BSN 246 HESI Health Assessment V2 Exam |Questions and Answers PDF | Latest 2025/ 2026 Update | GRADED A| 100% Correct- Nightingale

BSN 246 HESI Health Assessment V2 Exam |Questions and Answers PDF | Latest 2025/ 2026 Update | GRADED A| 100% Correct- Nightingale Question: The nurse asks a female client about the proverb "Glass Houses," and she replies, "It will break the windows." Which conclusion should be documented about this client's response? Answer: Impaired Thinking Question: In assessing a clients neck the nurse hears a blowing swish when auscultating ... the carotid artery. how should the nurse document this finding? Answer: left carotid artery bruit present, no bruit heard in the right carotid artery Question: To assess a client's pupillary reaction to accommodation, what action should the nurse take? Answer: Observe pupil size when focusing on a near object and then a far object. Question: During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement? Answer: NPO Question: When inspecting an adult woman's skin the nurse observes several areas of ecchymosis on her trunk and extremities. Which information in the client's history requires additional follow-up by the nurse? Answer: Takes an oral anticoagulant Question: While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take? Answer: Use a doppler ultrasonic stethoscope. Question: The nurse is examining an older female and suspects that she has a dysfunction in her... should the nurse perform to further assess for a hip dysfunction? Answer: Abduct each hip while the client is supine Question: NGN- SHOULDER unable to move the arm away from the body Answer: Abduction Question: NGN- ELBOW only able to straighten joint 20 degrees Answer: Extension Question: NGN- wrist able to bend wrist back toward forearm Answer: Extension Question: While auscultating a clients abdomen, the nurse hears a low pitched blowing sound in the upper midline area. which is the likely indication of this finding? Answer: Possible renal artery stenosis. Question: An adult client exhibits an allergic reaction to an Insect bite. The nurse should observe the client's skin for which finding? Answer: Wheals Question: When assessing a client's rectal bleeding, which findings should the nurse document? Answer: Color characteristics of each stool Question: An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement? Answer: Notify the healthcare provider of the rebound tenderness. Question: A 29 year old 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? Answer: Describe having a "body-wracking dry cough" of 6 weeks duration. Question: A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis? Answer: Intranasal edema and swelling of turbinates. Question: When completeing a health assessment for a client being admitted with... the sputum. which communication technique should the nurse use to obtain ... Answer: open ended questions Question: NGN- abdominal aortic aneurysm repare Answer: turn off suction while auscultating auscultate Question: The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle? Answer: Sharp, severe pain. Question: A adult client presents with complaints of gnawing epigastric pain. The pain is worse when is hungry and abates if he eats something. What problem do these symptoms suggest? Answer: Peptic ulcer disease Question: An older male client reports to the nurse that his feet are cold. Before covering the client's feet, which assessment(s) should the nurse complete? Select all that apply. Answer: Observe color of the feet and toes. Assess volume of the pedal pulses. Palpate dorsal surface of feet for warmth. Question: The nurse anticipates difficulty locating the point of point of maximal impulse Answer: A 54-year-old who is 5 feet (152.4 cm) tall and weighs 300 pounds Question: 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? Answer: Iron deficiency anemia. Question: When obtaining a client's health history related to smoking cigarettes, the nurse plans to determine the client's smoking pack years. Which information should the nurse obtain for this calculation? Select all that apply. Answer: Packs of cigarettes smoked per day. Number of years the client smoked. Question: During an admission assessment, which approach should the nurse use to assess a client's speech patterns? Answer: Note the client's responses during the initial interview. Question: The nurse observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression. How should the nurse enter documentation of this finding in the client's electronic medical record (EMR)? Answer: wandering behavior with flat affect Question: NGN- rheumatoid arthritis Answer: applicable swollen joints -small joints of the hand -fever and fatigue -morning stiffness -symmetrical involvement Question: When performing a neurologic assessment on an alert client, the nurse observes that the client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment? Answer: PERRLA Question: While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first? Answer: Stand directly in front of the client and ask about any hearing loss. Question: The nurse is assessing a young adult female who is 5'5 and has a BMI score of 32. based on this BMI what should the nurse deduce about this clients general health? Answer: Obese, serious threat to well-being Question: In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action? Answer: Place the palm of the hand on the chest wall to feel vibrations while the