BSN 246 HESI HEALTH ASSESSMENT
EXAM V1 QUESTIONS AND ANSWERS
1. During a cardiac assessment, the nurse auscultates a low-pitched sound at the apex using
the bell of the stethoscope immediately after S2. How should the nurse document this
finding?
A. An S3 heart sound
B. A systolic murmur
C. An S4 heart sound
D. A pericardial friction rub
Answer: A
Conceptual Explanation: An S3 heart sound, or ventricular gallop, occurs early in diastole
just after S2. It is best heard at the apex with the bell.
2. When performing a physical examination of the abdomen, in what order should the nurse
perform the assessment techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
,C. Auscultation, Inspection, Percussion, Palpation
D. Percussion, Auscultation, Palpation, Inspection
Answer: B
Conceptual Explanation: The abdomen is always auscultated before percussion or
palpation to avoid altering bowel sounds.
3. A nurse is assessing a patient’s cranial nerves. Which nerve is being tested when the
patient is asked to shrug their shoulders against resistance?
A. Cranial Nerve X (Vagus)
B. Cranial Nerve IX (Glossopharyngeal)
C. Cranial Nerve XII (Hypoglossal)
D. Cranial Nerve XI (Spinal Accessory)
Answer: D
Conceptual Explanation: CN XI controls the trapezius and sternocleidomastoid muscles;
shrugging tests its motor function.
4. While assessing the lungs, the nurse hears high-pitched, musical whistling sounds primarily
during expiration. These are identified as:
A. Coarse crackles
B. Stridor
C. Pleural friction rub
, D. Wheezes
Answer: D
Conceptual Explanation: Wheezes are continuous, high-pitched musical sounds caused by
air squeezing through narrowed airways, common in asthma.
5. A patient has a blood pressure of 150/94 mmHg. The nurse notes that the blood pressure
cuff used was too small for the patient’s arm. How does this affect the reading?
A. The reading is falsely high
B. The reading is falsely low
C. Only the diastolic reading is affected
D. The reading is accurate regardless of size
Answer: A
Conceptual Explanation: Using a blood pressure cuff that is too narrow or small results in
a falsely elevated (high) blood pressure reading.
6. The nurse is assessing for tactile fremitus. Which condition would cause an increase in
fremitus?
A. Pneumothorax
B. Pneumonia with consolidation
C. Pleural effusion
D. Emphysema
EXAM V1 QUESTIONS AND ANSWERS
1. During a cardiac assessment, the nurse auscultates a low-pitched sound at the apex using
the bell of the stethoscope immediately after S2. How should the nurse document this
finding?
A. An S3 heart sound
B. A systolic murmur
C. An S4 heart sound
D. A pericardial friction rub
Answer: A
Conceptual Explanation: An S3 heart sound, or ventricular gallop, occurs early in diastole
just after S2. It is best heard at the apex with the bell.
2. When performing a physical examination of the abdomen, in what order should the nurse
perform the assessment techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
,C. Auscultation, Inspection, Percussion, Palpation
D. Percussion, Auscultation, Palpation, Inspection
Answer: B
Conceptual Explanation: The abdomen is always auscultated before percussion or
palpation to avoid altering bowel sounds.
3. A nurse is assessing a patient’s cranial nerves. Which nerve is being tested when the
patient is asked to shrug their shoulders against resistance?
A. Cranial Nerve X (Vagus)
B. Cranial Nerve IX (Glossopharyngeal)
C. Cranial Nerve XII (Hypoglossal)
D. Cranial Nerve XI (Spinal Accessory)
Answer: D
Conceptual Explanation: CN XI controls the trapezius and sternocleidomastoid muscles;
shrugging tests its motor function.
4. While assessing the lungs, the nurse hears high-pitched, musical whistling sounds primarily
during expiration. These are identified as:
A. Coarse crackles
B. Stridor
C. Pleural friction rub
, D. Wheezes
Answer: D
Conceptual Explanation: Wheezes are continuous, high-pitched musical sounds caused by
air squeezing through narrowed airways, common in asthma.
5. A patient has a blood pressure of 150/94 mmHg. The nurse notes that the blood pressure
cuff used was too small for the patient’s arm. How does this affect the reading?
A. The reading is falsely high
B. The reading is falsely low
C. Only the diastolic reading is affected
D. The reading is accurate regardless of size
Answer: A
Conceptual Explanation: Using a blood pressure cuff that is too narrow or small results in
a falsely elevated (high) blood pressure reading.
6. The nurse is assessing for tactile fremitus. Which condition would cause an increase in
fremitus?
A. Pneumothorax
B. Pneumonia with consolidation
C. Pleural effusion
D. Emphysema
