BSN 246 HESI Health Assessment V1/ACTUAL EXAM QUESTIONS AND
CORRECT ANSWERS NIGHTINGALE COLLEGE
The nurse is performing a thoracic assessment on a client with chronic asthma and
hyperinflation of the lungs. Which finding should be expected for this client?
Barrel chest
While palpating a client's breasts, the nurse detects a nontender, solitary, round
lobular mass that is solid and firm and slides easily through the breast tissue. The
findings of this breast exam are consistent with which condition?
Fibroadenoma.
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard
bowel sounds in the right upper quadrant. What action should the nurse take next?
Note the character and frequency of bowel sounds
During inspection of a client's mouth and pharynx, the nurse places a tongue blade
on the back of the tongue which causes the client to gag. After removing the
tongue blade, what action should the nurse take?
Document an intact gag reflex.
The nurse uses a tongue depressor to assess a client's mouth. Which structure
should the nurse be able to visualize?
Pharynx
As a part of a routine health assessment, the nurse assesses the kidneys as part of
the abdominal assessment. Which assessment finding should the nurse conclude is
normal when palpating the client's right kidney?
A round smooth mass that slides between the fingers.
A client reports lower abdominal pain and a feeling of pressure in the bladder.
Which assessment finding indicates acute urinary retention?
Dull sound percussed over bladder.
*Clients with acute urinary retention may present with lower abdominal pain and
,bladder distension. Percussion (tapping on the body wall) is performed to detect
differences in pitch. A dull sound produced when percussing a distended urinary
bladder is an indication of urinary retention.
The nurse examines the skin of an older adult client. Which skin variation is
considered a normal finding for a client in this age group?
Lentigines.
*Lentigines or commonly referred to as liver spots are irregularly shaped dark
spots on the skin caused by aging and extensive sun exposure. This skin variation
is a normal finding in an older adult client.
When teaching a client how to perform a monthly breast self-assessment, the nurse
should tell the client that it is most important to assess which part of the breast
more closely for changes?
Upper outer quadrant.
A client is reporting chest pain. What statement made by the client, helps the nurse
to understand this client has a naturalistic belief in the cause of illness?
"My life is really out of balance."
The nurse is preparing to assess the hearing of a client with a history of prolonged
exposure to occupational noise. Which hearing test provides the most reliable
assessment of hearing status?
Audiometry.
The nurse is performing a routine physical examination on an adult client. When
gathering a health history, which question is included in the CAGE questionnaire?
Have you ever felt guilty about your drinking?
*CAGE is the acronym for Cut down, Annoyed, Guilty, and Eye-opener. Nurse can
use it to assess for possible alcohol abuse.
The nurse is examining the hip joint of a client who reports hip pain. Which other
assessment is most helpful in determining the cause of the client's pain?
, Knee joint evaluation.
The nurse performs a series of cranial nerve tests on a client with a head injury.
Which test should the nurse use to assess damage to the first cranial nerve?
Occlude one nostril and have the client identify various odors.
The client reports to the nurse a recent exposure to the mumps. Which assessment
finding suggests the client has contracted the mumps?
Swelling anterior to the ear lobe on one side of the face
A nurse is working in a healthcare facility that serves a diverse population. What
action(s) by the nurse will allow the nurse to empathize with and understand this
population? (Select all that apply.)
Be open to people who are different.
Have a curiosity about people.
Become culturally competent.
Which findings can the nurse determine by palpating a client's skin? (Select all that
apply.)
Diaphoresis.
Scaling.
Which question should the nurse ask in order to test a client's remote memory?
What is your date of birth?
While assessing level of consciousness, the nurse finds that a client localizes to
pain, is confused during conversation, and opens the eyes to sound. How should
the nurse document the Glasgow score of this client?
12.
The Glasgow Coma Scale is used to establish baseline data based on eye opening,
motor response, and verbal response. The lowest possible score is 3 and the highest
is 15. This client's Glasgow Coma Scale (GCS) score is 12: Opening eyes to sound
is a score of 3, localizing to pain is a 5, and confusion during a conversation is a 4
(3 + 5 + 4 = 12).
