BSN 246 HESI 1 UPDATED QUESTIONS AND CORRECT
ANSWERS
Question:
1. An older client pushes the nurse's hand away when palpation is ini-tiated during physical
assessment. Which ad-ditional objective sign aids the nurse in as-sessing for abdominal tenderness?
Answer:
Rebound tenderness. Rationale An objective sign that can aid in determining abdominal tenderness is
the assessment of rebound tenderness when the person reports abdominal pain or when you elicit
tenderness during palpation.
Question:
2. The nurse palpates a weak pedal pulse in the client's right foot. Which assess-ment findings should
the nurse document that are consistent with diminished peripheral circulation? (Select all that apply.)
Answer:
Diminished hair on leg and .Skin cool to touch. Rationale Diminished hair on the legs and skin that is
cool to touch are expectant signs of decreased arterial blood flow.
Question:
3. An older client has just returned to the room following a sur-gical procedure. Which pain scale
should the nurse use when assess-ing the client's pain lev-el?
Answer:
Verbal descriptor scale. Rationale The descriptor scale uses words rather than numbers or pictures to
describe pain. This method of reporting pain is less confusing and less abstract for older adults. The
choices provided for rating the intensity of pain include the following: no pain, mild pain, moderate
pain, and severe pain.
Question:
4. How should the nurse assess for lower ex-tremity edema in a client who has been di-agnosed with
heart fail-ure?
Answer:
Measure bilateral ankle circumference with a non-stretchable tape mea-sure. Rationale An accurate
assessment of lower extremity edema is required when a client is treated for heart failure. Measuring
ankle circumference is more accurate than other objective measures that can rely on individual
inter-pretation, such as measuring pitting edema.
Question:
5. The nurse is testing the client's shoulders for range of motion. What should the nurse docu-ment to
record normal internal rotation?
Answer:
Range of 90 degrees when the hands are placed at the small of the back. Rationale To document
normal internal rotation of the shoulders, the client should be able to demonstrate a range of 90
degrees when the hands are placed at the small of the back.
Question:
6. The nurse observes peristaltic movement in the left lower quad-rant of a client's ab-domen. Which
further assessment of the area should the nurse per-form?
, Answer:
Observe the direction of movement. Rationale Increased peristaltic movements are occasionally seen
in very thin clients and may indicate the presence of intestinal obstruction. In addition to noting the
quadrant of origin, the nurse should also note the direction of the peristaltic flow and report these
findings to the healthcare provider.
Question:
7. The nurse is assess-ing bowel sounds for a hospitalized client. The nurse has heard bow-el sounds
in the right upper quadrant. Which action should the nurse take next?
Answer:
Note the character and frequency of bowel sounds. Rationale Bowel sounds originate from the air and
fluid movement through the stomach and intestines. A wide range of normal sounds can occur
de-pending on when the last meal was ingested. The nurse should assess for hyperactive or
hypoactive bowel sounds during auscultation, noting the character and frequency. It is not necessary
to count the number of bowel sounds per minute and to listen to all four quadrants. It is necessary to
listen for bowel sounds for a minimum of 5 minutes before declaring bowel sounds absent.
Question:
8. Following abdominal auscultation of a client who is admitted for signs of splenomegaly, which
additional as-sessment should the nurse use to verify splenomegaly?
Answer:
Percussion Rationale When splenomegaly is suspected, percussion of the spleen produces a dull
sound and is a safe method of verifying enlargement.
Question:
9. The nurse uses a tongue depressor to assess a client's mouth. Which structure should the nurse be
able to vi-sualize?
Answer:
Pharynx Rationale Depressing the tongue when examining the mouth allows the nurse to visualize the
pharynx, tonsils, and adenoids.
Question:
10. When assessing a client with dyspnea, the nurse hears an audi-ble inspiratory crow-ing sound.
Which lung sound should the nurse document?
Answer:
Stridor Rationale Stridor is an audible monophonic inspiratory crowing sound. Stridor in a client with
dyspnea indicates airway obstruction.
Question:
11. As a part of a rou-tine health assessment, the nurse assesses the kidneys as part of the abdominal
assess-ment. Which assess-ment finding should the nurse conclude is normal when palpating the
client's right kid-ney?
