BSN 246 HESI Health Assessment V1/ACTUAL EXAM –
NIGHTINGALE COLLEGE WITH COMPLETE SOLUTION
RATED A+ NEW EDITION
The nurse is performing a thoracic assessment on a client with chronic asthma and
hyperinfla on of the lungs. Which finding should be expected for this client? - Ans Barrel chest
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel
sounds in the right upper quadrant. What ac on should the nurse take next? - Ans Note the
character and frequency of bowel sounds
During inspec on of a client's mouth and pharynx, the nurse places a tongue blade on the back
of the tongue which causes the client to gag. A(er removing the tongue blade, what ac on
should the nurse take? - Ans Document an intact gag reflex.
When teaching a client how to perform a monthly breast self-assessment, the nurse should tell
the client that it is most important to assess which part of the breast more closely for changes?
- Ans Upper outer quadrant.
The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a chest
measurement of 42 inches, waist measurement of 45 inches, and hip measurement of 50
inches. What important message should the nurse explain to the client to promote health
promo on? - Ans A waist circumference is greater than 35 inches in women puts you at higher
risk for type 2 diabetes and heart disease."
The nurse performs a physical assessment on an older female client. Which change from the
prior exam may be an indica on of osteoporosis? - Ans Height reduc on of 1.5 inches.
While conduc ng an interview to obtain a health history, the nurse no ces that the client
pauses frequently and looks at the nurse expectantly. Which response is best for the nurse to
provide? - Ans Sit quietly to allow the client to respond comfortably.
,A client is in the clinical for a yearly physical examina on. Which ac on should the nurse take
when preparing to examine the client's abdomen? - Ans Ask the client to urinate before
beginning the examina on.
Which respiratory condi on should the nurse document a(er measuring a respiratory rate of 8
breaths/minute? - Ans Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit? - Ans Measure the apical
pulse and compare it to the peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point of maximal
impulse and the radial pulse palpated at the wrist.
A client has been diagnosed with bilateral lower lobe atelectasis. What percussion sound
should the nurse expect to hear when percussing over the client's lower lobes? - Ans Dull, thud-
like.
A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing to
complete a head-to-toe assessment and will begin at the head of the client. Which technique
should the nurse use to begin the assessment? - Ans Inspect the hair and skin.
The nurse is assessing a healthy young adult during an annual physical examina on. Which
assessment technique should the nurse implement when palpa ng the abdominal aorta? - Ans
Deep palpa on above and to the le( of the umbilicus.
The nurse is conduc ng a family history as part of the assessment interview. Which ac on
should the nurse take to ensure that sufficient informa on about the client's blood rela ves is
obtained? - Ans Document at least 3 genera ons of the client's family medical history.
, The nurse is tes ng the client's shoulders for range of mo on. What should the nurse
document to record normal internal rota on? - Ans Range of 90 degrees when the hands are
placed at the small of the back.
A client presents with a rash along the occipital area of the hairline and reports intense itching.
How should the nurse begin the objec ve part of the examina on? - Ans Inspect the scalp
looking for nits.
The nurse is assessing a client's range of mo on as the client bends the right knee up to the
chest while keeping the le( leg straight, but is unable to keep the le( thigh on the table. The
assessment is repeated for the le( knee, and the client is unable to keep the right thigh on the
table. How should the nurse document this finding? - Ans A flexion deformity referred to as a
posi ve Thomas test.
During a skin asssessment, the nurse notes, round and discrete lesions that are dark red in
color and will not blanch. The lesions range from 1 to 3 mm in size. What is the first ques on
the nurse should ask the client? - Ans Have you no ce any irregular bleeding
A client with progressive hearing loss appears distressed when the registered nurse (RN) asks
open-ended ques ons about the client's health history. Which forms of communica on should
the RN use? - Ans Face the client so the client can see the RN's mouth.
Check if the client's hearing aides are working properly.
Reduce environmental noise surrounding the client.
A client states that she had a mastectomy of her le( breast last year and now experiences
lymphedema. What should the nurse expect to find when examining the client? - Ans Swelling
of the le( arm and non-piBng edema.
A client has just returned from the recovery room and asks to get out of bed to go to the
bathroom. The nurse decides to obtain orthosta c vital signs first. How will the nurse posi on
the client to begin this procedure? - Ans Lying.
