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BSN 246 HESI Health Assessment Exam V1 (Latest 2025/ 2026 Update) Questions & Answers| Grade A| 100% Correct (Verified Solutions)- Nightingale $10.99
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BSN 246 HESI Health Assessment Exam V1 (Latest 2025/ 2026 Update) Questions & Answers| Grade A| 100% Correct (Verified Solutions)- Nightingale
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BSN 246 HESI Health Assessment Exam V1 (Latest 2025/ 2026 Update) Questions & Answers| Grade A| 100% Correct (Verified Solutions)- Nightingale QUESTION While performing a head-to-toe assessment, the nurse assesses the client's pupillary accommodation. During the second portion of the test, the ...

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  • April 15, 2025
  • 22
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

Subjects

  • bsn 246 nightinga
  • a client is in the clinical for a yearly physical
  • while performing a head to toe assessment the nur
  • bsn246bsn 246bsn hesi 246 health assessment
  • bsn246bsn 246bsn 246 health assessment

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BSNl 246l HESIl Healthl Assessmentl Examl
V1l (Latestl 2025/l 2026l Update)l Questionsl
&l Answers|l Gradel A|l 100%l Correctl
(Verifiedl Solutions)-l Nightingale
Q:l Whilel performingl al head-to-toel assessment,l thel nursel assessesl thel client'sl pupillaryl
accommodation.l Duringl thel secondl portionl ofl thel test,l thel nursel notesl thatl thel client'sl
pupilsl constrictl andl therel isl al convergencel ofl thel axesl ofl thel eyes.l Whatl actionl shouldl
thel nursel implementl next?

Documentl al normall finding.
Requestl al referrall tol anl opthamologist.
Repeatl thel testl afterl havingl thel clientl restl forl 5l minutes.
Askl thel client,l "Havel youl noticedl thatl youl cannotl seel thingsl closel up?"

Answer:
Documentl al normall finding.
Rationale
Whenl testingl forl pupillaryl accommodation,l thel nursel asksl thel clientl tol focusl onl al
distantl objectl andl thenl shiftl thel gazel tol al penlightl tipl nearl thel nose.l Focusingl onl al
distantl objectl causesl bothl pupilsl tol dilatel shiftingl thel gazel tol al nearl objectl (al fingerl
orl al penlightl tip),l whichl isl heldl aboutl 7l tol 8l cml (3l inches)l froml thel client'sl nose,l
shouldl resultl inl bilaterall pupillaryl constrictionl withl bothl eyesl focusedl onl thel objectl
simultaneously.



Q:l Whichl terml shouldl thel nursel usel tol documentl inl thel client'sl medicall recordl forl al
high-pitchedl scratchyl soundl duringl auscultationl ofl thel heart?

Murmur.
Ejectionl click.
Frictionl rub.
Normall heartl sound.

Answer:
Frictionl rub.
Rationale

,Al high-pitched,l scratchy,l orl gratingl soundl heardl duringl auscultationl ofl thel heartl isl
calledl al pericardiall frictionl rub,l whichl isl associatedl withl inflammationl ofl thel
pericardium,l oftenl seenl duringl thel followingl weekl inl al clientl afterl al myocardiall
infarction.l Tol bestl hearl thel pericardiall frictionl rub,l thel nursel shouldl havel thel clientl
sittingl uprightl andl leaningl forwardl whilel thel clientl holdsl theirl breathl andl thel nursel
listensl withl thel diaphragml ofl thel stethoscopel atl thel apexl andl leftl lowerl sternall border.



Q:l Thel nursel observesl peristalticl movementl inl thel leftl lowerl quadrantl ofl al client'sl
abdomen.l Whichl furtherl assessmentl ofl thel areal shouldl thel nursel perform?

Observel thel directionl ofl movement.
Auscultatel thel areal ofl movement.
Lightlyl palpatel thel areal ofl movement.
Percussl thel areal ofl movement.

Answer:
Observel thel directionl ofl movement.
Rationale
Increasedl peristalticl movementsl arel occasionallyl seenl inl veryl thinl clientsl andl mayl
indicatel thel presencel ofl intestinall obstruction.l Inl additionl tol notingl thel quadrantl ofl
origin,l thel nursel shouldl alsol notel thel directionl ofl thel peristalticl flowl andl reportl thesel
findingsl tol thel healthcarel provider.



Q:l Duringl al skinl assessment,l thel nursel notes,l roundl andl discretel lesionsl thatl arel
darkl redl inl colorl andl willl notl blanch.l Thel lesionsl rangel froml 1l tol 3l mml inl size.l
Whatl isl thel firstl questionl thel nursel shouldl askl thel client?

"Havel youl noticedl anyl unusuall bleeding?"
"Havel youl fallenl recently?"
"Howl oftenl dol youl drinkl alcohol?"
"Havel youl beenl exposedl tol anyonel withl al rashl lately?"

Answer:
"Havel youl noticedl anyl unusuall bleeding?"
Rationale
Petechiael arel small,l reddish-purplel lesionsl thatl dol notl fadel orl blanchl whenl pressurel isl
appliedl andl oftenl indicatel anl increasel inl capillaryl fragility.l Petechiael isl al conditionl
usuallyl seenl inl clientsl withl thrombocytopenia.l Petechiael mayl indicatel abnormall clottingl

, factors.l Mostl ofl thel diseasesl thatl causel petechiael causel bleedingl andl microembolisml
formation.



Q:l Afterl completingl thel initiall generall assessment,l thel nursel isl nowl completingl al
focusedl abdominall assessmentl ofl al clientl whol wasl admittedl forl abdominall pain.l Whichl
assessmentl isl mostl importantl forl thel nursel tol implement?

Inspectl forl abdominall distensionl thenl percussl forl tympany.
Palpatel thel abdomenl afterl auscultatingl forl bowell sounds.
Measurel thel client'sl oxygenl saturation.
Askl ifl painl medicationl wasl taken.

Answer:
Palpatel thel abdomenl afterl auscultatingl forl bowell sounds.
Rationale
Duringl al focusedl assessmentl ofl thel abdomen,l thel nursel shouldl palpatel forl abdominall
tensionl andl tendernessl afterl auscultatingl forl bowell sounds,l whichl canl bel alteredl byl
palpationl andl percussion.l Thel abdominall assessmentl shouldl progressl inl thel sequencel ofl
inspection,l auscultation,l palpation,l andl thenl percussion.



Q:l Al clientl isl inl thel clinicall forl al yearlyl physicall examination.l Whichl actionl shouldl
thel nursel takel whenl preparingl tol examinel thel client'sl abdomen?

Keepl thel rooml cooll sol thel clientl isl notl perspiring.
Askl thel clientl tol urinatel beforel beginningl thel examination.
Examinel painfull orl tenderl areasl first.
Positionl thel clientl supinel withl armsl overl thel head.

Answer:
Askl thel clientl tol urinatel beforel beginningl thel examination.
Rationale
Anl emptyl bladderl aidsl inl abdominall walll relaxation.l Thel nursel shouldl askl thel clientl tol
emptyl thel bladderl beforel examiningl thel abdomen.



Q:l Thel nursel isl performingl al head-to-toel assessmentl onl al client.l Thel nursel isl
assessingl thel client'sl pupillaryl lightl reflexl byl firstl darkeningl thel rooml andl askingl thel
personl tol gazel intol thel distance.l Then,l thel nursel advancesl al lightl towardl onel eyel froml
thel client'sl side.l Whatl wouldl thel nursel expectl tol seel atl thisl time?

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