
11. A client reports experiencing chest pain that worsens with deep inspiration and improves when leaning
forward. Based on this description, which condition should the nurse suspect?
A. Myocardial infarction with ischemic chest pain
B. Pericarditis with inflammation of the pericardial sac
C. Pulmonary embolism with sudden onset of pleuritic pain
D. Costochondritis with localized chest wall tenderness
Correct Answer: B. Pericarditis with inflammation of the pericardial sac
12. The nurse is assessing a client's peripheral pulses and notes that the dorsalis pedis pulse is weak and
difficult to palpate. Which action should the nurse take to confirm the presence of peripheral circulation?
A. Document the pulse as absent and notify the healthcare provider
B. Use a Doppler ultrasound device to detect blood flow in the vessel
C. Apply firm pressure to the pulse site and palpate for 30 seconds
D. Compare the finding with the radial pulse on the same extremity
Correct Answer: B. Use a Doppler ultrasound device to detect blood flow in the vessel
13. During an eye examination, the nurse uses an ophthalmoscope to assess the client's fundus and notes that
the optic disc appears pale with sharp margins. Which condition should the nurse suspect based on this
finding?
A. Papilledema indicating increased intracranial pressure
B. Glaucoma with optic nerve damage and visual field loss
C. Optic atrophy with degeneration of the optic nerve fibers
D. Diabetic retinopathy with microvascular changes
Correct Answer: C. Optic atrophy with degeneration of the optic nerve fibers
14. A client with hypertension reports taking their prescribed medication inconsistently because of
bothersome side effects. Which nursing action is most appropriate to address this client's concern?
A. Instruct the client to stop taking the medication and schedule an immediate appointment
B. Advise the client to take the medication at bedtime to minimize the side effects
C. Explore the side effects and collaborate with the provider to adjust the treatment plan
