BSN 246 HESI HEALTH ASSESSMENT
V1: EXAM, WITH
CORRECT/ACCURATE ANSWERS
Question : The nurse is performing a thoracic assessment on a
client with chronic asthma and hyperinflation of the lungs.Which finding should be expected for this client?
CORRECT ANSWER: Barrel chest
Question : The nurse is assessing bowel sounds for a
hospitalized client. The nurse has heard bowel sounds in the right upper quadrant. What action should the nurse take next?
CORRECT ANSWER : Note the character and frequency of
bowel sounds
Question : During inspection 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. After removing the tongue blade, what action should the nurse take?
CORRECT ANSWER : Document an intact gag reflex.
Question : 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?
CORRECT ANSWER : Upper outer quadrant.
Question : 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 promotion?
CORRECT ANSWER : A waist circumference is greater
than 35 inches in women puts you at higher risk for type 2 diabetes and heart disease."
Question : The nurse performs a physical assessment on an
older female client. Which change from the prior exam may be an indication of osteoporosis?
CORRECT ANSWER : Height reduction of 1.5 inches.
Question : While conducting an interview to obtain a health
history, the nurse notices that the client pauses frequently and looks at the nurse expectantly. Which response is best for the nurse to provide?
CORRECT ANSWER : Sit quietly to allow the client to
respond comfortably.
Question : A client is in the clinical for a yearly physical
examination. Which action should the nurse take when preparing to examine the client's abdomen?
CORRECT ANSWER : Ask the client to urinate before
beginning the examination.
Question : Which respiratory condition should the nurse
document after measuring a respiratory rate of 8 breaths/minute?
CORRECT ANSWER : Bradypnea.
Question : Which procedure should the nurse use to assessfor
a pulse deficit?
CORRECT ANSWER : 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.
Question : 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?
CORRECT ANSWER : Dull, thud-like.
Question : 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?
CORRECT ANSWER : Inspect the hair and skin.
Question : The nurse is assessing a healthy young adult
during an annual physical examination. Which assessment