BSN 246 HESI Health Assessment V1 fully
solved 2025
Course
BSN 246
Question 1: Abnormal Lung Sounds
Q: A nurse is performing a respiratory assessment on a patient and hears wheezing during
expiration. What is the most likely cause of the wheezing?
A:
Wheezing is a high-pitched sound produced by narrowed airways, typically during expiration.
The most likely cause of wheezing is asthma, chronic obstructive pulmonary disease
(COPD), or bronchospasm due to inflammation or constriction of the airways.
Question 2: Inspection of the Jugular Vein
Q: When inspecting the jugular veins in a patient, the nurse notices distention while the patient is
lying at a 30-degree angle. What does this finding most likely indicate?
A:
Jugular vein distention (JVD) at a 30-degree angle typically suggests right-sided heart failure,
which is associated with increased venous pressure. It may also indicate fluid overload,
pulmonary hypertension, or pericardial disease.
Question 3: Assessment of Peripheral Pulses
Q: The nurse assesses the patient's posterior tibial pulse and cannot palpate it. What is the next
step the nurse should take?
A:
If the posterior tibial pulse is absent, the nurse should check the dorsalis pedis pulse. If both
pulses are absent, further assessment with a Doppler ultrasound should be done to assess for
vascular occlusion or poor circulation. It may also be important to assess for signs of peripheral
arterial disease (PAD).
Question 4: Understanding Cyanosis
,Q: A patient presents with a bluish tint to the lips and nails. The nurse suspects central cyanosis.
What is the likely cause of central cyanosis?
A:
Central cyanosis, which causes a bluish color to the lips and tongue, indicates poor oxygenation
or impaired oxygen transport. Possible causes include respiratory failure, cardiac defects,
pulmonary disease, or severe hypoxia.
Question 5: Focused Cardiac Assessment
Q: During a cardiac assessment, the nurse hears a systolic murmur at the left sternal border.
Which heart valve disorder is most commonly associated with this finding?
A:
A systolic murmur heard at the left sternal border is commonly associated with aortic stenosis
or mitral regurgitation. A detailed assessment and echocardiogram are needed to confirm the
exact cause.
Question 6: Physical Examination of the Abdomen
Q: When performing an abdominal exam, the nurse notes that the patient’s abdomen is distended
with a visible mass. What is the first action the nurse should take?
A:
The nurse should first assess the location, shape, and consistency of the mass, as well as any
associated symptoms such as pain, tenderness, or bowel sounds. The nurse should also ask
about recent changes in the patient’s diet, bowel habits, or weight. Further diagnostic tests like
an abdominal ultrasound or CT scan may be necessary for evaluation.
Question 7: Neurological Assessment
Q: The nurse asks the patient to close their eyes and touch their nose with their index finger. The
patient performs this correctly with no difficulty. Which of the following actions would assess
the cerebellum's function further?
A:
To further assess cerebellar function, the nurse should perform the Romberg test (asking the
patient to stand with feet together and eyes closed, watching for swaying). Alternatively, rapid
alternating movements or heel-to-shin tests can also assess cerebellar coordination and
function.
, Question 8: Skin Assessment
Q: A patient presents with a round, red, elevated lesion on the skin that is about 3 cm in
diameter, with a scaly surface. Which type of lesion does this describe?
A:
This description suggests a plaque, which is a type of primary skin lesion. The lesion is
typically associated with psoriasis or other chronic inflammatory skin conditions. A biopsy may
be needed for a definitive diagnosis.
Question 9: Assessment of Edema
Q: The nurse is assessing a patient for edema and notes pitting edema in the lower extremities.
What does this finding indicate?
A:
Pitting edema is indicative of fluid retention and may be associated with heart failure, kidney
disease, or circulatory issues. The nurse should assess the extent of edema, measure its severity,
and consider other symptoms, such as weight gain, shortness of breath, or decreased urine
output.
Question 10: Head and Neck Assessment
Q: A patient reports a sensation of fullness in the neck. On physical examination, the nurse
palpates a nodule on the thyroid gland. What should the nurse do next?
A:
The nurse should assess the nodule's size, consistency, mobility, and any associated pain. It is
important to check for signs of hyperthyroidism or hypothyroidism (e.g., changes in energy
levels, weight, or temperature tolerance). The nurse should refer the patient for further
evaluation with ultrasound and potentially a fine-needle aspiration biopsy to assess for
benign or malignant thyroid disease.
Question 11: Respiratory Assessment
Q: When assessing a patient’s respiratory status, the nurse notes the use of accessory muscles
during inspiration. What is this most likely a sign of?