client speaks Question: While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate? Answer: Cardiac Enlargement Question: A client complains of stomach pain and localizes it in the middle section of the abdomen below the xyphoid process. the nurse should describe the pain as occurring in which region of the abdomen Answer: epigastric region Question: The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which question should the nurse ask first? "Have you _________ __________ ___________?" Answer: been sleeping well? Question: An female client comes to the clinic troubled by breast tenderness before her menstrual periods. On examination, the nurse note generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take? Answer: Request a return visit after her menstrual period for a breast exam re-check. Question: The nurse is examining a female client who states she has no complaints. she has had no physical exam in years. the nurse palpates enlarged lymph nodes in the axilla. which finding is the most important for the nurse to report to the health care provider? Answer: Non-tender firm lymph nodes Question: cleaning gutters with ladder- fell to ground injury to right forearm "i tried to break my fall by stretching my arm it hurts and i heard it break" Answer: NGN- NKA at home meds acetomeninophen 100mg PO daily for sinus headache last dose two days ago AXO 4 PERRLA Denies LOC with fall/ head injury forearm bent and misaligned/ closed injury skin intact pain 0/10 Capillary Refill is second Pressure placed on nail should cause B Question: When family is concerned about their father's recent memory loss. Which assessment should the nurse suggest? Answer: Determine if the client can recall what he ate for breakfast Question: Which assessment finding supports the client statement, "my feet swell all the time"? Answer: 2+ pitting edema of the ankles bilaterally Question: An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement? Answer: Evaluate the client for bladder distention. Question: The nurse examines a client's right great toe. The joint is red, edematous, and very painful with limited range of motion. The client's serum uric acid levels are elevated. Which action should the nurse tell the client to make? Answer: Encourage fluid intake. Question: The nurse assesses a client who comes to the clinic with neck stiffness and di....the nurse inquire further about lifestyle habits? Answer: evaluation of the cranial nerve XI flexion Question: A client presents with itching and pain of the left ear that started several days after....coming from the ear with a musty oder. How should the nurse expect the appear? Answer: red, edematous ear canal with no visualization of the tympanic membrane Question: The nurse completes palpation of the thoratic region of the abdomen Answer: Non-tender Question: 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? Answer: Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts. Question: To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take? Answer: Both hands to hands Question: The nurse observes that a client is experiencing melena. What serum laboratory test should the nurse monitor in response to this finding? Answer: HTC Question: While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perineal area and anus. Which findings indicates a normal appearance of the anus? Answer: A. Increased pigmentation and coarse skin. Question: During assessment of a client's abdomen, the nurse observes that the client's umbilicus is depressed and below the surface of the abdomen. What action should the nurse take in response to this observation? Answer: Normal Finding Question: Which skill should the nurse have an older client demonstrate to evaluate performance of daily living activities? Answer: Open a bar of soap Question: After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high pitched almost continuous gurgling in two quadrants. What action should the nurse implement? Answer: Auscultate the remaining two quadrants. Question: 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? Answer: Observe skin for erythema, edema, and warmth Question: A client grimaces while preforming range of motion of the left knee during an annual health assessment . which movements should the nurse utilize to assess the clients ability to normally perform range of motion on the right knee? Answer: extension, flexion and hyperextension Question: In observing a client's face, which assessment finding requires the most immediate intervention by the nurse? Answer: Oral mucosa is cyanotic Question: While assessing the legs of a female client, the nurse observes leathery-looking skin. The client reports aching tired legs that swell if she stands for long periods of time. To screen for venous insufficiency, the nurse should ask the client if she has experienced which subject finding? Answer: Decreased pain when legs are elevated. Question: The nurse is assessing a client with gallstones for jaundice. Which action should the nurse perform to confirm this information? Answer: Examine client's sclera for icterus Question: The nurse performs a two point discrimination test by applying two sterile needles lightly to the fingertips and moving the needle tips in ever closing distances. a middle aged adult client senses two points at a distance of 3 mm on the fingertips and 10 mm on the palms of hands which interpretation of this finding is accurate? Answer: B. Normal sensory finding