Nightingale College BSN 246 Exam 2 (pdf) | 2026/2027 | HESI Health
Assessment V2 | Concepts of Nursing I
1. A client with dark skin is reporting a painful and itchy area on the lower
left leg. What should the nurse look for when assessing this client's skin for
inflammation?
A) Redness
B) Warmth
C) Change in consistency
D) Edema
Correct Answer: Change in consistency
Rationale: In clients with dark skin, signs of inflammation like erythema and
warmth can be difficult to detect visually. A change in skin consistency, such
as induration, hardness, or a palpable lump, is often a more reliable indicator
of an inflammatory process.
2. When assessing facial nerve function (Cranial Nerve VII) in a 96-year-old
client, the nurse asks the client to smile in an exaggerated manner. Which
finding is most important for the nurse to further assess?
A) Both sides of the mouth move symmetrically
B) Only one side of the mouth moves when smiling
C) The client is unable to pucker their lips
D) The client reports facial pain
Correct Answer: Only one side of the mouth moves when smiling
Rationale: Asymmetrical facial movement when smiling suggests a potential
issue with the facial nerve, such as Bell's Palsy or a cerebrovascular accident
,(stroke). This finding warrants immediate and further neurological
assessment.
3. A client comes to the clinic due to shoulder discomfort and intermittent
pain while swimming. When performing range-of-motion exercises, which
finding would the nurse identify as a limitation in external rotation of the
shoulder?
A) Inability to place the hands at the small of the back
B) Inability to reach behind the head to touch the opposite ear
C) Inability to lift the arms straight out to the side
D) Inability to touch the opposite shoulder with the hand
Correct Answer: Inability to reach behind the head to touch the opposite ear
Rationale: External rotation of the shoulder is assessed by asking the client
to reach behind their head and touch the opposite ear or the back of their
neck. Difficulty with this motion indicates a limitation in external rotation.
4. While using the technique of inspection during a musculoskeletal
assessment, the nurse assesses for which possible findings? (Select all that
apply)
A) Kyphosis
B) Atrophy
C) Contracture
D) Crepitus
Correct Answer: Kyphosis, Atrophy, Contracture
Rationale: Inspection involves visual observation. Kyphosis (a spinal
curvature), atrophy (muscle wasting), and contracture (a permanent
,shortening of a muscle) are all visible findings. Crepitus is an auditory or
palpable finding assessed during joint movement.
5. In observing a client's face, which assessment finding requires the most
immediate intervention by the nurse?
A) Facial asymmetry
B) Absence of facial hair
C) Oral mucosa is cyanotic
D) Presence of freckles
Correct Answer: Oral mucosa is cyanotic
Rationale: Cyanosis of the oral mucosa is a late sign of severe hypoxemia
and indicates inadequate tissue oxygenation. This is a life-threatening finding
that requires immediate intervention, such as administering oxygen and
notifying the healthcare provider.
6. A male client tells the nurse that he sometimes experiences shortness of
breath. The nurse determines that the client's respirations are regular and
deep, and his respiratory rate is 14 breaths/minute. What is the best nursing
action?
A) Administer oxygen via nasal cannula
B) Ask the client to describe the episodes of dyspnea in more detail
C) Auscultate lung sounds immediately
D) Check oxygen saturation with pulse oximetry
Correct Answer: Ask the client to describe the episodes of dyspnea in more
detail
, Rationale: The client's vital signs are within normal limits, so immediate
intervention is not required. Gathering more subjective data about the
dyspnea, such as its triggers, duration, and severity, will help guide further
focused assessment.
7. What is the primary purpose of a health history interview?
A) To perform a physical exam
B) To gather subjective data from the patient
C) To prescribe medications
D) To interpret diagnostic tests
Correct Answer: To gather subjective data from the patient
Rationale: The health history interview is the primary method for collecting
subjective data, which includes the patient's perceptions, feelings, and
concerns about their health. This information guides the subsequent physical
examination and diagnostic testing.
8. When performing a head-to-toe assessment, which technique should the
nurse use to begin?
