BSN 246
BSN 246 HESI Health Assessment Exam (Latest
Update) 138 Questions and Verified Answers |100% Correct|
Grade A- Nightingale
Successmaestro Stuvia
This Document Contains:
BSN 246 HESI Health Assessment Exam
138 Questions and Verified Answers
BSN 246 HESI Exam
Nightingale College
, 246 HESI HEALTH ASSESSMENT
138 Questions
1. The nurse is obtaining a health history for a client prior to a scheduled
cholecystectomy. While interviewing the client, which assessment technique should the
nurse use when asking about the client's use of illegal drugs and alcohol?
A Allow the client to decline answering social questions.
B Obtain a drug urine screen to verify legitimacy of client's stated history.
C Use the term illegal or illicit to describe street drugs.
D Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts.
2. While auscultating a client's breath sounds, the nurse hears vesicular sounds in the
bases of both lungs posteriorly. Which action should the nurse take in response to this
finding?
A Report the client's abnormal lung sounds to the healthcare provider.
B Continue with the remainder of the client's physical assessment. (vesicular bs is normal)
C Ask the client to cough and then auscultate at the site again.
D Measure the client's oxygen saturation with a pulse oximeter.
3. An adult male client informs the nurse that he came to the clinic to see if, "Maybe I
have lung cancer or something," and wants to get checked out since, "I can't seem to
get rid of this body-wracking dry cough that has been hanging around for the last six
weeks." Which computer documentation of this client's concerns should the nurse
enter?
A An adult male present with fears that he has "lung cancer."
B Describes having a body-wracking dry cough" of 6 weeks duration.
C Expresses concern of "lung cancer" symptoms for last 6 weeks.
D Presents with a hacking non-productive cough of 6 weeks duration.
,4. A client who is admitted for an acute stroke reports the onset of a burning sensation in
the hands and legs. Which action should the nurse implement to identify additional
findings that are consistent with the client's paresthesia?
A Review the client’s serum electrolyte.
B Evaluate client's muscle strength and hand grips.
C Check distal phalanges capillary refill.
D Observe skin for erythema, edema, and warmth.
Paresthesia is an abnormal feeling in the skin that can feel like tingling, burning, pricking, numbness, itching, or pins and
needles
5. During an admission assessment, which approach should the nurse use to assess a
client's speech patterns?
A Listen while the client reads items listed on the menu.
B Ask the client to complete a common proverb or saying.
C Note the client's responses during the initial interview.
D Have the client repeat a phrase containing alliteration.
6. In assessing an adult client, the nurse calculates the body mass index (BMI) as 14
kg/m2. Which nursing problem should be included in this client's plan of care?
Reference Range:
Underweight: BMI is less than 18.5; Normal weight: BMI is 18.5 to 24.9; Overweight: BMI
is 25 to 29.9; Obese: BMI is 30 or more
A Fluid volume excess.
B Unbalanced nutrition, less than body needs.
C Unbalanced nutrition, greater than body needs.
D Fluid volume deficit.
7. To assess a client's pupillary reaction to accommodation, what action should the nurse
take?
A Observe pupil size when focusing on a near object and then a far object.
B Compare the shape of each of the pupils bilaterally with normal room light.
C Note the speed of pupil constriction when a penlight is shined into the eye.
D Determine if dilation of the pupils occurs when the room is darkened.
8. A male client arrives at the clinic for follow-up health assessment after recent antibiotic
treatment for pneumonia without hospitalization. Which technique should the nurse
implement to assess for adventitious lung sounds?
, A Have the client lay flat while listening to the anterior surface of the chest.
B Use the bell of the stethoscope to listen to the lung fields over lower lobes.
C Shave all chest hair that may distort sounds heard through the diaphragm.
D Press the stethoscope's diaphragm firmly on the skin over each lung field.
9. Which is the best approach for the nurse to use when interviewing a client about
alcohol and substance use?
A Get the most difficult questions over with first.
B Ask questions in a vague, non-specific format.
C Share personal values to put the client at ease.
D Begin with questions that are less sensitive in nature.
10. An older adult client with a history of heart failure (HF) is brought to the clinic by a
family member. Which finding(s) confirm to the nurse that the client is experiencing an
exacerbation of the HF? Select all that apply.
A Jugular venous distension.
B Peripheral edema.
C Dyspnea.
D Intercostal retractions.
E Headaches.
11. During the admission assessment, a male client admitted with chest pain states he has
no breathing problems and no trouble sleeping at night. To obtain further data
regarding possible orthopnea, which action should the nurse take?
A Observe for jugular vein distention while the client is flat in bed.
B Measure the client's blood pressure when he is lying and standing.
C Ask the client how many pillows he sleeps on at night.
D Auscultate the client's breath sounds while he is supine.
12. The nurse observes the presence of brittle, concave curves to the nails of a client on
assessment. Which information should the nurse obtain from the client that may
explain the appearance of the nails?
A Coronary heart disease.
B Iron deficiency anemia.
C Diabetes mellitus.
