BSN 246 HESI Health Assessment V2
Exam –- Nightingale College.
(PDF) Questions and Ansẉers with
rationales 2026\2027 update
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Questions and Ansẉers
format set of multiple-choice
Expert-Verified rationales
Verified ẉith trusted textbooks
,───────────────────────────────────────────────────────
─
A nurse is conducting a health history with a patient who complains
of abdominal pain. Which question is most appropriate for the nurse
to ask to determine the aggravating factors of the pain?
A) "When did the pain start?"
B) "What does the pain feel like?"
C) "What makes the pain worse?"
D) "Where exactly is the pain located?"
Answer: C
Rationale: Aggravating factors refer to what makes the symptom
worse. Option A assesses onset, Option B assesses quality, and
Option D assesses location.
During an interview, a patient states, "I just can't seem to stop
drinking, but my wife is making me." Which defense mechanism is
the patient displaying?
A) Denial
B) Projection
C) Rationalization
D) Minimization
Answer: C
Rationale: Rationalization is creating false but logical excuses to
justify unacceptable behavior or feelings. The patient is blaming his
wife for his drinking rather than taking responsibility.
,The nurse is assessing a patient's mental status. Which assessment
finding requires immediate intervention?
A) The patient is oriented to person but not place or time.
B) The patient has constricted pupils and responds slowly to verbal
stimuli.
C) The patient is anxious and fidgeting during the interview.
D) The patient has a Glasgow Coma Scale score of 15.
Answer: B
Rationale: Constricted pupils and slow response to verbal stimuli
indicate a potentially severe neurological or opioid toxicity issue
requiring immediate intervention. Option A indicates confusion but
is not immediately life-threatening. Option C is anxiety. Option D is
a perfect GCS score.
When assessing a patient's nutritional status, which of the following
is the best indicator of long-term protein status?
A) Prealbumin
B) Transferrin
C) Albumin
D) Total lymphocyte count
Answer: C
Rationale: Albumin has a half-life of 18 to 20 days, making it a good
indicator of long-term protein status. Prealbumin has a half-life of 2
days and reflects short-term status.
A nurse is assessing a patient's skin turgor. The nurse grasps the
skin over the clavicle, pulls it up, and releases it. The skin remains
tented. This finding indicates:
A) Normal elasticity.
B) Severe dehydration.
C) Aging changes.
D) Overhydration.
, Answer: B
Rationale: Tenting (skin remaining in a pinched state) indicates
decreased skin turgor, which is a classic sign of dehydration or
severe fluid volume deficit.
While assessing the skin of an older adult, the nurse notes multiple
dark, raised, warty-looking lesions on the trunk that feel stuck on.
The nurse recognizes these as:
A) Actinic keratosis.
B) Squamous cell carcinoma.
C) Seborrheic keratosis.
D) Basal cell carcinoma.
Answer: C
Rationale: Seborrheic keratosis presents as raised, warty, pigmented
lesions that look "stuck on" and are common in older adults. Actinic
keratosis is premalignant and usually scaly.
The nurse is assessing a patient's wound and notes a shallow, moist
ulcer with a red-pink wound bed without slough. This would be
classified as a Stage:
A) I
B) II
C) III
D) IV
Answer: B
Rationale: A Stage II pressure injury involves partial-thickness loss of
the dermis, presenting as a shallow, open ulcer with a red-pink
wound bed, without slough.
Exam –- Nightingale College.
(PDF) Questions and Ansẉers with
rationales 2026\2027 update
This Exam contains:
Guarantee passing score
Questions and Ansẉers
format set of multiple-choice
Expert-Verified rationales
Verified ẉith trusted textbooks
,───────────────────────────────────────────────────────
─
A nurse is conducting a health history with a patient who complains
of abdominal pain. Which question is most appropriate for the nurse
to ask to determine the aggravating factors of the pain?
A) "When did the pain start?"
B) "What does the pain feel like?"
C) "What makes the pain worse?"
D) "Where exactly is the pain located?"
Answer: C
Rationale: Aggravating factors refer to what makes the symptom
worse. Option A assesses onset, Option B assesses quality, and
Option D assesses location.
During an interview, a patient states, "I just can't seem to stop
drinking, but my wife is making me." Which defense mechanism is
the patient displaying?
A) Denial
B) Projection
C) Rationalization
D) Minimization
Answer: C
Rationale: Rationalization is creating false but logical excuses to
justify unacceptable behavior or feelings. The patient is blaming his
wife for his drinking rather than taking responsibility.
,The nurse is assessing a patient's mental status. Which assessment
finding requires immediate intervention?
A) The patient is oriented to person but not place or time.
B) The patient has constricted pupils and responds slowly to verbal
stimuli.
C) The patient is anxious and fidgeting during the interview.
D) The patient has a Glasgow Coma Scale score of 15.
Answer: B
Rationale: Constricted pupils and slow response to verbal stimuli
indicate a potentially severe neurological or opioid toxicity issue
requiring immediate intervention. Option A indicates confusion but
is not immediately life-threatening. Option C is anxiety. Option D is
a perfect GCS score.
When assessing a patient's nutritional status, which of the following
is the best indicator of long-term protein status?
A) Prealbumin
B) Transferrin
C) Albumin
D) Total lymphocyte count
Answer: C
Rationale: Albumin has a half-life of 18 to 20 days, making it a good
indicator of long-term protein status. Prealbumin has a half-life of 2
days and reflects short-term status.
A nurse is assessing a patient's skin turgor. The nurse grasps the
skin over the clavicle, pulls it up, and releases it. The skin remains
tented. This finding indicates:
A) Normal elasticity.
B) Severe dehydration.
C) Aging changes.
D) Overhydration.
, Answer: B
Rationale: Tenting (skin remaining in a pinched state) indicates
decreased skin turgor, which is a classic sign of dehydration or
severe fluid volume deficit.
While assessing the skin of an older adult, the nurse notes multiple
dark, raised, warty-looking lesions on the trunk that feel stuck on.
The nurse recognizes these as:
A) Actinic keratosis.
B) Squamous cell carcinoma.
C) Seborrheic keratosis.
D) Basal cell carcinoma.
Answer: C
Rationale: Seborrheic keratosis presents as raised, warty, pigmented
lesions that look "stuck on" and are common in older adults. Actinic
keratosis is premalignant and usually scaly.
The nurse is assessing a patient's wound and notes a shallow, moist
ulcer with a red-pink wound bed without slough. This would be
classified as a Stage:
A) I
B) II
C) III
D) IV
Answer: B
Rationale: A Stage II pressure injury involves partial-thickness loss of
the dermis, presenting as a shallow, open ulcer with a red-pink
wound bed, without slough.
