BSN 246 HESI HEALTH ASSESSMENT
EXAM V2 - QUESTIONS AND VERIFIED
ANSWERS |100% CORRECT| GRADE A+
NIGHTINGALE
1. When assessing a patient for a physiological split S2, which technique should the nurse
employ?
A. Auscultate with the bell at the apex while the patient holds their breath.
B. Auscultate with the diaphragm at the second right intercostal space during inspiration.
C. Auscultate with the bell at the fifth intercostal space during expiration.
D. Auscultate with the diaphragm at the second left intercostal space during inspiration.
Answer: D
Conceptual Explanation: A physiological split S2 is best heard over the pulmonic area
(2nd LICS) during inspiration because increased venous return to the right heart delays
pulmonic valve closure.
2. A nurse observes a patient’s breathing pattern characterized by increasing depth and
frequency followed by a period of apnea. This is documented as:
A. Cheyne-Stokes respirations
B. Kussmaul’s respirations
,C. Biot’s respirations
D. Bradypnea
Answer: A
Conceptual Explanation: Cheyne-Stokes respirations are cycles of hyperpnea and apnea,
often seen in heart failure or increased intracranial pressure.
3. During an abdominal assessment, the nurse notes a positive Blumberg sign. What does this
indicate?
A. Peritoneal irritation or appendicitis
B. Gallbladder inflammation
C. Kidney infection (pyelonephritis)
D. Splenic enlargement
Answer: A
Conceptual Explanation: The Blumberg sign, or rebound tenderness, is a reliable
indicator of peritonitis or peritoneal inflammation common in appendicitis.
4. Which assessment finding is most characteristic of a patient with advanced arterial
insufficiency in the lower extremities?
A. Pale, cool skin with diminished pedal pulses
B. Thickened, leathery skin and weeping ulcers
C. Pitting edema and brownish skin discoloration
, D. Warm skin with prominent varicose veins
Answer: A
Conceptual Explanation: Arterial insufficiency results in decreased blood flow, leading to
coolness, pallor, and weakened distal pulses.
5. When performing the Weber test, the patient reports hearing the sound better in the right
ear. The nurse should interpret this as:
A. A normal finding if air conduction is greater than bone conduction.
B. Lateralization to the left ear, indicating sensorineural hearing loss.
C. Lateralization to the right ear, indicating either conductive loss in the right or
sensorineural loss in the left.
D. An expected finding in elderly patients due to presbycusis.
Answer: C
Conceptual Explanation: In the Weber test, sound lateralizes to the ear with conductive
loss or away from the ear with sensorineural loss.
6. The nurse asks a patient to stick out their tongue and move it from side to side. Which
cranial nerve is being assessed?
A. Cranial Nerve IX (Glossopharyngeal)
B. Cranial Nerve XII (Hypoglossal)
C. Cranial Nerve X (Vagus)
EXAM V2 - QUESTIONS AND VERIFIED
ANSWERS |100% CORRECT| GRADE A+
NIGHTINGALE
1. When assessing a patient for a physiological split S2, which technique should the nurse
employ?
A. Auscultate with the bell at the apex while the patient holds their breath.
B. Auscultate with the diaphragm at the second right intercostal space during inspiration.
C. Auscultate with the bell at the fifth intercostal space during expiration.
D. Auscultate with the diaphragm at the second left intercostal space during inspiration.
Answer: D
Conceptual Explanation: A physiological split S2 is best heard over the pulmonic area
(2nd LICS) during inspiration because increased venous return to the right heart delays
pulmonic valve closure.
2. A nurse observes a patient’s breathing pattern characterized by increasing depth and
frequency followed by a period of apnea. This is documented as:
A. Cheyne-Stokes respirations
B. Kussmaul’s respirations
,C. Biot’s respirations
D. Bradypnea
Answer: A
Conceptual Explanation: Cheyne-Stokes respirations are cycles of hyperpnea and apnea,
often seen in heart failure or increased intracranial pressure.
3. During an abdominal assessment, the nurse notes a positive Blumberg sign. What does this
indicate?
A. Peritoneal irritation or appendicitis
B. Gallbladder inflammation
C. Kidney infection (pyelonephritis)
D. Splenic enlargement
Answer: A
Conceptual Explanation: The Blumberg sign, or rebound tenderness, is a reliable
indicator of peritonitis or peritoneal inflammation common in appendicitis.
4. Which assessment finding is most characteristic of a patient with advanced arterial
insufficiency in the lower extremities?
A. Pale, cool skin with diminished pedal pulses
B. Thickened, leathery skin and weeping ulcers
C. Pitting edema and brownish skin discoloration
, D. Warm skin with prominent varicose veins
Answer: A
Conceptual Explanation: Arterial insufficiency results in decreased blood flow, leading to
coolness, pallor, and weakened distal pulses.
5. When performing the Weber test, the patient reports hearing the sound better in the right
ear. The nurse should interpret this as:
A. A normal finding if air conduction is greater than bone conduction.
B. Lateralization to the left ear, indicating sensorineural hearing loss.
C. Lateralization to the right ear, indicating either conductive loss in the right or
sensorineural loss in the left.
D. An expected finding in elderly patients due to presbycusis.
Answer: C
Conceptual Explanation: In the Weber test, sound lateralizes to the ear with conductive
loss or away from the ear with sensorineural loss.
6. The nurse asks a patient to stick out their tongue and move it from side to side. Which
cranial nerve is being assessed?
A. Cranial Nerve IX (Glossopharyngeal)
B. Cranial Nerve XII (Hypoglossal)
C. Cranial Nerve X (Vagus)