NIGHTINGALE COLLEGE WITH COMPLETE SOLUTION
RATED A+ NEW EDITION
The nurse is performing a thoracic assessment on a client with chronic asthma and
hyperinfla on of the lungs. Which finding should be expected for this client? - Ans Barrel chest
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel
sounds in the right upper quadrant. What ac on should the nurse take next? - Ans Note the
character and frequency of bowel sounds
During inspec on of a client's mouth and pharynx, the nurse places a tongue blade on the back
of the tongue which causes the client to gag. A(er removing the tongue blade, what ac on
should the nurse take? - Ans Document an intact gag reflex.
When teaching a client how to perform a monthly breast self-assessment, the nurse should tell
the client that it is most important to assess which part of the breast more closely for changes?
- Ans Upper outer quadrant.
The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a chest
measurement of 42 inches, waist measurement of 45 inches, and hip measurement of 50
inches. What important message should the nurse explain to the client to promote health
promo on? - Ans A waist circumference is greater than 35 inches in women puts you at higher
risk for type 2 diabetes and heart disease."
The nurse performs a physical assessment on an older female client. Which change from the
prior exam may be an indica on of osteoporosis? - Ans Height reduc on of 1.5 inches.
While conduc ng an interview to obtain a health history, the nurse no ces that the client
pauses frequently and looks at the nurse expectantly. Which response is best for the nurse to
provide? - Ans Sit quietly to allow the client to respond comfortably.
,A client is in the clinical for a yearly physical examina on. Which ac on should the nurse take
when preparing to examine the client's abdomen? - Ans Ask the client to urinate before
beginning the examina on.
Which respiratory condi on should the nurse document a(er measuring a respiratory rate of 8
breaths/minute? - Ans Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit? - Ans Measure the apical
pulse and compare it to the peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point of maximal
impulse and the radial pulse palpated at the wrist.
A client has been diagnosed with bilateral lower lobe atelectasis. What percussion sound
should the nurse expect to hear when percussing over the client's lower lobes? - Ans Dull, thud-
like.
A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing to
complete a head-to-toe assessment and will begin at the head of the client. Which technique
should the nurse use to begin the assessment? - Ans Inspect the hair and skin.
The nurse is assessing a healthy young adult during an annual physical examina on. Which
assessment technique should the nurse implement when palpa ng the abdominal aorta? - Ans
Deep palpa on above and to the le( of the umbilicus.
The nurse is conduc ng a family history as part of the assessment interview. Which ac on
should the nurse take to ensure that sufficient informa on about the client's blood rela ves is
obtained? - Ans Document at least 3 genera ons of the client's family medical history.
, The nurse is tes ng the client's shoulders for range of mo on. What should the nurse
document to record normal internal rota on? - Ans Range of 90 degrees when the hands are
placed at the small of the back.
A client presents with a rash along the occipital area of the hairline and reports intense itching.
How should the nurse begin the objec ve part of the examina on? - Ans Inspect the scalp
looking for nits.
The nurse is assessing a client's range of mo on as the client bends the right knee up to the
chest while keeping the le( leg straight, but is unable to keep the le( thigh on the table. The
assessment is repeated for the le( knee, and the client is unable to keep the right thigh on the
table. How should the nurse document this finding? - Ans A flexion deformity referred to as a
posi ve Thomas test.
During a skin asssessment, the nurse notes, round and discrete lesions that are dark red in
color and will not blanch. The lesions range from 1 to 3 mm in size. What is the first ques on
the nurse should ask the client? - Ans Have you no ce any irregular bleeding
A client with progressive hearing loss appears distressed when the registered nurse (RN) asks
open-ended ques ons about the client's health history. Which forms of communica on should
the RN use? - Ans Face the client so the client can see the RN's mouth.
Check if the client's hearing aides are working properly.
Reduce environmental noise surrounding the client.
A client states that she had a mastectomy of her le( breast last year and now experiences
lymphedema. What should the nurse expect to find when examining the client? - Ans Swelling
of the le( arm and non-piBng edema.
A client has just returned from the recovery room and asks to get out of bed to go to the
bathroom. The nurse decides to obtain orthosta c vital signs first. How will the nurse posi on
the client to begin this procedure? - Ans Lying.
