BSN 246 HESI HEALTH ASSESSMENT EXAM VERSION
QUESTIONS AND ANSWERS GRADED A+/ HESI HEALTH
ASSESSMENT EXAM/ BSN 246 EXAM
The registered nurse (RN) reviews the new prescription, phenelzine (Nardil), a monoamine
oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is
most important for the RN to assess?
A. Consumption of any alcohol or tyramine-rich foods.
B. Complaints of nausea or vomiting.
C. Therapeutic serum drug levels.
D. Blood pressure and pulse prior to taking each dose. - ANSWER-A. Consumption of any
alcohol or tyramine-rich foods.
Rationale
The consumption of any type of tyramine containing foods such as aged cheeses, fermented fruits
and vegetables, smoked or cured meats, dark wines and other alcoholic products should be
avoided when a client is prescribed a MAOIs due to the a food-drug interaction causing a
hypertensive crisis which can lead to a hemorrhagic stroke.
The registered nurse (RN) is evaluating a client who presents with symptoms of viral
gastroenteritis. Which assessment finding should the RN report to the healthcare provider?
A. Dry mucous membranes and lips.
B. Rebound abdominal tenderness over right lower quadrant.
C. Dizziness when client ambulates from a sitting position.
D. Poor skin turgor over client's wrist. - ANSWER-B. Rebound abdominal tenderness over
right lower quadrant.
Rationale
RLQ rebound abdominal tenderness may be related to acute appendicitis and should be reported
to the healthcare provider.
,The registered nurse (RN) is caring for an Asian client who refuses to make eye contact
during conversations. How should the RN assess this client's response?
A. The client cannot understand the nurse.
B. The client is uncomfortable with the nurse.
C. The client is treating the nurse with respect.
D. The client is purposefully disrespecting the nurse. - ANSWER-C. The client is treating the
nurse with respect.
Rationale
In some Asian cultures, it is not appropriate to look a person of authority in the eye, so the client
is being respectful by looking down while speaking with the nurse.
The registered nurse (RN) is caring for a client with acute pancreatitis and assesses the
admission laboratory results. What laboratory value should the RN anticipate being elevated
with this diagnosis?
A. Triglycerides.
B. Amylase.
C. Creatinine.
D. Uric acid. - ANSWER-B. Amylase.
Rationale
An elevated amylase level is associated with acute pancreatitis.
The registered nurse (RN) is assessing a male client who arrives at the clinic with severe abdominal
cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose
stools with rectal bleeding. Which condition should the RN ask the client about his medical history?
A. Irritable bowel syndrome.
B. Diverticulitis.
C. Crohn's disease.
D. Ulcerative colitis. - ANSWER-D. Ulcerative colitis.
Rationale
, The RN should ask the client if he has a history of ulcerative colitis, which is characterized by
severe abdominal cramping, pain, tenesmus, and dehydration .
The registered nurse (RN) is caring for an older client who recently experienced a fractured
pelvis from a fall. Which assessment finding is most important for the RN to report the
healthcare provider?
A. Lower back pain.
B. Headache of 7 on scale 1 to 10.
C. Blood pressure of 140/98.
D. Dyspnea. - ANSWER-D. Dyspnea.
Rationale
A client with a large bone fracture is at risk for intramedullary fat leaking into the blood stream
and becoming embolic. Dyspnea is an indication of fat embolism to the lungs and should be
reported to the healthcare provider immediately.
A female client calls the clinic and talks with the registered nurse (RN) to inquire about a
possible reaction after taking amoxicillin for 5 days. She reports having vaginal discomfort,
itching, and a white discharge. The RN should discuss which action with the client?
A. Discontinue the antibiotic because original symptoms have subsided.
B. Continue taking medication until finished until the symptoms subside.
C. Consult with healthcare provider about another treatment for this effect.
D. Use an over-the-counter (OTC) vaginal wash to flush out the secretions. - ANSWER-C.
Consult with healthcare provider about another treatment for this effect.
Rationale
A superinfection with normal flora yeast may occur during antibiotic therapy. If suspected, the new
onset of findings should be reported to the healthcare provider for another prescribed treatment
to treat the superinfection.
The registered nurse (RN) did not note that a prescription dose was recently changed and did not
note the updated medication administration record (MAR). After giving the client the original
dose, the RN reports the medication error to the nurse manager. What consequences will the RN
experience due to this error in medication administration?
