BSN 246 HESI HEALTH ASSESSMENT V1 EXAM
2025/2026 (ACTUAL EXAM) QUESTIONS AND
VERIFIED ANSWERS (NIGHTINGALE COLLEGE)
The nurse is performing a thoracic assessment on a client with chronic asthma and hyperinf
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
lation of the lungs. Which finding should be expected for this client? - ans-Barrel chest
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel s
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ounds in the right upper quadrant. What action should the nurse take next? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
Note the character and frequency of bowel sounds
xz xz xz xz xz xz xz
During inspection of a client's mouth and pharynx, the nurse places a tongue blade on the b
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ack of the tongue which causes the client to gag. After removing the tongue blade, what acti
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
on should the nurse take? - ans-Document an intact gag reflex.
xz xz xz xz xz xz xz xz xz xz
When teaching a client how to perform a monthly breast self-
xz xz xz xz xz xz xz xz xz xz
assessment, the nurse should tell the client that it is most important to assess which part of t
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
he breast more closely for changes? - ans-Upper outer quadrant.
xz xz xz xz xz xz xz xz xz
The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a ches
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
t measurement of 42 inches, waist measurement of 45 inches, and hip measurement of 50 i
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
nches. What important message should the nurse explain to the client to promote health pr
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
omotion? - ans- xz xz
A waist circumference is greater than 35 inches in women puts you at higher risk for type 2 d
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
iabetes and heart disease." xz xz xz
The nurse performs a physical assessment on an older female client. Which change from th
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
e prior exam may be an indication of osteoporosis? - ans-Height reduction of 1.5 inches.
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
While conducting an interview to obtain a health history, the nurse notices that the client pa
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
uses frequently and looks at the nurse expectantly. Which response is best for the nurse to
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
provide? - ans-Sit quietly to allow the client to respond comfortably.
xz xz xz xz xz xz xz xz xz xz
A client is in the clinical for a yearly physical examination. Which action should the nurse tak
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
e when preparing to examine the client's abdomen? - ans-
xz xz xz xz xz xz xz xz xz
Ask the client to urinate before beginning the examination.
xz xz xz xz xz xz xz xz
Which respiratory condition should the nurse document after measuring a respiratory rate o
xz xz xz xz xz xz xz xz xz xz xz xz
f 8 breaths/minute? - ans-Bradypnea.
xz xz xz xz
,Which procedure should the nurse use to assessfor a pulse deficit? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz
Measure the apical pulse and compare it to the peripheral pulse. xz xz xz xz xz xz xz xz xz xz
*A pulse deficit is a palpable difference between the apical pulse at the point of maximal imp
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ulse and the radial pulse palpated at the wrist.
xz xz xz xz xz xz xz xz
A client has been diagnosed with bilateral lower lobe atelectasis. What percussion sound s
xz xz xz xz xz xz xz xz xz xz xz xz xz
hould the nurse expect to hear when percussing over the client's lower lobes? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
Dull, thud-like. xz
A client is being assessed upon admission to the medical-
xz xz xz xz xz xz xz xz xz
surgical unit. The nurse is preparing to complete a head-to-
xz xz xz xz xz xz xz xz xz
toe assessment and will begin at the head of the client. Which technique should the nurse u
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
se to begin the assessment? - ans-Inspect the hair and skin.
xz xz xz xz xz xz xz xz xz xz
The nurse is assessing a healthy young adult during an annual physical examination. Whic
xz xz xz xz xz xz xz xz xz xz xz xz xz
h assessment technique should the nurse implement when palpating the abdominal aorta?
xz xz xz xz xz xz xz xz xz xz xz
- ans-Deep palpation above and to the left of the umbilicus.
xz xz xz xz xz xz xz xz xz xz xz
The nurse is conducting a family history as part of the assessment interview. Which action s
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
hould the nurse take to ensure that sufficient information about the client's blood relatives is
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
obtained? - ans-Document at least 3 generations of the client's family medical history.
xz xz xz xz xz xz xz xz xz xz xz xz
The nurse is testing the client's shoulders for range of motion. What should the nurse docu
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ment to record normal internal rotation? - ans-
xz xz xz xz xz xz xz
Range of 90 degrees when the hands are placed at the small of the back.
