BSN 246 HESI Health Assessment V2 EXAM
Actual Quetions & Verified Answers
BSN 246 HESI Health Assessment V2 Exam 1
### Question 1
The nurse examines a client's abdomen. Which finding indicates
an abnormal response when palpating the spleen?
- A) No palpable mass noted.
- B) Tenderness reported upon deep palpation.
- C) Firm mass palpated at bottom of left rib cage.
- D) Softness in the lateral aspect of the abdomen.
-ANSWER:-C) Firm mass palpated at bottom of left rib cage.
Rationale:The spleen is usually not palpable unless it is enlarged.
A firm mass in this area may indicate splenomegaly, which is
abnormal.
### Question 2
In auscultating for the presence of a carotid artery bruit, the nurse
places the bell of the stethoscope at which location?
- A) Over the left subclavian artery.
,- B) Over the aortic arch.
- C) Over the carotid artery.
- D) Over the temporal artery.
-ANSWER:-C) Over the carotid artery.
Rationale:The bell of the stethoscope is applied directly over the
carotid artery to listen for bruits, which are abnormal sounds
indicating turbulent blood flow, possibly due to stenosis.
### Question 3
A male client arrives at the clinic for a follow-up health
assessment after recent antibiotic treatment for pneumonia
without
hospitalization. Which technique should the nurse implement to
assess for adventitious lung sounds?
- A) Place the stethoscope's diaphragm lightly on the skin.
- B) Press the stethoscope's diaphragm firmly on the skin over
each lung field.
- C) Ask the client to breathe normally while using the bell of
the stethoscope.
- D) Use the diaphragm lightly over each lung field and listen
for changes.
,-ANSWER:-B) Press the stethoscope's diaphragm firmly on the
skin over each lung field.
Rationale:Applying the diaphragm firmly enhances the
transmission of breath sounds and allows the nurse to detect any
adventitious sounds such as wheezes or crackles effectively.
### Question 4
A 29-year-old male client informs the nurse that he came to the
clinic to see if, "Maybe I have lung cancer or something," and
wants to get checked out since, "I can't seem to get rid of this
body-wracking dry cough that has been hanging around for the
last six weeks." Which computer documentation of this client's
concerns should the nurse enter?
- A) "Patient reports a persistent cough accompanied by
wheezing."
- B) "Client describes having a 'body-wracking dry cough' of 6
weeks duration."
- C) "The client expresses concern about possible lung cancer
symptoms."
- D) "Client presents with a cough lasting more than a month."
-ANSWER:-B) "Client describes having a 'body-wracking dry
cough' of 6 weeks duration."
Rationale:The documentation should reflect the client's own
description of their symptoms. Using the client's words captures
, the severity and character of the cough, providing clear
information for future assessments.
---
### Question 5
A 75-year-old client with a recent history of a cerebrovascular
accident (CVA) presents with right hemiparesis. The nurse tests
the deep tendon reflexes on the right side and elicits a brisk 4+
response. Which interpretation of this finding is accurate?
- A) Normal response suggesting healthy neuromuscular
function.
- B) Hypoactive response consistent with a lower motor
neuron disorder.
- C) Hyperactive response consistent with an upper motor
neuron disorder.
- D) Reflexes indicate potential peripheral nerve damage.
-ANSWER:-C) Hyperactive response consistent with an upper
motor neuron disorder.
Rationale:In the context of a recent CVA, a brisk deep tendon
reflex (4+) indicates upper motor neuron damage, which typically
results in increased reflex activity and hyperreflexia.
### Question 6
Actual Quetions & Verified Answers
BSN 246 HESI Health Assessment V2 Exam 1
### Question 1
The nurse examines a client's abdomen. Which finding indicates
an abnormal response when palpating the spleen?
- A) No palpable mass noted.
- B) Tenderness reported upon deep palpation.
- C) Firm mass palpated at bottom of left rib cage.
- D) Softness in the lateral aspect of the abdomen.
-ANSWER:-C) Firm mass palpated at bottom of left rib cage.
Rationale:The spleen is usually not palpable unless it is enlarged.
A firm mass in this area may indicate splenomegaly, which is
abnormal.
### Question 2
In auscultating for the presence of a carotid artery bruit, the nurse
places the bell of the stethoscope at which location?
- A) Over the left subclavian artery.
,- B) Over the aortic arch.
- C) Over the carotid artery.
- D) Over the temporal artery.
-ANSWER:-C) Over the carotid artery.
Rationale:The bell of the stethoscope is applied directly over the
carotid artery to listen for bruits, which are abnormal sounds
indicating turbulent blood flow, possibly due to stenosis.
### Question 3
A male client arrives at the clinic for a follow-up health
assessment after recent antibiotic treatment for pneumonia
without
hospitalization. Which technique should the nurse implement to
assess for adventitious lung sounds?
- A) Place the stethoscope's diaphragm lightly on the skin.
- B) Press the stethoscope's diaphragm firmly on the skin over
each lung field.
- C) Ask the client to breathe normally while using the bell of
the stethoscope.
- D) Use the diaphragm lightly over each lung field and listen
for changes.
,-ANSWER:-B) Press the stethoscope's diaphragm firmly on the
skin over each lung field.
Rationale:Applying the diaphragm firmly enhances the
transmission of breath sounds and allows the nurse to detect any
adventitious sounds such as wheezes or crackles effectively.
### Question 4
A 29-year-old male client informs the nurse that he came to the
clinic to see if, "Maybe I have lung cancer or something," and
wants to get checked out since, "I can't seem to get rid of this
body-wracking dry cough that has been hanging around for the
last six weeks." Which computer documentation of this client's
concerns should the nurse enter?
- A) "Patient reports a persistent cough accompanied by
wheezing."
- B) "Client describes having a 'body-wracking dry cough' of 6
weeks duration."
- C) "The client expresses concern about possible lung cancer
symptoms."
- D) "Client presents with a cough lasting more than a month."
-ANSWER:-B) "Client describes having a 'body-wracking dry
cough' of 6 weeks duration."
Rationale:The documentation should reflect the client's own
description of their symptoms. Using the client's words captures
, the severity and character of the cough, providing clear
information for future assessments.
---
### Question 5
A 75-year-old client with a recent history of a cerebrovascular
accident (CVA) presents with right hemiparesis. The nurse tests
the deep tendon reflexes on the right side and elicits a brisk 4+
response. Which interpretation of this finding is accurate?
- A) Normal response suggesting healthy neuromuscular
function.
- B) Hypoactive response consistent with a lower motor
neuron disorder.
- C) Hyperactive response consistent with an upper motor
neuron disorder.
- D) Reflexes indicate potential peripheral nerve damage.
-ANSWER:-C) Hyperactive response consistent with an upper
motor neuron disorder.
Rationale:In the context of a recent CVA, a brisk deep tendon
reflex (4+) indicates upper motor neuron damage, which typically
results in increased reflex activity and hyperreflexia.
### Question 6
