HESI HEALTH ASSESSMENT AND PHYSICAL EXAMINATION
LATEST VERSION UPDATED AND REVISED IN 2025-2026
The nurse applies pressure over an area of the lower abdomen where the client
reports pain. The client denies pain upon palpation, but reports pain when the
pressure is released. What action should the nurse implement? A. Offer to
administer a laxative prescribed for PRN use.
B. Obtain a prescription to catheterize the client's bladder.
C. Instruct the client in distraction and relation techniques.
D. Notify the healthcare provider of the rebound tenderness.
(- Correct answer is D. As this could be a sign of appendicitis.
The nurse is assessing an ulcer on a client's lower extremity, which is likely the
result of either venous or arterial insufficiency. Which assessment technique
,should the nurse use to differentiate the pathophysiology causing the ulcer? A.
Measure the degree of join range of motion in the extremity.
B. Compare the skin turgor of the client's upper and lower leg.
C. Observe the specific location and appearance of the ulceration.
D. Note any change in the color of the ulcer when the leg is moved
(- Correct answer is C. Location and appearance of the ulcer would give us the type
(venous vs arterial)
The nurse is conducting a physical assessment of a young adult. Which
information provides the best indication of the individual's nutritional status? A.
Status of current appetite.
B. A 24-hour diet history.
C. History of a recent weight loss.
D. Condition of hair, nails, and skin.
(- Correct answer is D. Hair, nail, and skin are the most important reflection of
nutritional status.
The nurse is assessing a healthy adult male during an annual physical examination.
The nurse auscultates the client's abdomen and hears gurgling sound every ten
seconds. What action should the nurse take in response to this finding? A.
Document this normal bowel sound activity in the record.
B. Encourage increased consumption of fiber in the diet.
C. Observe the next bowel movement for signs of bleeding.
D. Report the hyperactivity to the healthcare provider.
(- Correct answer is A. Normal Bowel sound consist of clicks and gurgles and 5-30
per minute. An occasional borborygmus (Loud prolonged gurgle) may be hear.
, In observing a client's face, which assessment finding requires the most immediate
intervention by the nurse?
A. Eyelids are matted and crusted.
B. Cornea are jaundiced.
C. Oral mucosa is cyanotic.
D. Face is flushed and diaphoretic.
(- Answer is C. Blue lips occur when the skin on the lips takes on a bluish tint or
color. This generally is due to either a lock of oxygen in the blood or to extremely
cold temperatures. When the skin becomes a bluish color, the symptom is called
cyanosis. Most commonly, blue lips are caused by a lack of oxygen in the blood.
Most causes of cyanosis are serious and symptom of your body not getting enough
oxygen. Over time, this condition will become life-threatening. It can lead to
respiratory failure, heart failure, and even death, if left untreated.
While obtaining a health history, a male client tells the nurse that he sometimes
experiences shortness of breath. The nurse determines that the client's respirators
are regular and deep, and his respiratory rate is 14 breaths/minutes. What is the
best nursing action?
A. Ask the client to perform light exercise and observe the respiratory effect.
B. Document "dyspnea on exertion" in the client's medical record.
C. Ask the client to describe the episodes of dyspnea in more detail.
D. Explain to the client the possible causes of dyspnea or "shortness of breath." (-
Correct answer is C. Both respiratory rate and breath sounds are normal.
Further assessment is needed by asking the client to describe his SOB
LATEST VERSION UPDATED AND REVISED IN 2025-2026
The nurse applies pressure over an area of the lower abdomen where the client
reports pain. The client denies pain upon palpation, but reports pain when the
pressure is released. What action should the nurse implement? A. Offer to
administer a laxative prescribed for PRN use.
B. Obtain a prescription to catheterize the client's bladder.
C. Instruct the client in distraction and relation techniques.
D. Notify the healthcare provider of the rebound tenderness.
(- Correct answer is D. As this could be a sign of appendicitis.
The nurse is assessing an ulcer on a client's lower extremity, which is likely the
result of either venous or arterial insufficiency. Which assessment technique
,should the nurse use to differentiate the pathophysiology causing the ulcer? A.
Measure the degree of join range of motion in the extremity.
B. Compare the skin turgor of the client's upper and lower leg.
C. Observe the specific location and appearance of the ulceration.
D. Note any change in the color of the ulcer when the leg is moved
(- Correct answer is C. Location and appearance of the ulcer would give us the type
(venous vs arterial)
The nurse is conducting a physical assessment of a young adult. Which
information provides the best indication of the individual's nutritional status? A.
Status of current appetite.
B. A 24-hour diet history.
C. History of a recent weight loss.
D. Condition of hair, nails, and skin.
(- Correct answer is D. Hair, nail, and skin are the most important reflection of
nutritional status.
The nurse is assessing a healthy adult male during an annual physical examination.
The nurse auscultates the client's abdomen and hears gurgling sound every ten
seconds. What action should the nurse take in response to this finding? A.
Document this normal bowel sound activity in the record.
B. Encourage increased consumption of fiber in the diet.
C. Observe the next bowel movement for signs of bleeding.
D. Report the hyperactivity to the healthcare provider.
(- Correct answer is A. Normal Bowel sound consist of clicks and gurgles and 5-30
per minute. An occasional borborygmus (Loud prolonged gurgle) may be hear.
, In observing a client's face, which assessment finding requires the most immediate
intervention by the nurse?
A. Eyelids are matted and crusted.
B. Cornea are jaundiced.
C. Oral mucosa is cyanotic.
D. Face is flushed and diaphoretic.
(- Answer is C. Blue lips occur when the skin on the lips takes on a bluish tint or
color. This generally is due to either a lock of oxygen in the blood or to extremely
cold temperatures. When the skin becomes a bluish color, the symptom is called
cyanosis. Most commonly, blue lips are caused by a lack of oxygen in the blood.
Most causes of cyanosis are serious and symptom of your body not getting enough
oxygen. Over time, this condition will become life-threatening. It can lead to
respiratory failure, heart failure, and even death, if left untreated.
While obtaining a health history, a male client tells the nurse that he sometimes
experiences shortness of breath. The nurse determines that the client's respirators
are regular and deep, and his respiratory rate is 14 breaths/minutes. What is the
best nursing action?
A. Ask the client to perform light exercise and observe the respiratory effect.
B. Document "dyspnea on exertion" in the client's medical record.
C. Ask the client to describe the episodes of dyspnea in more detail.
D. Explain to the client the possible causes of dyspnea or "shortness of breath." (-
Correct answer is C. Both respiratory rate and breath sounds are normal.
Further assessment is needed by asking the client to describe his SOB