ANSWERS
Question:
1. An older client pushes the nurse's hand away when palpation is ini-tiated during physical
assessment. Which ad-ditional objective sign aids the nurse in as-sessing for abdominal tenderness?
Answer:
Rebound tenderness. Rationale An objective sign that can aid in determining abdominal tenderness is
the assessment of rebound tenderness when the person reports abdominal pain or when you elicit
tenderness during palpation.
Question:
2. The nurse palpates a weak pedal pulse in the client's right foot. Which assess-ment findings should
the nurse document that are consistent with diminished peripheral circulation? (Select all that apply.)
Answer:
Diminished hair on leg and .Skin cool to touch. Rationale Diminished hair on the legs and skin that is
cool to touch are expectant signs of decreased arterial blood flow.
Question:
3. An older client has just returned to the room following a sur-gical procedure. Which pain scale
should the nurse use when assess-ing the client's pain lev-el?
Answer:
Verbal descriptor scale. Rationale The descriptor scale uses words rather than numbers or pictures to
describe pain. This method of reporting pain is less confusing and less abstract for older adults. The
choices provided for rating the intensity of pain include the following: no pain, mild pain, moderate
pain, and severe pain.
Question:
4. How should the nurse assess for lower ex-tremity edema in a client who has been di-agnosed with
heart fail-ure?
Answer:
Measure bilateral ankle circumference with a non-stretchable tape mea-sure. Rationale An accurate
assessment of lower extremity edema is required when a client is treated for heart failure. Measuring
ankle circumference is more accurate than other objective measures that can rely on individual
inter-pretation, such as measuring pitting edema.
Question:
5. The nurse is testing the client's shoulders for range of motion. What should the nurse docu-ment to
record normal internal rotation?
Answer:
Range of 90 degrees when the hands are placed at the small of the back. Rationale To document
normal internal rotation of the shoulders, the client should be able to demonstrate a range of 90
degrees when the hands are placed at the small of the back.
Question:
6. The nurse observes peristaltic movement in the left lower quad-rant of a client's ab-domen. Which
further assessment of the area should the nurse per-form?
, Answer:
Observe the direction of movement. Rationale Increased peristaltic movements are occasionally seen
in very thin clients and may indicate the presence of intestinal obstruction. In addition to noting the
quadrant of origin, the nurse should also note the direction of the peristaltic flow and report these
findings to the healthcare provider.
Question:
7. The nurse is assess-ing bowel sounds for a hospitalized client. The nurse has heard bow-el sounds
in the right upper quadrant. Which action should the nurse take next?
Answer:
Note the character and frequency of bowel sounds. Rationale Bowel sounds originate from the air and
fluid movement through the stomach and intestines. A wide range of normal sounds can occur
de-pending on when the last meal was ingested. The nurse should assess for hyperactive or
hypoactive bowel sounds during auscultation, noting the character and frequency. It is not necessary
to count the number of bowel sounds per minute and to listen to all four quadrants. It is necessary to
listen for bowel sounds for a minimum of 5 minutes before declaring bowel sounds absent.
Question:
8. Following abdominal auscultation of a client who is admitted for signs of splenomegaly, which
additional as-sessment should the nurse use to verify splenomegaly?
Answer:
Percussion Rationale When splenomegaly is suspected, percussion of the spleen produces a dull
sound and is a safe method of verifying enlargement.
Question:
9. The nurse uses a tongue depressor to assess a client's mouth. Which structure should the nurse be
able to vi-sualize?
Answer:
Pharynx Rationale Depressing the tongue when examining the mouth allows the nurse to visualize the
pharynx, tonsils, and adenoids.
Question:
10. When assessing a client with dyspnea, the nurse hears an audi-ble inspiratory crow-ing sound.
Which lung sound should the nurse document?
Answer:
Stridor Rationale Stridor is an audible monophonic inspiratory crowing sound. Stridor in a client with
dyspnea indicates airway obstruction.
Question:
11. As a part of a rou-tine health assessment, the nurse assesses the kidneys as part of the abdominal
assess-ment. Which assess-ment finding should the nurse conclude is normal when palpating the
client's right kid-ney?