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
A client presents with a rash along the occipital area of the hairline and reports intense itchi
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ng. How should the nurse begin the objective part of the examination? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz
Inspect the scalp looking for nits. xz xz xz xz xz
The nurse is assessing a client's range of motion as the client bends the right knee up to the
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
chest while keeping the left leg straight, but is unable to keep the left thigh on the table. The
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
assessment is repeated for the left knee, and the client is unable to keep the right thigh on th
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
e table. How should the nurse document this finding? - ans-
xz xz xz xz xz xz xz xz xz xz
A flexion deformity referred to as a positive Thomas test.
xz xz xz xz xz xz xz xz xz
During a skin asssessment, the nurse notes, round and discrete lesions that are dark red in
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
color and will not blanch. The lesions range from 1 to 3 mm in size. What is the first question
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
the nurse should ask the client? - ans-Have you notice any irregular bleeding
xz xz xz xz xz xz xz xz xz xz xz xz
A client with progressive hearing loss appears distressed when the registered nurse (RN) a
xz xz xz xz xz xz xz xz xz xz xz xz xz
sks open- xz
ended questions about the client's health history. Which forms of communication should th
xz xz xz xz xz xz xz xz xz xz xz xz
e RN use? - ans-Face the client so the client can see the RN's mouth.
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
Check if the client's hearing aides are working properly.
xz xz xz xz xz xz xz xz
, Reduce environmental noise surrounding the client.
xz xz xz xz xz
A client states that she had a mastectomy of her left breast last year and now experiences ly
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
mphedema. What should the nurse expect to find when examining the client? - ans- xz xz xz xz xz xz xz xz xz xz xz xz xz
Swelling of the left arm and non-pitting edema. xz xz xz xz xz xz xz
A client has just returned from the recovery room and asks to get out of bed to go to the bath
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
room. The nurse decides to obtain orthostatic vital signs first. How will the nurse position th
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
e client to begin this procedure? - ans-Lying.
xz xz xz xz xz xz xz
A postmenopausal female client is undergoing a routine physical examination. She has rep
xz xz xz xz xz xz xz xz xz xz xz xz
orted nothing out of the ordinary. When performing the examination of the genitourinary sys
xz xz xz xz xz xz xz xz xz xz xz xz xz
tem, the nurse finds an irregularly enlarged uterus with firm, mobile, painless nodules in the
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
uterine wall. How should the nurse explain this finding to the client? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz
You have benign fibroid tumors, a common occurrence in women your age.
xz xz xz xz xz xz xz xz xz xz xz
A client is reporting chest pain. What statement made by the client, helps the nurse to under
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
stand this client has a naturalistic belief in the cause of illness? -
xz xz xz xz xz xz xz xz xz xz xz xz
ans-"My life is really out of balance."
xz xz xz xz xz xz xz
The nurse is preparing to assess the hearing of a client with a history of prolonged exposure
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
to occupational noise. Which hearing test provides the most reliable assessment of hearin
xz xz xz xz xz xz xz xz xz xz xz xz xz
g status? - ans-Audiometry.
xz xz xz
The nurse is performing a routine physical examination on an adult client. When gathering
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
a health history, which question is included in the CAGE questionnaire? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz
Have you ever felt guilty about your drinking?
xz xz xz xz xz xz xz
*CAGE is the acronym for Cut down, Annoyed, Guilty, and Eye-
xz xz xz xz xz xz xz xz xz xz
opener. Nurse can use it to assess for possible alcohol abuse.
xz xz xz xz xz xz xz xz xz xz
The nurse is examining the hip joint of a client who reports hip pain. Which other assessme
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
nt is most helpful in determining the cause of the client's pain? - ans-Knee joint evaluation.
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
The nurse performs a series of cranial nerve tests on a client with a head injury. Which test s
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
hould the nurse use to assess damage to the first cranial nerve? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz
Occlude one nostril and have the client identify various odors.
xz xz xz xz xz xz xz xz xz
The client reports to the nurse a recent exposure to the mumps. Which assessment finding
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
suggests the client has contracted the mumps? - ans- xz xz xz xz xz xz xz xz
Swelling anterior to the ear lobe on one side of the face
xz xz xz xz xz xz xz xz xz xz xz
A nurse is working in a healthcare facility that serves a diverse population. What action(s) b
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
y the nurse will allow the nurse to empathize with and understand this population?
