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,BSN 246 HESI Health Assessment Exam V2
MULTIPLE CHOICES
Question 1: A 29-year-old male client tells the nurse, "Maybe I have lung cancer or something," and
states he cannot get rid of a dry cough that has lasted six weeks. Which documentation best reflects
this client's concerns?
A) Presents with a hacking non-productive cough of 6 weeks duration.
B) Describes having a "body-wracking dry cough" of 6 weeks duration.
C) Expresses concern of "lung cancer" symptoms for the last 6 weeks.
D) Young adult male presents with fears that he has "lung cancer."
Answer: B
Rationale: The chief complaint should be documented using the client's own words to accurately
capture their subjective experience and avoid making diagnostic assumptions. Using quotation marks
preserves the client's description and severity of symptoms.
Question 2: A 75-year-old client with a recent cerebrovascular accident (CVA) presents with right
hemiparesis. The nurse tests deep tendon reflexes on the right side and elicits a brisk 4+ response.
What does this finding indicate?
A) A normal reflex response.
B) Absent or sluggish response consistent with a lower motor neuron lesion.
C) Flaccid paralysis.
D) Hyperactive response consistent with an upper motor neuron disorder.
Answer: D
Rationale: A brisk 4+ deep tendon reflex response is hyperactive and indicates an upper motor neuron
disorder, which is consistent with the client's history of CVA. Upper motor neuron lesions cause
increased muscle tone and hyperreflexia.
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,Question 3: The nurse examines a client's abdomen. Which finding indicates an abnormal response
when palpating the spleen?
A) Pain noted when palpating McBurney's point.
B) Tip of spleen palpable when client is asked to forcefully exhale.
C) Rebound tenderness with compression over the right upper quadrant.
D) Firm mass palpated at the bottom of the left rib cage.
Answer: D
Rationale: The spleen is normally not palpable. A firm mass at the bottom of the left rib cage suggests
splenomegaly, which is abnormal. McBurney's point tenderness is associated with appendicitis, not
splenic assessment.
Question 4: In auscultating for the presence of a carotid artery bruit, where should the nurse place the
bell of the stethoscope?
A) Over the left subclavian artery.
B) Over the aortic arch.
C) Over the carotid artery.
D) Over the temporal artery.
Answer: C
Rationale: The bell of the stethoscope is placed directly over the carotid artery to auscultate for
bruits, which indicate turbulent blood flow suggestive of arterial stenosis. The bell is used to detect
low-pitched sounds.
Question 5: A male client returns for follow-up after antibiotic treatment for pneumonia. Which
technique should the nurse implement to assess for adventitious lung sounds?
A) Use the bell of the stethoscope to listen to the lung fields over the lower lobes.
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, B) Have the client lie flat while listening to the anterior surface of the chest.
C) Press the stethoscope's diaphragm firmly on the skin over each lung field.
D) Shave all chest hair that may distort sounds heard through the diaphragm.
Answer: C
Rationale: The diaphragm of the stethoscope should be pressed firmly against the skin over each lung
field to effectively transmit high-pitched breath sounds. The nurse should listen to all lung fields,
moving from side to side for comparison.
Question 6: A client with streptococcus pharyngitis reports high fever, difficulty swallowing, and a
muffled voice. Which complication should the nurse suspect?
A) Foreign body obstruction.
B) Laryngeal polyps.
C) Peritonsillar abscess.
D) Nasal polyps.
Answer: C
Rationale: High fever, difficulty swallowing (odynophagia), and a muffled voice ("hot potato" voice)
are classic signs of a peritonsillar abscess, a complication of streptococcal pharyngitis. The abscess
forms pus behind the tonsil.
Question 7: While obtaining a health history, a client tells the nurse he sometimes experiences
shortness of breath. The nurse determines respirations are regular and deep at 14 breaths/minute.
What is the best nursing action?
A) Administer oxygen immediately.
B) Ask the client to describe the episodes of dyspnea in more detail.
C) Notify the healthcare provider about the client's condition.
