Health Assessment Hesi Practice
Questions & Answers
2024/2025
Verified Answers
A+ Guaranteed!
A nurse conducting a physical assessment is observing the client's balance and
performing tests to determine the client's sense of equilibrium. Which cranial nerve is
the nurse assessing?
1. Cranial nerve II
2. Cranial nerve IX
3. Cranial nerve VII
4. Cranial nerve VIII - ANSWER 4. Cranial nerve VIII
Cranial nerve VIII is the acoustic nerve. Hearing tests are performed to assess the
cochlear portion of this nerve. Tests to assess equilibrium, such as observation of the
client's balance when the client is walking or standing, involve the vestibular portion.
A nurse performing a neurological assessment of a client who has sustained a stroke
(brain attack) is preparing to check for stereognosis. Which action should the nurse take
to perform this assessment?
1. Placing an object in the client's hand and asking the client to identify it
2. Tracing a number on the client's hand and asking the client to identify it
3. Moving the client's finger up and down and asking the client which way it is being
moved
,4. Making two simultaneous pinpricks on the skin and asking the client to distinguish
them - ANSWER 1. Placing an object in the client's hand and asking the client to
identify it
Stereognosis is the client's ability to recognize objects placed in his or her hand.
A nurse performing an abdominal assessment of a client is preparing to auscultate for
bowel sounds. In which part of the abdomen should the nurse place the stethoscope
first?
1. Left upper quadrant
2. Left lower quadrant
3. Right upper quadrant
4. Right lower quadrant - ANSWER 4. Right lower quadrant
To auscultate for bowel sounds, the nurse places the diaphragm endpiece of the
stethoscope lightly against the skin, then begins to auscultate in the right lower
abdominal quadrant, in the area of the ileocecal valve, because bowel sounds are
always present there normally.
A nurse performing a physical assessment of a client is checking the client's mouth and
throat. As part of the assessment, the nurse plans to assess the function of cranial
nerve XII. What should the nurse ask the client to do as a means of assessing this
nerve?
1. Frown
2. Show the teeth
3. Stick out the tongue
4. Say "ah" as the tongue is depressed with a tongue blade - ANSWER 3. Stick out
the tongue
To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse asks the
client to stick out the tongue. The nurse then notes the forward thrust in the midline as
the client protrudes the tongue. The nurse also asks the client to verbalize certain words
and then listen for clear, distinct speech.
Discontinuous high-pitched crackling sounds heard during inspiration that do not clear
with coughing - ANSWER Fine Crackles
,Loud, low-pitched bubbling and gurgling sounds heard on inspiration (may be present
on expiration); may decrease with coughing or suctioning but reappear - ANSWER
Coarse Crackles
High-pitched, continuous musical sounds heard during inspiration or expiration -
ANSWER Wheezing
Loud, low-pitched, coarse rumbling sounds heard during inspiration or expiration; may
be cleared by coughing - ANSWER Rhonchi
Dry, grating quality sounds heard best during inspiration; does not clear with coughing -
ANSWER Pleural Friction Rub
Moderately pitched; heard over the major bronchi - ANSWER Bronchovesicular
sounds
Low-pitched rustling; heard over the peripheral lung fields - ANSWER Vesicular
sounds
High-pitched, with a harsh, hollow, tubular quality heard over the trachea and larynx -
ANSWER Bronchial sounds
A nurse preparing to perform a respiratory assessment of an adult client is reading the
client's medical record. The nurse sees that the health care provider noted resonance
on percussion of the client's posterior chest. What interpretation does the nurse make of
this finding?
1. The client has normal, healthy lungs.
2. The client may have a pneumothorax.
3. The client most likely has a lung tumor.
4. An excessive amount of air is present in the lungs. - ANSWER 1. The client has
normal, healthy lungs.
Resonance on percussion predominates in healthy adult lung tissue.
When too much air is present such as in the case of emphysema where it is trapped in
the alveoli and pneumothorax where it is trapped in the pleural space leading to lung
collapse. - ANSWER Hyperresonance
, Indicates an abnormal density in the lungs, such as that noted in pneumonia, pleural
effusion, or atelectasis or in the presence of a tumor. - ANSWER Dull note on
percussion of the lungs
A nurse performing a breast examination is preparing to palpate the client's breasts. Into
which position should the nurse assist the client to perform palpation?
1. A standing position, with the client holding both arms above her head
2. A standing position, with the client holding her hands firmly on her hips
3. A supine position, with the arm on the side being examined positioned across the
chest
4. A supine position, with the arm on the side being examined positioned behind the
head and a small pillow placed under the shoulder on the same side - ANSWER 4. A
supine position, with the arm on the side being examined positioned behind the head
and a small pillow placed under the shoulder on the same side
To palpate the breasts, the nurse assists the client into a supine position and positions
the client's arm on the side being examined behind the head. A small pillow is placed
under the shoulder on the same side. The nurse uses the pads of the first three fingers
to gently compress the breast tissue against the chest wall and notes tissue
consistency. Palpation is performed systematically, with care taken to ensure that the
entire breast and tail are palpated.
A nurse performing a neck assessment of a client is testing the status of cranial nerve
XI. What does the nurse ask the client to do to enable assessment of this nerve?
1. Smile
2. Lift the eyebrows
3. Stick out the tongue
4. Shrug the shoulders against resistance - ANSWER 4. Shrug the shoulders against
resistance
Cranial nerve XI (spinal accessory nerve) is tested by asking the client to shrug the
shoulders against the resistance of the nurse's hand and to turn the head to each side
as the nurse tries to resist the client's movement.
Increased lumbar curvature - ANSWER Lordosis (Swayback)
Exaggeration of the posterior curvature of the thoracic spine - ANSWER Kyphosis
(hunchback)
Questions & Answers
2024/2025
Verified Answers
A+ Guaranteed!