xz xz xz xz xz xz xz xz xz xz xz xz xz
(Select all that apply.) - ans-Be open to people who are different.
xz xz xz xz xz xz xz xz xz xz xz xz
2025/2026 (ACTUAL EXAM) QUESTIONS AND
VERIFIED ANSWERS (NIGHTINGALE COLLEGE)
The nurse is performing a thoracic assessment on a client with chronic asthma and hyperinf
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
lation of the lungs. Which finding should be expected for this client? - ans-Barrel chest
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel s
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ounds in the right upper quadrant. What action should the nurse take next? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
Note the character and frequency of bowel sounds
xz xz xz xz xz xz xz
During inspection of a client's mouth and pharynx, the nurse places a tongue blade on the b
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ack of the tongue which causes the client to gag. After removing the tongue blade, what acti
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
on should the nurse take? - ans-Document an intact gag reflex.
xz xz xz xz xz xz xz xz xz xz
When teaching a client how to perform a monthly breast self-
xz xz xz xz xz xz xz xz xz xz
assessment, the nurse should tell the client that it is most important to assess which part of t
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
he breast more closely for changes? - ans-Upper outer quadrant.
xz xz xz xz xz xz xz xz xz
The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a ches
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
t measurement of 42 inches, waist measurement of 45 inches, and hip measurement of 50 i
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
nches. What important message should the nurse explain to the client to promote health pr
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
omotion? - ans- xz xz
A waist circumference is greater than 35 inches in women puts you at higher risk for type 2 d
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
iabetes and heart disease." xz xz xz
The nurse performs a physical assessment on an older female client. Which change from th
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
e prior exam may be an indication of osteoporosis? - ans-Height reduction of 1.5 inches.
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
While conducting an interview to obtain a health history, the nurse notices that the client pa
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
uses frequently and looks at the nurse expectantly. Which response is best for the nurse to
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
provide? - ans-Sit quietly to allow the client to respond comfortably.
xz xz xz xz xz xz xz xz xz xz
A client is in the clinical for a yearly physical examination. Which action should the nurse tak
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
e when preparing to examine the client's abdomen? - ans-
xz xz xz xz xz xz xz xz xz
Ask the client to urinate before beginning the examination.
xz xz xz xz xz xz xz xz
Which respiratory condition should the nurse document after measuring a respiratory rate o
xz xz xz xz xz xz xz xz xz xz xz xz
f 8 breaths/minute? - ans-Bradypnea.
xz xz xz xz
,Which procedure should the nurse use to assessfor a pulse deficit? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz
Measure the apical pulse and compare it to the peripheral pulse. xz xz xz xz xz xz xz xz xz xz
*A pulse deficit is a palpable difference between the apical pulse at the point of maximal imp
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ulse and the radial pulse palpated at the wrist.
xz xz xz xz xz xz xz xz
A client has been diagnosed with bilateral lower lobe atelectasis. What percussion sound s
xz xz xz xz xz xz xz xz xz xz xz xz xz
hould the nurse expect to hear when percussing over the client's lower lobes? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
Dull, thud-like. xz
A client is being assessed upon admission to the medical-
xz xz xz xz xz xz xz xz xz
surgical unit. The nurse is preparing to complete a head-to-
xz xz xz xz xz xz xz xz xz
toe assessment and will begin at the head of the client. Which technique should the nurse u
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
se to begin the assessment? - ans-Inspect the hair and skin.
xz xz xz xz xz xz xz xz xz xz
The nurse is assessing a healthy young adult during an annual physical examination. Whic
xz xz xz xz xz xz xz xz xz xz xz xz xz
h assessment technique should the nurse implement when palpating the abdominal aorta?
xz xz xz xz xz xz xz xz xz xz xz
- ans-Deep palpation above and to the left of the umbilicus.
xz xz xz xz xz xz xz xz xz xz xz
The nurse is conducting a family history as part of the assessment interview. Which action s
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
hould the nurse take to ensure that sufficient information about the client's blood relatives is
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
obtained? - ans-Document at least 3 generations of the client's family medical history.
xz xz xz xz xz xz xz xz xz xz xz xz
The nurse is testing the client's shoulders for range of motion. What should the nurse docu
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ment to record normal internal rotation? - ans-
xz xz xz xz xz xz xz
Range of 90 degrees when the hands are placed at the small of the back.
