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MED SURG HESI Health Assesment
2025-
Health Assessment Section
1 . Case Study (Multiple Response ) Scenario:
A 70-Year-Old Patient Is Admitted To The Hospital With Shortness Of
Breath, Fatigue, And Lower Extremity Swelling. During The Health
History, The Patient Mentions A History Of Congestive Heart Failure
(CHF) And Hypertension.
Question: Based On This History, Which Assessment Findings Are
Expected? (Select All That Apply)
A. Crackles In The Lungs
B. Pitting Edema In The Legs
C. Jugular Vein Distention
D. Bounding Radial Pulses
E. Orthopnea Answers: A, B, C, E Rationale:
Crackles In The Lungs Result From Pulmonary Congestion.
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Pitting Edema Is A Common Symptom Of Fluid Retention.
Jugular Vein Distention (JVD) Is A Sign Of Right-Sided Heart Failure.
Orthopnea, Or Difficulty Breathing When Lying Flat, Is A Hallmark Of
CHF.
Bounding Pulses Are Not Typical Of CHF And Are More Associated With
Hyperdynamic States. 2 . Select-All-That-Apply (SATA ) Question:
A Nurse Is Assessing A Patient Who Complains Of Abdominal Pain.
Which Assessment Steps Should The Nurse Include? (Select All That
Apply)
A. Inspect The Abdomen For Distention Or Masses.
B. Palpate Tender Areas First.
C. Auscultate Bowel Sounds In All Four Quadrants.
D. Percuss For Areas Of Tympany And Dullness.
E. Assess For Rebound Tenderness. Answers: A, C, D, E Rationale:
Inspection Helps Identify Visible Abnormalities.
Auscultation Precedes Palpation And Percussion To Avoid Altering
Bowel Sounds.
Percussion Identifies Gas Or Fluid Presence.
Rebound Tenderness Tests For Peritoneal Irritation.
Palpating Tender Areas First Is Incorrect; Tender Areas Should Be
Assessed Last To Prevent Guarding Or Discomfort.
3 . Multiple-Choice Question:
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A Nurse Is Performing A Cranial Nerve Assessment. The Patient Cannot
Identify Smells. Which Cranial Nerve Is Likely Impaired?
A. I (Olfactory)
B. II (Optic)
C. VII (Facial)
D. XII (Hypoglossal) Answer: A. I (Olfactory) Rationale:
The Olfactory Nerve (CN I) Is Responsible For The Sense Of Smell. Other
Options Involve Vision, Facial Expressions, And Tongue Movement.
4 . Case Study (Matrix ) Scenario:
A 45-Year-Old Patient Presents With Complaints Of Fever, Headache,
And Neck Stiffness. The Nurse Suspects Meningitis.
Question: Match The Assessment Findings To Their Relevance In
Diagnosing Meningitis:
Assessment Finding Relevance
Positive Brudzinski's Sign A. Indicates Meningeal Irritation
Hyperactive Deep Tendon Reflexes B. Unrelated To Meningitis
Photophobia C. Common In Meningitis
Decreased Capillary Refill D. Not Related To Meningitis Answers:
Positive Brudzinski's Sign → A
Downloaded by NELSON KIIRU ()
Lomoarcpsd|26582732
MED SURG HESI Health Assesment
2025-
Health Assessment Section
1 . Case Study (Multiple Response ) Scenario:
A 70-Year-Old Patient Is Admitted To The Hospital With Shortness Of
Breath, Fatigue, And Lower Extremity Swelling. During The Health
History, The Patient Mentions A History Of Congestive Heart Failure
(CHF) And Hypertension.
Question: Based On This History, Which Assessment Findings Are
Expected? (Select All That Apply)
A. Crackles In The Lungs
B. Pitting Edema In The Legs
C. Jugular Vein Distention
D. Bounding Radial Pulses
E. Orthopnea Answers: A, B, C, E Rationale:
Crackles In The Lungs Result From Pulmonary Congestion.
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
Pitting Edema Is A Common Symptom Of Fluid Retention.
Jugular Vein Distention (JVD) Is A Sign Of Right-Sided Heart Failure.
Orthopnea, Or Difficulty Breathing When Lying Flat, Is A Hallmark Of
CHF.
Bounding Pulses Are Not Typical Of CHF And Are More Associated With
Hyperdynamic States. 2 . Select-All-That-Apply (SATA ) Question:
A Nurse Is Assessing A Patient Who Complains Of Abdominal Pain.
Which Assessment Steps Should The Nurse Include? (Select All That
Apply)
A. Inspect The Abdomen For Distention Or Masses.
B. Palpate Tender Areas First.
C. Auscultate Bowel Sounds In All Four Quadrants.
D. Percuss For Areas Of Tympany And Dullness.
E. Assess For Rebound Tenderness. Answers: A, C, D, E Rationale:
Inspection Helps Identify Visible Abnormalities.
Auscultation Precedes Palpation And Percussion To Avoid Altering
Bowel Sounds.
Percussion Identifies Gas Or Fluid Presence.
Rebound Tenderness Tests For Peritoneal Irritation.
Palpating Tender Areas First Is Incorrect; Tender Areas Should Be
Assessed Last To Prevent Guarding Or Discomfort.
3 . Multiple-Choice Question:
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, lOMoARcPSD|26582732
A Nurse Is Performing A Cranial Nerve Assessment. The Patient Cannot
Identify Smells. Which Cranial Nerve Is Likely Impaired?
A. I (Olfactory)
B. II (Optic)
C. VII (Facial)
D. XII (Hypoglossal) Answer: A. I (Olfactory) Rationale:
The Olfactory Nerve (CN I) Is Responsible For The Sense Of Smell. Other
Options Involve Vision, Facial Expressions, And Tongue Movement.
4 . Case Study (Matrix ) Scenario:
A 45-Year-Old Patient Presents With Complaints Of Fever, Headache,
And Neck Stiffness. The Nurse Suspects Meningitis.
Question: Match The Assessment Findings To Their Relevance In
Diagnosing Meningitis:
Assessment Finding Relevance
Positive Brudzinski's Sign A. Indicates Meningeal Irritation
Hyperactive Deep Tendon Reflexes B. Unrelated To Meningitis
Photophobia C. Common In Meningitis
Decreased Capillary Refill D. Not Related To Meningitis Answers:
Positive Brudzinski's Sign → A
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