A:
The use of accessory muscles during inspiration is a sign of respiratory distress and indicates
solved 2025
Course
BSN 246
Question 1: Abnormal Lung Sounds
Q: A nurse is performing a respiratory assessment on a patient and hears wheezing during
expiration. What is the most likely cause of the wheezing?
A:
Wheezing is a high-pitched sound produced by narrowed airways, typically during expiration.
The most likely cause of wheezing is asthma, chronic obstructive pulmonary disease
(COPD), or bronchospasm due to inflammation or constriction of the airways.
Question 2: Inspection of the Jugular Vein
Q: When inspecting the jugular veins in a patient, the nurse notices distention while the patient is
lying at a 30-degree angle. What does this finding most likely indicate?
A:
Jugular vein distention (JVD) at a 30-degree angle typically suggests right-sided heart failure,
which is associated with increased venous pressure. It may also indicate fluid overload,
pulmonary hypertension, or pericardial disease.
Question 3: Assessment of Peripheral Pulses
Q: The nurse assesses the patient's posterior tibial pulse and cannot palpate it. What is the next
step the nurse should take?
A:
If the posterior tibial pulse is absent, the nurse should check the dorsalis pedis pulse. If both
pulses are absent, further assessment with a Doppler ultrasound should be done to assess for
vascular occlusion or poor circulation. It may also be important to assess for signs of peripheral
arterial disease (PAD).
Question 4: Understanding Cyanosis
,Q: A patient presents with a bluish tint to the lips and nails. The nurse suspects central cyanosis.
What is the likely cause of central cyanosis?
A:
Central cyanosis, which causes a bluish color to the lips and tongue, indicates poor oxygenation
or impaired oxygen transport. Possible causes include respiratory failure, cardiac defects,
pulmonary disease, or severe hypoxia.
Question 5: Focused Cardiac Assessment
Q: During a cardiac assessment, the nurse hears a systolic murmur at the left sternal border.
Which heart valve disorder is most commonly associated with this finding?
A:
A systolic murmur heard at the left sternal border is commonly associated with aortic stenosis
or mitral regurgitation. A detailed assessment and echocardiogram are needed to confirm the
exact cause.
Question 6: Physical Examination of the Abdomen
Q: When performing an abdominal exam, the nurse notes that the patient’s abdomen is distended
with a visible mass. What is the first action the nurse should take?
A:
The nurse should first assess the location, shape, and consistency of the mass, as well as any
associated symptoms such as pain, tenderness, or bowel sounds. The nurse should also ask
about recent changes in the patient’s diet, bowel habits, or weight. Further diagnostic tests like
an abdominal ultrasound or CT scan may be necessary for evaluation.
Question 7: Neurological Assessment
Q: The nurse asks the patient to close their eyes and touch their nose with their index finger. The
patient performs this correctly with no difficulty. Which of the following actions would assess
the cerebellum's function further?
A:
To further assess cerebellar function, the nurse should perform the Romberg test (asking the
patient to stand with feet together and eyes closed, watching for swaying). Alternatively, rapid
alternating movements or heel-to-shin tests can also assess cerebellar coordination and
function.
, Question 8: Skin Assessment
Q: A patient presents with a round, red, elevated lesion on the skin that is about 3 cm in
diameter, with a scaly surface. Which type of lesion does this describe?
A:
This description suggests a plaque, which is a type of primary skin lesion. The lesion is
typically associated with psoriasis or other chronic inflammatory skin conditions. A biopsy may
be needed for a definitive diagnosis.
Question 9: Assessment of Edema
Q: The nurse is assessing a patient for edema and notes pitting edema in the lower extremities.
What does this finding indicate?
A:
Pitting edema is indicative of fluid retention and may be associated with heart failure, kidney
disease, or circulatory issues. The nurse should assess the extent of edema, measure its severity,
and consider other symptoms, such as weight gain, shortness of breath, or decreased urine
output.
Question 10: Head and Neck Assessment
Q: A patient reports a sensation of fullness in the neck. On physical examination, the nurse
palpates a nodule on the thyroid gland. What should the nurse do next?
A:
The nurse should assess the nodule's size, consistency, mobility, and any associated pain. It is
important to check for signs of hyperthyroidism or hypothyroidism (e.g., changes in energy
levels, weight, or temperature tolerance). The nurse should refer the patient for further
evaluation with ultrasound and potentially a fine-needle aspiration biopsy to assess for
benign or malignant thyroid disease.
Question 11: Respiratory Assessment
Q: When assessing a patient’s respiratory status, the nurse notes the use of accessory muscles
during inspiration. What is this most likely a sign of?
A:
The use of accessory muscles during inspiration is a sign of respiratory distress and indicates