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,BSN 246 HESI Health Assessment Exam V2
MULTIPLE CHOICES
Question 1: A 29-year-old male client tells the nurse, "Maybe I have lung cancer or something," and
states he cannot get rid of a dry cough that has lasted six weeks. Which documentation best reflects
this client's concerns?
A) Presents with a hacking non-productive cough of 6 weeks duration.
B) Describes having a "body-wracking dry cough" of 6 weeks duration.
C) Expresses concern of "lung cancer" symptoms for the last 6 weeks.
D) Young adult male presents with fears that he has "lung cancer."
Answer: B
Rationale: The chief complaint should be documented using the client's own words to accurately
capture their subjective experience and avoid making diagnostic assumptions. Using quotation marks
preserves the client's description and severity of symptoms.
Question 2: A 75-year-old client with a recent cerebrovascular accident (CVA) presents with right
hemiparesis. The nurse tests deep tendon reflexes on the right side and elicits a brisk 4+ response.
What does this finding indicate?
A) A normal reflex response.
B) Absent or sluggish response consistent with a lower motor neuron lesion.
C) Flaccid paralysis.
D) Hyperactive response consistent with an upper motor neuron disorder.
Answer: D
Rationale: A brisk 4+ deep tendon reflex response is hyperactive and indicates an upper motor neuron
disorder, which is consistent with the client's history of CVA. Upper motor neuron lesions cause
increased muscle tone and hyperreflexia.
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,Question 3: The nurse examines a client's abdomen. Which finding indicates an abnormal response
when palpating the spleen?
A) Pain noted when palpating McBurney's point.
B) Tip of spleen palpable when client is asked to forcefully exhale.
C) Rebound tenderness with compression over the right upper quadrant.
D) Firm mass palpated at the bottom of the left rib cage.
Answer: D
Rationale: The spleen is normally not palpable. A firm mass at the bottom of the left rib cage suggests
splenomegaly, which is abnormal. McBurney's point tenderness is associated with appendicitis, not
splenic assessment.
Question 4: In auscultating for the presence of a carotid artery bruit, where should the nurse place the
bell of the stethoscope?
A) Over the left subclavian artery.
B) Over the aortic arch.
C) Over the carotid artery.
D) Over the temporal artery.
Answer: C
Rationale: The bell of the stethoscope is placed directly over the carotid artery to auscultate for
bruits, which indicate turbulent blood flow suggestive of arterial stenosis. The bell is used to detect
low-pitched sounds.
Question 5: A male client returns for follow-up after antibiotic treatment for pneumonia. Which
technique should the nurse implement to assess for adventitious lung sounds?
A) Use the bell of the stethoscope to listen to the lung fields over the lower lobes.
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, B) Have the client lie flat while listening to the anterior surface of the chest.
C) Press the stethoscope's diaphragm firmly on the skin over each lung field.
D) Shave all chest hair that may distort sounds heard through the diaphragm.
Answer: C
Rationale: The diaphragm of the stethoscope should be pressed firmly against the skin over each lung
field to effectively transmit high-pitched breath sounds. The nurse should listen to all lung fields,
moving from side to side for comparison.
Question 6: A client with streptococcus pharyngitis reports high fever, difficulty swallowing, and a
muffled voice. Which complication should the nurse suspect?
A) Foreign body obstruction.
B) Laryngeal polyps.
C) Peritonsillar abscess.
D) Nasal polyps.
Answer: C
Rationale: High fever, difficulty swallowing (odynophagia), and a muffled voice ("hot potato" voice)
are classic signs of a peritonsillar abscess, a complication of streptococcal pharyngitis. The abscess
forms pus behind the tonsil.
Question 7: While obtaining a health history, a client tells the nurse he sometimes experiences
shortness of breath. The nurse determines respirations are regular and deep at 14 breaths/minute.
What is the best nursing action?
A) Administer oxygen immediately.
B) Ask the client to describe the episodes of dyspnea in more detail.
C) Notify the healthcare provider about the client's condition.
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