,Nightingale BSN 246 Final Exam | Concepts of Nursing I HESI
Health Assessment (2026) Q&A
1. What is the first step in a general survey during a health assessment?
A) Measure vital signs
B) Observe overall appearance
C) Palpate lymph nodes
D) Auscultate lungs
Correct Answer: Observe overall appearance
Rationale: The general survey begins with observing the patient's overall appearance,
behavior, and mobility. This initial visual assessment provides valuable information about
the patient's general health status and guides the remainder of the physical examination.
2. Which vital sign is most indicative of acute hypoxia?
A) Blood pressure
B) Pulse oximetry
C) Temperature
D) Respiratory rate
Correct Answer: Pulse oximetry
Rationale: Pulse oximetry measures oxygen saturation, directly reflecting hypoxia. A
decrease in SpO₂ indicates a drop in the amount of oxygen in the blood, which is a critical
sign of respiratory compromise.
,3. What is the normal range for adult oral temperature in Fahrenheit?
A) 95.0-97.0°F
B) 97.0-99.0°F
C) 99.0-101.0°F
D) 101.0-103.0°F
Correct Answer: 97.0-99.0°F
Rationale: Normal adult oral temperature is typically 97.0-99.0°F. This range can vary
slightly depending on the individual and the time of day.
4. A patient's blood pressure is 160/90 mmHg. This indicates:
A) Normal blood pressure
B) Stage 2 hypertension
C) Hypotension
D) Prehypertension
Correct Answer: Stage 2 hypertension
Rationale: Stage 2 hypertension is defined as a systolic blood pressure of 140 mmHg or
higher or a diastolic blood pressure of 90 mmHg or higher. A reading of 160/90 mmHg
falls into this category.
5. The nurse is preparing to perform a physical assessment. Which action should the
nurse take first?
A) Obtain and review the client's medical history
B) Auscultate heart and lung sounds
, C) Perform hand hygiene
D) Introduce yourself to the client
Correct Answer: Introduce yourself to the client
Rationale: The first step in any patient interaction is to introduce yourself to establish
rapport and build trust. This is essential for effective communication and a positive
therapeutic relationship.
6. A client is in the clinic and is reporting lower abdominal pain and constipation. Which
information is of greatest concern to the nurse when obtaining the health history from this
client?
A) Client reports a history of hemorrhoids
B) Client reports a family history of colon cancer on mother's side
C) Client reports recent changes in bowel habits
D) Client reports a history of constipation
Correct Answer: Client reports a family history of colon cancer on mother's side
Rationale: A family history of colon cancer is a significant risk factor that requires further
investigation and possibly earlier screening. It is of greater concern than hemorrhoids or
constipation, which are more common and often benign.
7. During a health history interview, which type of data is the patient's report of chest pain
that occurs with exertion and is relieved by rest?
A) Objective data
B) Subjective data
C) Clinical data
Health Assessment (2026) Q&A
1. What is the first step in a general survey during a health assessment?
A) Measure vital signs
B) Observe overall appearance
C) Palpate lymph nodes
D) Auscultate lungs
Correct Answer: Observe overall appearance
Rationale: The general survey begins with observing the patient's overall appearance,
behavior, and mobility. This initial visual assessment provides valuable information about
the patient's general health status and guides the remainder of the physical examination.
2. Which vital sign is most indicative of acute hypoxia?
A) Blood pressure
B) Pulse oximetry
C) Temperature
D) Respiratory rate
Correct Answer: Pulse oximetry
Rationale: Pulse oximetry measures oxygen saturation, directly reflecting hypoxia. A
decrease in SpO₂ indicates a drop in the amount of oxygen in the blood, which is a critical
sign of respiratory compromise.
,3. What is the normal range for adult oral temperature in Fahrenheit?
A) 95.0-97.0°F
B) 97.0-99.0°F
C) 99.0-101.0°F
D) 101.0-103.0°F
Correct Answer: 97.0-99.0°F
Rationale: Normal adult oral temperature is typically 97.0-99.0°F. This range can vary
slightly depending on the individual and the time of day.
4. A patient's blood pressure is 160/90 mmHg. This indicates:
A) Normal blood pressure
B) Stage 2 hypertension
C) Hypotension
D) Prehypertension
Correct Answer: Stage 2 hypertension
Rationale: Stage 2 hypertension is defined as a systolic blood pressure of 140 mmHg or
higher or a diastolic blood pressure of 90 mmHg or higher. A reading of 160/90 mmHg
falls into this category.
5. The nurse is preparing to perform a physical assessment. Which action should the
nurse take first?
A) Obtain and review the client's medical history
B) Auscultate heart and lung sounds
, C) Perform hand hygiene
D) Introduce yourself to the client
Correct Answer: Introduce yourself to the client
Rationale: The first step in any patient interaction is to introduce yourself to establish
rapport and build trust. This is essential for effective communication and a positive
therapeutic relationship.
6. A client is in the clinic and is reporting lower abdominal pain and constipation. Which
information is of greatest concern to the nurse when obtaining the health history from this
client?
A) Client reports a history of hemorrhoids
B) Client reports a family history of colon cancer on mother's side
C) Client reports recent changes in bowel habits
D) Client reports a history of constipation
Correct Answer: Client reports a family history of colon cancer on mother's side
Rationale: A family history of colon cancer is a significant risk factor that requires further
investigation and possibly earlier screening. It is of greater concern than hemorrhoids or
constipation, which are more common and often benign.
7. During a health history interview, which type of data is the patient's report of chest pain
that occurs with exertion and is relieved by rest?
A) Objective data
B) Subjective data
C) Clinical data