BSN 246 HESI Health Assessment Exam (Latest
Update) 138 Questions and Verified Answers |100% Correct|
Grade A- Nightingale
Successmaestro Stuvia
This Document Contains:
BSN 246 HESI Health Assessment Exam
138 Questions and Verified Answers
BSN 246 HESI Exam
Nightingale College
, 246 HESI HEALTH ASSESSMENT
138 Questions
1. The nurse is obtaining a health history for a client prior to a scheduled
cholecystectomy. While interviewing the client, which assessment technique should the
nurse use when asking about the client's use of illegal drugs and alcohol?
A Allow the client to decline answering social questions.
B Obtain a drug urine screen to verify legitimacy of client's stated history.
C Use the term illegal or illicit to describe street drugs.
D Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts.
2. While auscultating a client's breath sounds, the nurse hears vesicular sounds in the
bases of both lungs posteriorly. Which action should the nurse take in response to this
finding?
A Report the client's abnormal lung sounds to the healthcare provider.
B Continue with the remainder of the client's physical assessment. (vesicular bs is normal)
C Ask the client to cough and then auscultate at the site again.
D Measure the client's oxygen saturation with a pulse oximeter.
3. An adult male client informs the nurse that he came to the clinic to see if, "Maybe I
have lung cancer or something," and wants to get checked out since, "I can't seem to
get rid of this body-wracking dry cough that has been hanging around for the last six
weeks." Which computer documentation of this client's concerns should the nurse
enter?
A An adult male present with fears that he has "lung cancer."
B Describes having a body-wracking dry cough" of 6 weeks duration.
C Expresses concern of "lung cancer" symptoms for last 6 weeks.
D Presents with a hacking non-productive cough of 6 weeks duration.
,4. A client who is admitted for an acute stroke reports the onset of a burning sensation in
the hands and legs. Which action should the nurse implement to identify additional
findings that are consistent with the client's paresthesia?
A Review the client’s serum electrolyte.
B Evaluate client's muscle strength and hand grips.
C Check distal phalanges capillary refill.
D Observe skin for erythema, edema, and warmth.
Paresthesia is an abnormal feeling in the skin that can feel like tingling, burning, pricking, numbness, itching, or pins and
needles
5. During an admission assessment, which approach should the nurse use to assess a
client's speech patterns?
A Listen while the client reads items listed on the menu.
B Ask the client to complete a common proverb or saying.
C Note the client's responses during the initial interview.
D Have the client repeat a phrase containing alliteration.
6. In assessing an adult client, the nurse calculates the body mass index (BMI) as 14
kg/m2. Which nursing problem should be included in this client's plan of care?
Reference Range:
Underweight: BMI is less than 18.5; Normal weight: BMI is 18.5 to 24.9; Overweight: BMI
is 25 to 29.9; Obese: BMI is 30 or more
A Fluid volume excess.
B Unbalanced nutrition, less than body needs.
C Unbalanced nutrition, greater than body needs.
D Fluid volume deficit.
7. To assess a client's pupillary reaction to accommodation, what action should the nurse
take?
A Observe pupil size when focusing on a near object and then a far object.
B Compare the shape of each of the pupils bilaterally with normal room light.
C Note the speed of pupil constriction when a penlight is shined into the eye.
D Determine if dilation of the pupils occurs when the room is darkened.
8. A male client arrives at the clinic for follow-up health assessment after recent antibiotic
treatment for pneumonia without hospitalization. Which technique should the nurse
implement to assess for adventitious lung sounds?
, A Have the client lay flat while listening to the anterior surface of the chest.
B Use the bell of the stethoscope to listen to the lung fields over lower lobes.
C Shave all chest hair that may distort sounds heard through the diaphragm.
D Press the stethoscope's diaphragm firmly on the skin over each lung field.
9. Which is the best approach for the nurse to use when interviewing a client about
alcohol and substance use?
A Get the most difficult questions over with first.
B Ask questions in a vague, non-specific format.
C Share personal values to put the client at ease.
D Begin with questions that are less sensitive in nature.
10. An older adult client with a history of heart failure (HF) is brought to the clinic by a
family member. Which finding(s) confirm to the nurse that the client is experiencing an
exacerbation of the HF? Select all that apply.
A Jugular venous distension.
B Peripheral edema.
C Dyspnea.
D Intercostal retractions.
E Headaches.
11. During the admission assessment, a male client admitted with chest pain states he has
no breathing problems and no trouble sleeping at night. To obtain further data
regarding possible orthopnea, which action should the nurse take?
A Observe for jugular vein distention while the client is flat in bed.
B Measure the client's blood pressure when he is lying and standing.
C Ask the client how many pillows he sleeps on at night.
D Auscultate the client's breath sounds while he is supine.
12. The nurse observes the presence of brittle, concave curves to the nails of a client on
assessment. Which information should the nurse obtain from the client that may
explain the appearance of the nails?
A Coronary heart disease.
B Iron deficiency anemia.
C Diabetes mellitus.