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
A client presents with a rash along the occipital area of the hairline and reports intense itchi
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ng. How should the nurse begin the objective part of the examination? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz
Inspect the scalp looking for nits. xz xz xz xz xz
The nurse is assessing a client's range of motion as the client bends the right knee up to the
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
chest while keeping the left leg straight, but is unable to keep the left thigh on the table. The
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
assessment is repeated for the left knee, and the client is unable to keep the right thigh on th
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
e table. How should the nurse document this finding? - ans-
xz xz xz xz xz xz xz xz xz xz
A flexion deformity referred to as a positive Thomas test.
xz xz xz xz xz xz xz xz xz
During a skin asssessment, the nurse notes, round and discrete lesions that are dark red in
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
color and will not blanch. The lesions range from 1 to 3 mm in size. What is the first question
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
the nurse should ask the client? - ans-Have you notice any irregular bleeding
xz xz xz xz xz xz xz xz xz xz xz xz
A client with progressive hearing loss appears distressed when the registered nurse (RN) a
xz xz xz xz xz xz xz xz xz xz xz xz xz
sks open- xz
ended questions about the client's health history. Which forms of communication should th
xz xz xz xz xz xz xz xz xz xz xz xz
e RN use? - ans-Face the client so the client can see the RN's mouth.
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
Check if the client's hearing aides are working properly.
xz xz xz xz xz xz xz xz
, Reduce environmental noise surrounding the client.
xz xz xz xz xz
A client states that she had a mastectomy of her left breast last year and now experiences ly
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
mphedema. What should the nurse expect to find when examining the client? - ans- xz xz xz xz xz xz xz xz xz xz xz xz xz
Swelling of the left arm and non-pitting edema. xz xz xz xz xz xz xz
A client has just returned from the recovery room and asks to get out of bed to go to the bath
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
room. The nurse decides to obtain orthostatic vital signs first. How will the nurse position th
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
e client to begin this procedure? - ans-Lying.
xz xz xz xz xz xz xz
A postmenopausal female client is undergoing a routine physical examination. She has rep
xz xz xz xz xz xz xz xz xz xz xz xz
orted nothing out of the ordinary. When performing the examination of the genitourinary sys
xz xz xz xz xz xz xz xz xz xz xz xz xz
tem, the nurse finds an irregularly enlarged uterus with firm, mobile, painless nodules in the
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
uterine wall. How should the nurse explain this finding to the client? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz
You have benign fibroid tumors, a common occurrence in women your age.
xz xz xz xz xz xz xz xz xz xz xz
A client is reporting chest pain. What statement made by the client, helps the nurse to under
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
stand this client has a naturalistic belief in the cause of illness? -
xz xz xz xz xz xz xz xz xz xz xz xz
ans-"My life is really out of balance."
xz xz xz xz xz xz xz
The nurse is preparing to assess the hearing of a client with a history of prolonged exposure
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
to occupational noise. Which hearing test provides the most reliable assessment of hearin
xz xz xz xz xz xz xz xz xz xz xz xz xz
g status? - ans-Audiometry.
xz xz xz
The nurse is performing a routine physical examination on an adult client. When gathering
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
a health history, which question is included in the CAGE questionnaire? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz
Have you ever felt guilty about your drinking?
xz xz xz xz xz xz xz
*CAGE is the acronym for Cut down, Annoyed, Guilty, and Eye-
xz xz xz xz xz xz xz xz xz xz
opener. Nurse can use it to assess for possible alcohol abuse.
xz xz xz xz xz xz xz xz xz xz
The nurse is examining the hip joint of a client who reports hip pain. Which other assessme
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
nt is most helpful in determining the cause of the client's pain? - ans-Knee joint evaluation.
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
The nurse performs a series of cranial nerve tests on a client with a head injury. Which test s
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
hould the nurse use to assess damage to the first cranial nerve? - ans-
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Occlude one nostril and have the client identify various odors.
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The client reports to the nurse a recent exposure to the mumps. Which assessment finding
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suggests the client has contracted the mumps? - ans- xz xz xz xz xz xz xz xz
Swelling anterior to the ear lobe on one side of the face
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A nurse is working in a healthcare facility that serves a diverse population. What action(s) b
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y the nurse will allow the nurse to empathize with and understand this population?
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(Select all that apply.) - ans-Be open to people who are different.
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