BSN 246 HESI V3 HEALTH ASSESSMENT
PRACTICE QUESTIONS AND ANSWERS
RATED A+ | NIGHTINGALE | 2025/2026
GUIDE
The nurse is performing a neurological assessment on a client and notes
a positive Romberg's test. The nurse makes this determination based on
which observation?
1. An involuntary rhythmic, rapid, twitching of the eyeballs
2. A dorsiflexion of the great toe with fanning of the other toes
3. A significant sway when the client stands erect with feet together,
arms at the side, and the eyes closed
4. A lack of normal sense of position when the client is unable to return
extended fingers to a point of reference
- Correct Answer - 3. A significant sway when the client stands erect with
feet together, arms at the side, and the eyes closed
In Romberg's test, the client is asked to stand with the feet together and
the arms at the sides, and to close the eyes and hold the position;
normally the client can maintain posture and balance. A positive
Romberg's sign is a vestibular 409 neurological sign that is found when
a client exhibits a loss of balance when closing the eyes. This may occur
with cerebellar ataxia, loss of proprioception, and loss of vestibular
function. A lack of normal sense of position coupled with an inability to
return extended fingers to a point of reference is a finding that indicates
,a problem with coordination. A positive gaze nystagmus evaluation
results in an involuntary rhythmic, rapid twitching of the eyeballs. A
positive Babinski's test results in dorsiflexion of the great toe with
fanning of the other toes; if this occurs in anyone older than 2 years it
indicates the presence of central nervous system disease.
The nurse notes documentation that a client is exhibiting Cheyne-Stokes
respirations. On assessment of the client, the nurse should expect to
note which finding?
1. Rhythmic respirations with periods of apnea
2. Regular rapid and deep, sustained respirations
3. Totally irregular respiration in rhythm and depth
4. Irregular respirations with pauses at the end of inspiration and
expiration - Correct Answer - 1. Rhythmic respirations with periods of
apnea
Cheyne-Stokes respirations are rhythmic respirations with periods of
apnea and can indicate a metabolic dysfunction in the cerebral
hemisphere or basal ganglia. Neurogenic hyperventilation is a regular,
rapid and deep, sustained respiration that can indicate a dysfunction in
the low midbrain and middle pons. Ataxic respirations are totally irregular
in rhythm and depth and indicate a dysfunction in the medulla. Apneustic
respirations are irregular respirations with pauses at the end of
inspiration and expiration and can indicate a dysfunction in the middle or
caudal pons.
, A client diagnosed with conductive hearing loss asks the nurse to explain
the cause of the hearing problem. The nurse plans to explain to the
client that this condition is caused by which problem?
1. A defect in the cochlea
2. A defect in cranial nerve VIII
3. A physical obstruction to the transmission of sound waves
4. A defect in the sensory fibers that lead to the cerebral cortex - Correct
Answer - 3. A physical obstruction to the transmission of sound waves
A conductive hearing loss occurs as a result of a physical obstruction to
the transmission of sound waves. A sensorineural hearing loss occurs as
a result of a pathological process in the inner ear, a defect in cranial
nerve VIII, or a defect of the sensory fibers that lead to the cerebral
cortex.
While performing a cardiac assessment on a client with an incompetent
heart valve, the nurse auscultates a murmur. The nurse documents the
finding and describes the sound as which?
1. Lub-dub sounds
2. Scratchy, leathery heart noise
3. A blowing or swooshing noise
4. Abrupt, high-pitched snapping noise - Correct Answer - 3. A blowing or
swooshing noise
PRACTICE QUESTIONS AND ANSWERS
RATED A+ | NIGHTINGALE | 2025/2026
GUIDE
The nurse is performing a neurological assessment on a client and notes
a positive Romberg's test. The nurse makes this determination based on
which observation?
1. An involuntary rhythmic, rapid, twitching of the eyeballs
2. A dorsiflexion of the great toe with fanning of the other toes
3. A significant sway when the client stands erect with feet together,
arms at the side, and the eyes closed
4. A lack of normal sense of position when the client is unable to return
extended fingers to a point of reference
- Correct Answer - 3. A significant sway when the client stands erect with
feet together, arms at the side, and the eyes closed
In Romberg's test, the client is asked to stand with the feet together and
the arms at the sides, and to close the eyes and hold the position;
normally the client can maintain posture and balance. A positive
Romberg's sign is a vestibular 409 neurological sign that is found when
a client exhibits a loss of balance when closing the eyes. This may occur
with cerebellar ataxia, loss of proprioception, and loss of vestibular
function. A lack of normal sense of position coupled with an inability to
return extended fingers to a point of reference is a finding that indicates
,a problem with coordination. A positive gaze nystagmus evaluation
results in an involuntary rhythmic, rapid twitching of the eyeballs. A
positive Babinski's test results in dorsiflexion of the great toe with
fanning of the other toes; if this occurs in anyone older than 2 years it
indicates the presence of central nervous system disease.
The nurse notes documentation that a client is exhibiting Cheyne-Stokes
respirations. On assessment of the client, the nurse should expect to
note which finding?
1. Rhythmic respirations with periods of apnea
2. Regular rapid and deep, sustained respirations
3. Totally irregular respiration in rhythm and depth
4. Irregular respirations with pauses at the end of inspiration and
expiration - Correct Answer - 1. Rhythmic respirations with periods of
apnea
Cheyne-Stokes respirations are rhythmic respirations with periods of
apnea and can indicate a metabolic dysfunction in the cerebral
hemisphere or basal ganglia. Neurogenic hyperventilation is a regular,
rapid and deep, sustained respiration that can indicate a dysfunction in
the low midbrain and middle pons. Ataxic respirations are totally irregular
in rhythm and depth and indicate a dysfunction in the medulla. Apneustic
respirations are irregular respirations with pauses at the end of
inspiration and expiration and can indicate a dysfunction in the middle or
caudal pons.
, A client diagnosed with conductive hearing loss asks the nurse to explain
the cause of the hearing problem. The nurse plans to explain to the
client that this condition is caused by which problem?
1. A defect in the cochlea
2. A defect in cranial nerve VIII
3. A physical obstruction to the transmission of sound waves
4. A defect in the sensory fibers that lead to the cerebral cortex - Correct
Answer - 3. A physical obstruction to the transmission of sound waves
A conductive hearing loss occurs as a result of a physical obstruction to
the transmission of sound waves. A sensorineural hearing loss occurs as
a result of a pathological process in the inner ear, a defect in cranial
nerve VIII, or a defect of the sensory fibers that lead to the cerebral
cortex.
While performing a cardiac assessment on a client with an incompetent
heart valve, the nurse auscultates a murmur. The nurse documents the
finding and describes the sound as which?
1. Lub-dub sounds
2. Scratchy, leathery heart noise
3. A blowing or swooshing noise
4. Abrupt, high-pitched snapping noise - Correct Answer - 3. A blowing or
swooshing noise