A nurse conducting a physical assessment is observing the client's balance and
performing tests to determine the client's sense of equilibrium. Which cranial nerve is
the nurse assessing?
1. Cranial nerve II
2. Cranial nerve IX
3. Cranial nerve VII
4. Cranial nerve VIII - ANSWER 4. Cranial nerve VIII
Cranial nerve VIII is the acoustic nerve. Hearing tests are performed to assess the
cochlear portion of this nerve. Tests to assess equilibrium, such as observation of the
client's balance when the client is walking or standing, involve the vestibular portion.
A nurse performing a neurological assessment of a client who has sustained a stroke
(brain attack) is preparing to check for stereognosis. Which action should the nurse take
to perform this assessment?
1. Placing an object in the client's hand and asking the client to identify it
2. Tracing a number on the client's hand and asking the client to identify it
3. Moving the client's finger up and down and asking the client which way it is being
moved
,4. Making two simultaneous pinpricks on the skin and asking the client to distinguish
them - ANSWER 1. Placing an object in the client's hand and asking the client to
identify it
Stereognosis is the client's ability to recognize objects placed in his or her hand.
A nurse performing an abdominal assessment of a client is preparing to auscultate for
bowel sounds. In which part of the abdomen should the nurse place the stethoscope
first?
1. Left upper quadrant
2. Left lower quadrant
3. Right upper quadrant
4. Right lower quadrant - ANSWER 4. Right lower quadrant
To auscultate for bowel sounds, the nurse places the diaphragm endpiece of the
stethoscope lightly against the skin, then begins to auscultate in the right lower
abdominal quadrant, in the area of the ileocecal valve, because bowel sounds are
always present there normally.
A nurse performing a physical assessment of a client is checking the client's mouth and
throat. As part of the assessment, the nurse plans to assess the function of cranial
nerve XII. What should the nurse ask the client to do as a means of assessing this
nerve?
1. Frown
2. Show the teeth
3. Stick out the tongue
4. Say "ah" as the tongue is depressed with a tongue blade - ANSWER 3. Stick out
the tongue
To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse asks the
client to stick out the tongue. The nurse then notes the forward thrust in the midline as
the client protrudes the tongue. The nurse also asks the client to verbalize certain words
and then listen for clear, distinct speech.
Discontinuous high-pitched crackling sounds heard during inspiration that do not clear
with coughing - ANSWER Fine Crackles
,Loud, low-pitched bubbling and gurgling sounds heard on inspiration (may be present
on expiration); may decrease with coughing or suctioning but reappear - ANSWER
Coarse Crackles
High-pitched, continuous musical sounds heard during inspiration or expiration -
ANSWER Wheezing
Loud, low-pitched, coarse rumbling sounds heard during inspiration or expiration; may
be cleared by coughing - ANSWER Rhonchi
Dry, grating quality sounds heard best during inspiration; does not clear with coughing -
ANSWER Pleural Friction Rub
Moderately pitched; heard over the major bronchi - ANSWER Bronchovesicular
sounds
Low-pitched rustling; heard over the peripheral lung fields - ANSWER Vesicular
sounds
High-pitched, with a harsh, hollow, tubular quality heard over the trachea and larynx -
ANSWER Bronchial sounds
A nurse preparing to perform a respiratory assessment of an adult client is reading the
client's medical record. The nurse sees that the health care provider noted resonance
on percussion of the client's posterior chest. What interpretation does the nurse make of
this finding?
1. The client has normal, healthy lungs.
2. The client may have a pneumothorax.
3. The client most likely has a lung tumor.
4. An excessive amount of air is present in the lungs. - ANSWER 1. The client has
normal, healthy lungs.
Resonance on percussion predominates in healthy adult lung tissue.
When too much air is present such as in the case of emphysema where it is trapped in
the alveoli and pneumothorax where it is trapped in the pleural space leading to lung
collapse. - ANSWER Hyperresonance
, Indicates an abnormal density in the lungs, such as that noted in pneumonia, pleural
effusion, or atelectasis or in the presence of a tumor. - ANSWER Dull note on
percussion of the lungs
A nurse performing a breast examination is preparing to palpate the client's breasts. Into
which position should the nurse assist the client to perform palpation?
1. A standing position, with the client holding both arms above her head
2. A standing position, with the client holding her hands firmly on her hips
3. A supine position, with the arm on the side being examined positioned across the
chest
4. A supine position, with the arm on the side being examined positioned behind the
head and a small pillow placed under the shoulder on the same side - ANSWER 4. A
supine position, with the arm on the side being examined positioned behind the head
and a small pillow placed under the shoulder on the same side
To palpate the breasts, the nurse assists the client into a supine position and positions
the client's arm on the side being examined behind the head. A small pillow is placed
under the shoulder on the same side. The nurse uses the pads of the first three fingers
to gently compress the breast tissue against the chest wall and notes tissue
consistency. Palpation is performed systematically, with care taken to ensure that the
entire breast and tail are palpated.
A nurse performing a neck assessment of a client is testing the status of cranial nerve
XI. What does the nurse ask the client to do to enable assessment of this nerve?
1. Smile
2. Lift the eyebrows
3. Stick out the tongue
4. Shrug the shoulders against resistance - ANSWER 4. Shrug the shoulders against
resistance
Cranial nerve XI (spinal accessory nerve) is tested by asking the client to shrug the
shoulders against the resistance of the nurse's hand and to turn the head to each side
as the nurse tries to resist the client's movement.
Increased lumbar curvature - ANSWER Lordosis (Swayback)
Exaggeration of the posterior curvature of the thoracic spine - ANSWER Kyphosis
(hunchback)