A. The incident will be reported to the state's Board of Nursing (BON).
QUESTIONS AND ANSWERS GRADED A+/ HESI HEALTH
ASSESSMENT EXAM/ BSN 246 EXAM
The registered nurse (RN) reviews the new prescription, phenelzine (Nardil), a monoamine
oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is
most important for the RN to assess?
A. Consumption of any alcohol or tyramine-rich foods.
B. Complaints of nausea or vomiting.
C. Therapeutic serum drug levels.
D. Blood pressure and pulse prior to taking each dose. - ANSWER-A. Consumption of any
alcohol or tyramine-rich foods.
Rationale
The consumption of any type of tyramine containing foods such as aged cheeses, fermented fruits
and vegetables, smoked or cured meats, dark wines and other alcoholic products should be
avoided when a client is prescribed a MAOIs due to the a food-drug interaction causing a
hypertensive crisis which can lead to a hemorrhagic stroke.
The registered nurse (RN) is evaluating a client who presents with symptoms of viral
gastroenteritis. Which assessment finding should the RN report to the healthcare provider?
A. Dry mucous membranes and lips.
B. Rebound abdominal tenderness over right lower quadrant.
C. Dizziness when client ambulates from a sitting position.
D. Poor skin turgor over client's wrist. - ANSWER-B. Rebound abdominal tenderness over
right lower quadrant.
Rationale
RLQ rebound abdominal tenderness may be related to acute appendicitis and should be reported
to the healthcare provider.
,The registered nurse (RN) is caring for an Asian client who refuses to make eye contact
during conversations. How should the RN assess this client's response?
A. The client cannot understand the nurse.
B. The client is uncomfortable with the nurse.
C. The client is treating the nurse with respect.
D. The client is purposefully disrespecting the nurse. - ANSWER-C. The client is treating the
nurse with respect.
Rationale
In some Asian cultures, it is not appropriate to look a person of authority in the eye, so the client
is being respectful by looking down while speaking with the nurse.
The registered nurse (RN) is caring for a client with acute pancreatitis and assesses the
admission laboratory results. What laboratory value should the RN anticipate being elevated
with this diagnosis?
A. Triglycerides.
B. Amylase.
C. Creatinine.
D. Uric acid. - ANSWER-B. Amylase.
Rationale
An elevated amylase level is associated with acute pancreatitis.
The registered nurse (RN) is assessing a male client who arrives at the clinic with severe abdominal
cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose
stools with rectal bleeding. Which condition should the RN ask the client about his medical history?
A. Irritable bowel syndrome.
B. Diverticulitis.
C. Crohn's disease.
D. Ulcerative colitis. - ANSWER-D. Ulcerative colitis.
Rationale
, The RN should ask the client if he has a history of ulcerative colitis, which is characterized by
severe abdominal cramping, pain, tenesmus, and dehydration .
The registered nurse (RN) is caring for an older client who recently experienced a fractured
pelvis from a fall. Which assessment finding is most important for the RN to report the
healthcare provider?
A. Lower back pain.
B. Headache of 7 on scale 1 to 10.
C. Blood pressure of 140/98.
D. Dyspnea. - ANSWER-D. Dyspnea.
Rationale
A client with a large bone fracture is at risk for intramedullary fat leaking into the blood stream
and becoming embolic. Dyspnea is an indication of fat embolism to the lungs and should be
reported to the healthcare provider immediately.
A female client calls the clinic and talks with the registered nurse (RN) to inquire about a
possible reaction after taking amoxicillin for 5 days. She reports having vaginal discomfort,
itching, and a white discharge. The RN should discuss which action with the client?
A. Discontinue the antibiotic because original symptoms have subsided.
B. Continue taking medication until finished until the symptoms subside.
C. Consult with healthcare provider about another treatment for this effect.
D. Use an over-the-counter (OTC) vaginal wash to flush out the secretions. - ANSWER-C.
Consult with healthcare provider about another treatment for this effect.
Rationale
A superinfection with normal flora yeast may occur during antibiotic therapy. If suspected, the new
onset of findings should be reported to the healthcare provider for another prescribed treatment
to treat the superinfection.
The registered nurse (RN) did not note that a prescription dose was recently changed and did not
note the updated medication administration record (MAR). After giving the client the original
dose, the RN reports the medication error to the nurse manager. What consequences will the RN
experience due to this error in medication administration?
A. The incident will be reported to the state's Board of Nursing (BON).