A) Auscultate the heart
B) Inspect the hair and skin
C) Palpate the abdomen
D) Percuss the lungs
Correct Answer: Inspect the hair and skin
Rationale: A systematic head-to-toe assessment always begins with
inspection. The nurse should start by visually inspecting the head, including
Assessment V2 | Concepts of Nursing I
1. A client with dark skin is reporting a painful and itchy area on the lower
left leg. What should the nurse look for when assessing this client's skin for
inflammation?
A) Redness
B) Warmth
C) Change in consistency
D) Edema
Correct Answer: Change in consistency
Rationale: In clients with dark skin, signs of inflammation like erythema and
warmth can be difficult to detect visually. A change in skin consistency, such
as induration, hardness, or a palpable lump, is often a more reliable indicator
of an inflammatory process.
2. When assessing facial nerve function (Cranial Nerve VII) in a 96-year-old
client, the nurse asks the client to smile in an exaggerated manner. Which
finding is most important for the nurse to further assess?
A) Both sides of the mouth move symmetrically
B) Only one side of the mouth moves when smiling
C) The client is unable to pucker their lips
D) The client reports facial pain
Correct Answer: Only one side of the mouth moves when smiling
Rationale: Asymmetrical facial movement when smiling suggests a potential
issue with the facial nerve, such as Bell's Palsy or a cerebrovascular accident
,(stroke). This finding warrants immediate and further neurological
assessment.
3. A client comes to the clinic due to shoulder discomfort and intermittent
pain while swimming. When performing range-of-motion exercises, which
finding would the nurse identify as a limitation in external rotation of the
shoulder?
A) Inability to place the hands at the small of the back
B) Inability to reach behind the head to touch the opposite ear
C) Inability to lift the arms straight out to the side
D) Inability to touch the opposite shoulder with the hand
Correct Answer: Inability to reach behind the head to touch the opposite ear
Rationale: External rotation of the shoulder is assessed by asking the client
to reach behind their head and touch the opposite ear or the back of their
neck. Difficulty with this motion indicates a limitation in external rotation.
4. While using the technique of inspection during a musculoskeletal
assessment, the nurse assesses for which possible findings? (Select all that
apply)
A) Kyphosis
B) Atrophy
C) Contracture
D) Crepitus
Correct Answer: Kyphosis, Atrophy, Contracture
Rationale: Inspection involves visual observation. Kyphosis (a spinal
curvature), atrophy (muscle wasting), and contracture (a permanent
,shortening of a muscle) are all visible findings. Crepitus is an auditory or
palpable finding assessed during joint movement.
5. In observing a client's face, which assessment finding requires the most
immediate intervention by the nurse?
A) Facial asymmetry
B) Absence of facial hair
C) Oral mucosa is cyanotic
D) Presence of freckles
Correct Answer: Oral mucosa is cyanotic
Rationale: Cyanosis of the oral mucosa is a late sign of severe hypoxemia
and indicates inadequate tissue oxygenation. This is a life-threatening finding
that requires immediate intervention, such as administering oxygen and
notifying the healthcare provider.
6. A male client tells the nurse that he sometimes experiences shortness of
breath. The nurse determines that the client's respirations are regular and
deep, and his respiratory rate is 14 breaths/minute. What is the best nursing
action?
A) Administer oxygen via nasal cannula
B) Ask the client to describe the episodes of dyspnea in more detail
C) Auscultate lung sounds immediately
D) Check oxygen saturation with pulse oximetry
Correct Answer: Ask the client to describe the episodes of dyspnea in more
detail
, Rationale: The client's vital signs are within normal limits, so immediate
intervention is not required. Gathering more subjective data about the
dyspnea, such as its triggers, duration, and severity, will help guide further
focused assessment.
7. What is the primary purpose of a health history interview?
A) To perform a physical exam
B) To gather subjective data from the patient
C) To prescribe medications
D) To interpret diagnostic tests
Correct Answer: To gather subjective data from the patient
Rationale: The health history interview is the primary method for collecting
subjective data, which includes the patient's perceptions, feelings, and
concerns about their health. This information guides the subsequent physical
examination and diagnostic testing.
8. When performing a head-to-toe assessment, which technique should the
nurse use to begin?
A) Auscultate the heart
B) Inspect the hair and skin
C) Palpate the abdomen
D) Percuss the lungs
Correct Answer: Inspect the hair and skin
Rationale: A systematic head-to-toe assessment always begins with
inspection. The nurse should start by visually inspecting the head, including
