BSN 246 HESI Health Assessment V1 Exam |
Complete Questions & Answers with Rationales |
Verified Questions & Answers | Nightingale
College Health Assessment Exam Prep | Latest
2026/2027 Update | Graded A+
Question 1
A nurse is performing a general survey on a client. Which of the following
findings should the nurse document as a sign of potential distress?
A) Client maintains eye contact during the interview.
B) Client's speech is clear and moderate in pace.
C) Client is sitting upright and leaning forward with arms braced.
D) Client's body temperature is 37°C (98.6°F).
Answer: C) Client is sitting upright and leaning forward with arms
braced.
Explanation: The tripod position (leaning forward with arms braced)
is a classic sign of respiratory distress (e.g., COPD or asthma
exacerbation). It helps maximize lung expansion. Options A, B, and D
are normal findings.
,Question 2
When assessing the cranial nerves, the nurse asks the client to stick out
their tongue and move it from side to side. Which cranial nerve is being
tested?
A) Cranial Nerve V (Trigeminal)
B) Cranial Nerve VII (Facial)
C) Cranial Nerve X (Vagus)
D) Cranial Nerve XII (Hypoglossal)
Answer: D) Cranial Nerve XII (Hypoglossal)
Explanation: The Hypoglossal nerve (CN XII) controls tongue
movement. CN V is for facial sensation and chewing. CN VII is for
facial expressions and taste. CN X is for swallowing and gag reflex.
Question 3
A nurse is assessing the skin of an older adult client. Which of the
following findings should the nurse report as abnormal?
A) Decreased skin turgor.
B) Senile purpura on the forearms.
C) A new, irregularly shaped, multicolored mole.
D) Dry, flaky skin on the lower legs.
Answer: C) A new, irregularly shaped, multicolored mole.
Explanation: While decreased turgor, purpura, and dry skin are
common age-related changes, a new mole with irregular borders
,and varied colors is a warning sign for melanoma (ABCDE rule) and
must be reported.
Question 4
During an abdominal assessment, the nurse is unable to hear bowel
sounds in the right lower quadrant (RLQ). What is the nurse's priority
action?
A) Document the finding as absent bowel sounds.
B) Palpate the RLQ to check for a mass.
C) Auscultate the other three quadrants for 5 full minutes.
D) Notify the provider immediately for a possible bowel obstruction.
Answer: C) Auscultate the other three quadrants for 5 full minutes.
Explanation: Bowel sounds are irregular. It is standard practice to
listen for 5 minutes in one spot before documenting "absent" bowel
sounds. The nurse must check other quadrants to see if sounds are
present elsewhere before escalating.
Question 5
A client presents with a "mask-like" face, shuffling gait, and a pill-rolling
tremor. The nurse recognizes these findings as characteristic of:
A) Multiple Sclerosis.
B) Parkinson's Disease.
, C) Myasthenia Gravis.
D) Bell's Palsy.
Answer: B) Parkinson's Disease.
Explanation: The classic triad of Parkinson's includes tremor (pill-
rolling), rigidity (mask-like face), and bradykinesia (shuffling gait).
Multiple Sclerosis presents with visual disturbances and sensory
changes.
Question 6
The nurse is assessing a client's visual acuity using the Snellen chart. The
client reads the 20/40 line. How should the nurse interpret this result?
A) The client has normal vision.
B) The client can read at 20 feet what a person with normal vision can
read at 40 feet.
C) The client can read at 40 feet what a person with normal vision can
read at 20 feet.
D) The client is legally blind.
Answer: B) The client can read at 20 feet what a person with normal
vision can read at 40 feet.
Explanation: The numerator is the distance the client is standing
from the chart (20 ft). The denominator is the distance a person
with normal vision can read the same line. 20/40 means the client's
vision is worse than normal.
Complete Questions & Answers with Rationales |
Verified Questions & Answers | Nightingale
College Health Assessment Exam Prep | Latest
2026/2027 Update | Graded A+
Question 1
A nurse is performing a general survey on a client. Which of the following
findings should the nurse document as a sign of potential distress?
A) Client maintains eye contact during the interview.
B) Client's speech is clear and moderate in pace.
C) Client is sitting upright and leaning forward with arms braced.
D) Client's body temperature is 37°C (98.6°F).
Answer: C) Client is sitting upright and leaning forward with arms
braced.
Explanation: The tripod position (leaning forward with arms braced)
is a classic sign of respiratory distress (e.g., COPD or asthma
exacerbation). It helps maximize lung expansion. Options A, B, and D
are normal findings.
,Question 2
When assessing the cranial nerves, the nurse asks the client to stick out
their tongue and move it from side to side. Which cranial nerve is being
tested?
A) Cranial Nerve V (Trigeminal)
B) Cranial Nerve VII (Facial)
C) Cranial Nerve X (Vagus)
D) Cranial Nerve XII (Hypoglossal)
Answer: D) Cranial Nerve XII (Hypoglossal)
Explanation: The Hypoglossal nerve (CN XII) controls tongue
movement. CN V is for facial sensation and chewing. CN VII is for
facial expressions and taste. CN X is for swallowing and gag reflex.
Question 3
A nurse is assessing the skin of an older adult client. Which of the
following findings should the nurse report as abnormal?
A) Decreased skin turgor.
B) Senile purpura on the forearms.
C) A new, irregularly shaped, multicolored mole.
D) Dry, flaky skin on the lower legs.
Answer: C) A new, irregularly shaped, multicolored mole.
Explanation: While decreased turgor, purpura, and dry skin are
common age-related changes, a new mole with irregular borders
,and varied colors is a warning sign for melanoma (ABCDE rule) and
must be reported.
Question 4
During an abdominal assessment, the nurse is unable to hear bowel
sounds in the right lower quadrant (RLQ). What is the nurse's priority
action?
A) Document the finding as absent bowel sounds.
B) Palpate the RLQ to check for a mass.
C) Auscultate the other three quadrants for 5 full minutes.
D) Notify the provider immediately for a possible bowel obstruction.
Answer: C) Auscultate the other three quadrants for 5 full minutes.
Explanation: Bowel sounds are irregular. It is standard practice to
listen for 5 minutes in one spot before documenting "absent" bowel
sounds. The nurse must check other quadrants to see if sounds are
present elsewhere before escalating.
Question 5
A client presents with a "mask-like" face, shuffling gait, and a pill-rolling
tremor. The nurse recognizes these findings as characteristic of:
A) Multiple Sclerosis.
B) Parkinson's Disease.
, C) Myasthenia Gravis.
D) Bell's Palsy.
Answer: B) Parkinson's Disease.
Explanation: The classic triad of Parkinson's includes tremor (pill-
rolling), rigidity (mask-like face), and bradykinesia (shuffling gait).
Multiple Sclerosis presents with visual disturbances and sensory
changes.
Question 6
The nurse is assessing a client's visual acuity using the Snellen chart. The
client reads the 20/40 line. How should the nurse interpret this result?
A) The client has normal vision.
B) The client can read at 20 feet what a person with normal vision can
read at 40 feet.
C) The client can read at 40 feet what a person with normal vision can
read at 20 feet.
D) The client is legally blind.
Answer: B) The client can read at 20 feet what a person with normal
vision can read at 40 feet.
Explanation: The numerator is the distance the client is standing
from the chart (20 ft). The denominator is the distance a person
with normal vision can read the same line. 20/40 means the client's
vision is worse than normal.
