BSN 246 HESI HEALTH ASSESSMENT EXAM V2 PRACTICE
QUESTIONS & VERIFIED ANSWERS COMPREHENSIVE STUDY
GUIDE (2026)
1. In observing a client's face, which assessment
finding requires the most immediate intervention by the
nurse?
A. Oral mucosa is cyanotic.
B. Nasolabial folds present bilaterally
C. Smooth and even skin tone
D. Absence of facial drooping ANS: A. Oral mucosa is cyanotic.
2. While obtaining a health history, a male client tells the nurse that
he sometimes experiences shortness of breath. The nurse
determines that the client's respirators are regular and deep, and his
respiratory rate is 14 breaths/minutes. What is the best nursing
action? A. Administer oxygen immediately.
B. Ask the client to describe the episodes of dyspnea in more detail.
C. Notify the healthcare provider about the client's condition.
D. Place the client in a prone position to ease breathing. ANS: B. Ask
the client to describe the episodes of dyspnea in more detail.
3. When assessing a male client's respiratory status, which
technique should the nurse use to assess his anterior-posterior
(AP) chest diameter? A. Intervention.
B. Assessment.
C. Documentation.
D. Observation. ANS: D. Observation.
4. Which assessment finding supports the client's statement, "My feet
, swell all the time?"
A. No edema present.
B. 2+ pitting edema of ankles bilaterally.
C. Non-pitting edema of the lower extremities.
, D. Redness and warmth in the ankles.ANS: B. 2+ pitting edema of ankles
bilaterally.
5. The nurse is performing a cranial nerve exam on an 87-yearold client. The
nurse notes that the client has a reduced upward gaze, a decreased corneal
reflex, a high-frequency hearing loss, and a reduced gag reflex. What action
should the nurse take next?
A. Repeat the cranial nerve test to confirm the findings.
B. Document the findings and notify the healthcare provider.
C. Ask the client if they are experiencing any unusual symptoms.
D. Continue the assessment to the next pairs of cranial nerves. .ANS: D.
Continue the assessment to the next pairs of cranial nerves.
6. When performing a neurologic assessment on an alert client, the nurse
observes that the client's pupils are both round, 3 mm in size, and respond
briskly to light. Which
notation should the nurse use when documenting the assessment
A. PERRL
B. Dilated pupils
C. Unequal pupil size
D. Sluggish pupillary reaction? .ANS: A. PERRL
7. The nurse is assessing a female client who states that her hemorrhoids are
inflamed and hurt constantly. Which intervention is best for the nurse to complete
a focused assessment?
A. Position the client in the left lateral position to inspect the perianal area for
fissures or sacs.
B. Palpate the perianal area with both hands to assess skin elasticity.
C. Ask the client to stand and bend forward to assess the sacrum.
D. Apply deep palpation to the lower abdomen to detect tenderness. .ANS:
A.
Position the client in the left lateral position to inspect the perianal area for
fissures or sacs.
QUESTIONS & VERIFIED ANSWERS COMPREHENSIVE STUDY
GUIDE (2026)
1. In observing a client's face, which assessment
finding requires the most immediate intervention by the
nurse?
A. Oral mucosa is cyanotic.
B. Nasolabial folds present bilaterally
C. Smooth and even skin tone
D. Absence of facial drooping ANS: A. Oral mucosa is cyanotic.
2. While obtaining a health history, a male client tells the nurse that
he sometimes experiences shortness of breath. The nurse
determines that the client's respirators are regular and deep, and his
respiratory rate is 14 breaths/minutes. What is the best nursing
action? A. Administer oxygen immediately.
B. Ask the client to describe the episodes of dyspnea in more detail.
C. Notify the healthcare provider about the client's condition.
D. Place the client in a prone position to ease breathing. ANS: B. Ask
the client to describe the episodes of dyspnea in more detail.
3. When assessing a male client's respiratory status, which
technique should the nurse use to assess his anterior-posterior
(AP) chest diameter? A. Intervention.
B. Assessment.
C. Documentation.
D. Observation. ANS: D. Observation.
4. Which assessment finding supports the client's statement, "My feet
, swell all the time?"
A. No edema present.
B. 2+ pitting edema of ankles bilaterally.
C. Non-pitting edema of the lower extremities.
, D. Redness and warmth in the ankles.ANS: B. 2+ pitting edema of ankles
bilaterally.
5. The nurse is performing a cranial nerve exam on an 87-yearold client. The
nurse notes that the client has a reduced upward gaze, a decreased corneal
reflex, a high-frequency hearing loss, and a reduced gag reflex. What action
should the nurse take next?
A. Repeat the cranial nerve test to confirm the findings.
B. Document the findings and notify the healthcare provider.
C. Ask the client if they are experiencing any unusual symptoms.
D. Continue the assessment to the next pairs of cranial nerves. .ANS: D.
Continue the assessment to the next pairs of cranial nerves.
6. When performing a neurologic assessment on an alert client, the nurse
observes that the client's pupils are both round, 3 mm in size, and respond
briskly to light. Which
notation should the nurse use when documenting the assessment
A. PERRL
B. Dilated pupils
C. Unequal pupil size
D. Sluggish pupillary reaction? .ANS: A. PERRL
7. The nurse is assessing a female client who states that her hemorrhoids are
inflamed and hurt constantly. Which intervention is best for the nurse to complete
a focused assessment?
A. Position the client in the left lateral position to inspect the perianal area for
fissures or sacs.
B. Palpate the perianal area with both hands to assess skin elasticity.
C. Ask the client to stand and bend forward to assess the sacrum.
D. Apply deep palpation to the lower abdomen to detect tenderness. .ANS:
A.
Position the client in the left lateral position to inspect the perianal area for
fissures or sacs.
