BSN 246 HESI Physical Assessment
Questions With Complete Solutions
Course
BSN 246
1. During assessment of an elderly client, which finding requires immediate intervention?
Answer: New-onset confusion
Rationale: Acute confusion often signals delirium caused by infection, electrolyte imbalance, or
hypoxia—priority action needed.
2. While auscultating a client’s heart, the nurse hears a high-pitched, blowing diastolic
murmur. Where should the nurse assess next?
Answer: Apical impulse for displacement
Rationale: Diastolic murmurs like those from aortic regurgitation often cause left ventricular
hypertrophy and shift the apical impulse.
3. What does a positive Romberg test indicate?
Answer: Poor proprioception
Rationale: Swaying with eyes closed points to sensory ataxia, usually from posterior column
dysfunction or vestibular problems.
4. Which technique is used to assess for tactile fremitus?
Answer: Palpation with the palmar surface
Rationale: Vibrations are best felt with the base of the fingers; decreased fremitus = obstruction,
increased = consolidation.
5. Which finding during abdominal assessment is most concerning?
Answer: Pulsating midline mass above the umbilicus
Rationale: Suggests an abdominal aortic aneurysm—requires immediate reporting, do not
palpate further.
6. What does capillary refill greater than 3 seconds most likely indicate?
Answer: Impaired peripheral perfusion
Rationale: Delayed refill signals poor circulation due to vasoconstriction or reduced cardiac
output.
,7. What is the correct sequence of physical assessment techniques for the abdomen?
Answer: Inspection, auscultation, percussion, palpation
Rationale: Auscultation precedes palpation to avoid altering bowel sounds.
8. Which cranial nerve is tested by assessing for symmetrical rise of the soft palate?
Answer: Cranial nerve X (Vagus)
Rationale: The vagus nerve controls the soft palate and pharynx—symmetry ensures normal
function.
9. What is the best method to assess for dependent edema in the lower extremities?
Answer: Press firmly over the tibia for several seconds
Rationale: Pitting edema is measured by indentation depth and duration—check over bony
prominences.
10. What finding during a lung assessment indicates a pleural friction rub?
Answer: Low-pitched grating sound during both inspiration and expiration
Rationale: A pleural rub is a sign of inflammation between pleural layers—often painful and
biphasic.
11. A nurse is assessing a client’s eyes and notices a bright red area in the sclera. What
should the nurse do next?
Answer: Observe for further changes in vision or discomfort
Rationale: A subconjunctival hemorrhage is usually harmless and can occur with coughing or
sneezing. Monitor for any signs of visual disturbance or eye pain.
12. The nurse is palpating the abdomen and detects a firm, immobile mass in the right
upper quadrant. What is the most likely cause?
Answer: Gallbladder disease
Rationale: A firm, immobile mass in the RUQ suggests gallstones or a gallbladder tumor,
conditions that may cause pain and distension.
13. What is the purpose of the Weber test?
Answer: To assess for lateralization of sound
Rationale: The Weber test uses a tuning fork to determine if sound lateralizes to one ear.
,Conductive hearing loss causes lateralization to the affected ear, while sensorineural loss
results in sound lateralizing to the unaffected ear.
14. A client presents with a 2 cm, nontender, movable mass in the breast. The nurse should
document the findings as:
Answer: Benign breast mass
Rationale: A nontender, movable mass in the breast is commonly benign, such as a
fibroadenoma. Cancerous masses are often hard, fixed, and irregular.
15. During a neurologic exam, the nurse asks the patient to close their eyes and touch their
nose with their finger. What does this assess?
Answer: Cerebellar function
Rationale: This test assesses coordination and proprioception, which are controlled by the
cerebellum. Difficulty performing the task could suggest cerebellar dysfunction.
16. A nurse is assessing a client’s skin for signs of cyanosis. Where would the nurse most
likely notice cyanosis first?
Answer: Lips and nail beds
Rationale: Cyanosis is best observed in areas with high vascularization, such as the lips and
nail beds, where oxygen saturation issues are more readily visible.
17. When assessing a client’s pulse, the nurse notes that the pulse is irregular. What is the
priority action?
Answer: Check for an apical pulse
Rationale: An irregular pulse may suggest arrhythmias. To confirm the rhythm and rate, the
apical pulse should be checked for a full minute.
18. Which finding during a lung assessment suggests pleural effusion?
Answer: Dullness to percussion over the affected area
Rationale: Pleural effusion is the accumulation of fluid in the pleural space, causing dullness to
percussion and decreased breath sounds.
19. During assessment, the nurse notes the client has a decreased gag reflex. Which cranial
nerve(s) might be involved?
, Answer: Cranial nerves IX (Glossopharyngeal) and X (Vagus)
Rationale: The gag reflex involves the glossopharyngeal (IX) and vagus (X) nerves. A
decreased reflex suggests dysfunction in these nerves.
20. A nurse is assessing a client for signs of jaundice. What is the first area the nurse should
inspect?