CORRECT ANSWERS NIGHTINGALE COLLEGE
The nurse is performing a thoracic assessment on a client with chronic asthma and
hyperinflation of the lungs. Which finding should be expected for this client?
Barrel chest
While palpating a client's breasts, the nurse detects a nontender, solitary, round
lobular mass that is solid and firm and slides easily through the breast tissue. The
findings of this breast exam are consistent with which condition?
Fibroadenoma.
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard
bowel sounds in the right upper quadrant. What action should the nurse take next?
Note the character and frequency of bowel sounds
During inspection of a client's mouth and pharynx, the nurse places a tongue blade
on the back of the tongue which causes the client to gag. After removing the
tongue blade, what action should the nurse take?
Document an intact gag reflex.
The nurse uses a tongue depressor to assess a client's mouth. Which structure
should the nurse be able to visualize?
Pharynx
As a part of a routine health assessment, the nurse assesses the kidneys as part of
the abdominal assessment. Which assessment finding should the nurse conclude is
normal when palpating the client's right kidney?
A round smooth mass that slides between the fingers.
A client reports lower abdominal pain and a feeling of pressure in the bladder.
Which assessment finding indicates acute urinary retention?
Dull sound percussed over bladder.
*Clients with acute urinary retention may present with lower abdominal pain and
,bladder distension. Percussion (tapping on the body wall) is performed to detect
differences in pitch. A dull sound produced when percussing a distended urinary
bladder is an indication of urinary retention.
The nurse examines the skin of an older adult client. Which skin variation is
considered a normal finding for a client in this age group?
Lentigines.
*Lentigines or commonly referred to as liver spots are irregularly shaped dark
spots on the skin caused by aging and extensive sun exposure. This skin variation
is a normal finding in an older adult client.
When teaching a client how to perform a monthly breast self-assessment, the nurse
should tell the client that it is most important to assess which part of the breast
more closely for changes?
Upper outer quadrant.
A client is reporting chest pain. What statement made by the client, helps the nurse
to understand this client has a naturalistic belief in the cause of illness?
"My life is really out of balance."
The nurse is preparing to assess the hearing of a client with a history of prolonged
exposure to occupational noise. Which hearing test provides the most reliable
assessment of hearing status?
Audiometry.
The nurse is performing a routine physical examination on an adult client. When
gathering a health history, which question is included in the CAGE questionnaire?
Have you ever felt guilty about your drinking?
*CAGE is the acronym for Cut down, Annoyed, Guilty, and Eye-opener. Nurse can
use it to assess for possible alcohol abuse.
The nurse is examining the hip joint of a client who reports hip pain. Which other
assessment is most helpful in determining the cause of the client's pain?
, Knee joint evaluation.
The nurse performs a series of cranial nerve tests on a client with a head injury.
Which test should the nurse use to assess damage to the first cranial nerve?
Occlude one nostril and have the client identify various odors.
The client reports to the nurse a recent exposure to the mumps. Which assessment
finding suggests the client has contracted the mumps?
Swelling anterior to the ear lobe on one side of the face
A nurse is working in a healthcare facility that serves a diverse population. What
action(s) by the nurse will allow the nurse to empathize with and understand this
population? (Select all that apply.)
Be open to people who are different.
Have a curiosity about people.
Become culturally competent.
Which findings can the nurse determine by palpating a client's skin? (Select all that
apply.)
Diaphoresis.
Scaling.
Which question should the nurse ask in order to test a client's remote memory?
What is your date of birth?
While assessing level of consciousness, the nurse finds that a client localizes to
pain, is confused during conversation, and opens the eyes to sound. How should
the nurse document the Glasgow score of this client?
12.
The Glasgow Coma Scale is used to establish baseline data based on eye opening,
motor response, and verbal response. The lowest possible score is 3 and the highest
is 15. This client's Glasgow Coma Scale (GCS) score is 12: Opening eyes to sound
is a score of 3, localizing to pain is a 5, and confusion during a conversation is a 4
(3 + 5 + 4 = 12).
