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BSN 246 HESI HEALTH ASSESSMENT V1/ACTUAL EXAM -
NIGHTINGALE COLLEGE EXAM QUESTIONS
Actual Qs and Ans - Expert-Verified Explanation -Guaranteed passing score -100 Questions and Answers
-Format: Multiple-choice / Flashcard
Question 1: Which term should the nurse use to document in the client's medical record for a high-pitched scratchy sound during auscultation of the heart?
Answer:
Friction rub Question 2: How should the nurse assess for lower extremity edema in a client who has been diagnosed with heart failure?
Answer:
Measure bilateral ankle circumference with a non-stretchable tape measure.Question 3: The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation?(Select all that apply.)
Answer:
Diminished hair on legs.Skin cool to touch.
Question 4: asthma treated with Beta 2 receptor expected response
Answer:
rapid resolution of wheezing improved pulse ox
Question 5: The nurse is assessing a client for a hip flexion contracture. Which finding indicates a negative Thomas test when the client's right knee is brought toward the chest?
Answer:
The left leg remains on the table *The Thomas test is performed by having the client bring one knee toward the chest while the other leg remains extended on the table. A positive Thomas test is elicited when the extended leg rises off the table when the opposite leg's knee is brought up to the client's chest, indicating hip flexor contracture. If the extended leg (the left leg, in this example) remains on the table, the test is negative.Question 6: 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?
Answer:
Upper outer quadrant.Question 7: Which tool should the nurse use when assessing the neurological status of a client with traumatic brain injury?
Answer:
Glasgow Coma Scale.Question 8: The nurse is assessing a healthy young adult during an annual physical examination. Which assessment technique should the nurse implement when palpating the abdominal aorta?
Answer:
Deep palpation above and to the left of the umbilicus.Question 9: When assessing facial nerve function of a 96-year-old, the nurse asks the client to smile in an exaggerated manner. Which finding is most important for the nurse to further asses?
Answer:
Only one side of the mouth moves when smiling.Question 10: During the initial assessment, the nurse notes that a client has blurred vision with cloudy lenses. Which condition should the nurse document?
Answer:
Cataracts.
Question 11: The nurse is completing a physical assessment of a client who feel from a tree.The client's abdomen is soft with hyperactive bowel sounds in all four quadrants. Which assessment technique should the nurse implement when evaluating the client's spleen?
Answer:
Percuss the splenic area as the client takes a deep breath.Question 12: A client reports feeling increasingly fatigued for several months, and the nurse observes that the client's lips are pale. Which additional data should the nurse collect based on this presentation?
Answer:
Use of vitamin and iron supplements.
Question 13: Common complications of immobility include
Answer:
- stiff joints (early warning of contractures and atrophy)
- osteoporosis, decreased flexibility
- DVT, PE
- orthostatic hypotension
- atelectasis and pneumonia
- retention, UTIs, kidney stones
- pressure ulcers
- depression, anxiety, cognitive decline
Question 14: Which respiratory condition should the nurse document after measuring a respiratory rate of 8 breaths/minute?
Answer:
Bradypnea.Question 15: The nurse is assessing a client's middle lung lobe. What is the best location for the nurse to place a stethoscope diaphragm to hear normal lung sounds in this lobe?
Answer:
4th intercostal space, right midclavicular line.Question 16: A client reports lower abdominal pain and a feeling of pressure in the bladder.Which assessment finding indicates acute urinary retention?
Answer:
Dull sound percussed over bladder.*Clients with acute urinary retention may present with lower abdominal pain and bladder distension.Percussion (tapping on the body wall) is performed to detect differences in pitch. A dull sound produced
when percussing a distended urinary bladder is an indication of urinary retention.
Question 17: Which procedure should the nurse use to assessfor a pulse deficit?
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 18: Which information should the nurse obtain to identify the client's self-perception of health status?
Answer:
Health history Question 19: The nurse is conducting a family history as part of the assessment interview.Which action should the nurse take to ensure that sufficient information about the client's blood relatives is obtained?
Answer:
Document at least 3 generations of the client's family medical history.Question 20: Which condition is indicated by a fluorescent, yellow-green color when the nurse uses a Wood's lamp toexamine a client's skin lesions?
Answer:
Fungal infection.Question 21: The nurse is assessing a client who reports having shoulder pain. Which sign is the best indicator of a rotator cuff tear?
Answer:
Inability to slowly lower the arm when abducted.Question 22: 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?
Answer:
Dull, thud-like.
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