BSN 246 HESI HEALTH ASSESSMENT V1/ACTUAL EXAM
– NIGHTINGALE COLLEGE | 197 QUESTIONS AND
ANSWERS | WITH COMPLETE SOLUTION!!T
he 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? Answer - Barrel chest
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? Answer - 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? Answer - Document an
intact gag reflex.
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? Answer - Upper outer quadrant.
The nurse is assessing a postmenopausal client who has a BMI of 32. The client
has a chest measurement of 42 inches, waist measurement of 45 inches, and
hip measurement of 50 inches. What important message should the nurse
explain to the client to promote health promotion? Answer - A waist
,circumference is greater than 35 inches in women puts you at higher risk for
type 2 diabetes and heart disease."
The nurse performs a physical assessment on an older female client. Which
change from the prior exam may be an indication of osteoporosis? Answer -
Height reduction of 1.5 inches.
While conducting an interview to obtain a health history, the nurse notices that
the client pauses frequently and looks at the nurse expectantly. Which
response is best for the nurse to provide? Answer - Sit quietly to allow the
client to respond comfortably.
A client is in the clinical for a yearly physical examination. Which action should
the nurse take when preparing to examine the client's abdomen? Answer - Ask
the client to urinate before beginning the examination.
Which respiratory condition should the nurse document after measuring a
respiratory rate of 8 breaths/minute? Answer - Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit? Answer -
Measure the apical pulse and compare it to the peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point of
maximal impulse and the radial pulse palpated at the wrist.
A client has been diagnosed with bilateral lower lobe atelectasis. What
percussion sound should the nurse expect to hear when percussing over the
client's lower lobes? Answer - Dull, thud-like.
, A client is being assessed upon admission to the medical-surgical unit. The
nurse is preparing to complete a head-to-toe assessment and will begin at the
head of the client. Which technique should the nurse use to begin the
assessment? Answer - Inspect the hair and skin.
The nurse is assessing a healthy young adult during an annual physical
examination. Which assessment technique should the nurse implement when
palpating the abdominal aorta? Answer - Deep palpation above and to the left
of the umbilicus.
The nurse is conducting a family history as part of the assessment interview.
Which action should the nurse take to ensure that sufficient information about
the client's blood relatives is obtained? Answer - Document at least 3
generations of the client's family medical history.
The nurse is testing the client's shoulders for range of motion. What should the
nurse document to record normal internal rotation? Answer - Range of 90
degrees when the hands are placed at the small of the back.
A client presents with a rash along the occipital area of the hairline and reports
intense itching. How should the nurse begin the objective part of the
examination? Answer - Inspect the scalp looking for nits.
The nurse is assessing a client's range of motion as the client bends the right
knee up to the chest while keeping the left leg straight, but is unable to keep
the left thigh on the table. The assessment is repeated for the left knee, and
the client is unable to keep the right thigh on the table. How should the nurse
document this finding? Answer - A flexion deformity referred to as a positive
Thomas test.
During a skin asssessment, the nurse notes, round and discrete lesions that are
dark red in color and will not blanch. The lesions range from 1 to 3 mm in size.
– NIGHTINGALE COLLEGE | 197 QUESTIONS AND
ANSWERS | WITH COMPLETE SOLUTION!!T
he 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? Answer - Barrel chest
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? Answer - 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? Answer - Document an
intact gag reflex.
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? Answer - Upper outer quadrant.
The nurse is assessing a postmenopausal client who has a BMI of 32. The client
has a chest measurement of 42 inches, waist measurement of 45 inches, and
hip measurement of 50 inches. What important message should the nurse
explain to the client to promote health promotion? Answer - A waist
,circumference is greater than 35 inches in women puts you at higher risk for
type 2 diabetes and heart disease."
The nurse performs a physical assessment on an older female client. Which
change from the prior exam may be an indication of osteoporosis? Answer -
Height reduction of 1.5 inches.
While conducting an interview to obtain a health history, the nurse notices that
the client pauses frequently and looks at the nurse expectantly. Which
response is best for the nurse to provide? Answer - Sit quietly to allow the
client to respond comfortably.
A client is in the clinical for a yearly physical examination. Which action should
the nurse take when preparing to examine the client's abdomen? Answer - Ask
the client to urinate before beginning the examination.
Which respiratory condition should the nurse document after measuring a
respiratory rate of 8 breaths/minute? Answer - Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit? Answer -
Measure the apical pulse and compare it to the peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point of
maximal impulse and the radial pulse palpated at the wrist.
A client has been diagnosed with bilateral lower lobe atelectasis. What
percussion sound should the nurse expect to hear when percussing over the
client's lower lobes? Answer - Dull, thud-like.
, A client is being assessed upon admission to the medical-surgical unit. The
nurse is preparing to complete a head-to-toe assessment and will begin at the
head of the client. Which technique should the nurse use to begin the
assessment? Answer - Inspect the hair and skin.
The nurse is assessing a healthy young adult during an annual physical
examination. Which assessment technique should the nurse implement when
palpating the abdominal aorta? Answer - Deep palpation above and to the left
of the umbilicus.
The nurse is conducting a family history as part of the assessment interview.
Which action should the nurse take to ensure that sufficient information about
the client's blood relatives is obtained? Answer - Document at least 3
generations of the client's family medical history.
The nurse is testing the client's shoulders for range of motion. What should the
nurse document to record normal internal rotation? Answer - Range of 90
degrees when the hands are placed at the small of the back.
A client presents with a rash along the occipital area of the hairline and reports
intense itching. How should the nurse begin the objective part of the
examination? Answer - Inspect the scalp looking for nits.
The nurse is assessing a client's range of motion as the client bends the right
knee up to the chest while keeping the left leg straight, but is unable to keep
the left thigh on the table. The assessment is repeated for the left knee, and
the client is unable to keep the right thigh on the table. How should the nurse
document this finding? Answer - A flexion deformity referred to as a positive
Thomas test.
During a skin asssessment, the nurse notes, round and discrete lesions that are
dark red in color and will not blanch. The lesions range from 1 to 3 mm in size.