Answer: Sclera of the eyes
Rationale: Jaundice first appears in the sclera, due to bilirubin accumulation. It’s often the
earliest and most noticeable sign in the eyes.
21. A nurse assesses a client’s radial pulse and notes it is weak and thready. What is the
most likely cause of this finding?
Answer: Decreased cardiac output
Rationale: A weak, thready pulse often indicates hypotension, shock, or decreased cardiac
output due to inadequate perfusion.
22. What is the correct technique for assessing for rebound tenderness?
Answer: Press gently on the abdomen and then quickly release
Rationale: Rebound tenderness is a sign of peritoneal irritation. Pain upon quick release of
pressure suggests appendicitis or other abdominal pathology.
23. When performing an abdominal assessment, which action should the nurse take first?
Answer: Inspect the abdomen
Rationale: Inspection precedes palpation and auscultation to avoid altering bowel sounds or
causing discomfort.
24. A client’s pupils constrict in response to light, but do not constrict when looking at a
near object. What is this indicative of?
Answer: Accommodation reflex failure
Rationale: Failure to constrict when focusing on a near object suggests dysfunction of the
oculomotor nerve (CN III), impacting the accommodation reflex.
25. During a physical exam, the nurse notes a bruit over the carotid artery. What is the
significance of this finding?
Questions With Complete Solutions
Course
BSN 246
1. During assessment of an elderly client, which finding requires immediate intervention?
Answer: New-onset confusion
Rationale: Acute confusion often signals delirium caused by infection, electrolyte imbalance, or
hypoxia—priority action needed.
2. While auscultating a client’s heart, the nurse hears a high-pitched, blowing diastolic
murmur. Where should the nurse assess next?
Answer: Apical impulse for displacement
Rationale: Diastolic murmurs like those from aortic regurgitation often cause left ventricular
hypertrophy and shift the apical impulse.
3. What does a positive Romberg test indicate?
Answer: Poor proprioception
Rationale: Swaying with eyes closed points to sensory ataxia, usually from posterior column
dysfunction or vestibular problems.
4. Which technique is used to assess for tactile fremitus?
Answer: Palpation with the palmar surface
Rationale: Vibrations are best felt with the base of the fingers; decreased fremitus = obstruction,
increased = consolidation.
5. Which finding during abdominal assessment is most concerning?
Answer: Pulsating midline mass above the umbilicus
Rationale: Suggests an abdominal aortic aneurysm—requires immediate reporting, do not
palpate further.
6. What does capillary refill greater than 3 seconds most likely indicate?
Answer: Impaired peripheral perfusion
Rationale: Delayed refill signals poor circulation due to vasoconstriction or reduced cardiac
output.
,7. What is the correct sequence of physical assessment techniques for the abdomen?
Answer: Inspection, auscultation, percussion, palpation
Rationale: Auscultation precedes palpation to avoid altering bowel sounds.
8. Which cranial nerve is tested by assessing for symmetrical rise of the soft palate?
Answer: Cranial nerve X (Vagus)
Rationale: The vagus nerve controls the soft palate and pharynx—symmetry ensures normal
function.
9. What is the best method to assess for dependent edema in the lower extremities?
Answer: Press firmly over the tibia for several seconds
Rationale: Pitting edema is measured by indentation depth and duration—check over bony
prominences.
10. What finding during a lung assessment indicates a pleural friction rub?
Answer: Low-pitched grating sound during both inspiration and expiration
Rationale: A pleural rub is a sign of inflammation between pleural layers—often painful and
biphasic.
11. A nurse is assessing a client’s eyes and notices a bright red area in the sclera. What
should the nurse do next?
Answer: Observe for further changes in vision or discomfort
Rationale: A subconjunctival hemorrhage is usually harmless and can occur with coughing or
sneezing. Monitor for any signs of visual disturbance or eye pain.
12. The nurse is palpating the abdomen and detects a firm, immobile mass in the right
upper quadrant. What is the most likely cause?
Answer: Gallbladder disease
Rationale: A firm, immobile mass in the RUQ suggests gallstones or a gallbladder tumor,
conditions that may cause pain and distension.
13. What is the purpose of the Weber test?
Answer: To assess for lateralization of sound
Rationale: The Weber test uses a tuning fork to determine if sound lateralizes to one ear.
,Conductive hearing loss causes lateralization to the affected ear, while sensorineural loss
results in sound lateralizing to the unaffected ear.
14. A client presents with a 2 cm, nontender, movable mass in the breast. The nurse should
document the findings as:
Answer: Benign breast mass
Rationale: A nontender, movable mass in the breast is commonly benign, such as a
fibroadenoma. Cancerous masses are often hard, fixed, and irregular.
15. During a neurologic exam, the nurse asks the patient to close their eyes and touch their
nose with their finger. What does this assess?
Answer: Cerebellar function
Rationale: This test assesses coordination and proprioception, which are controlled by the
cerebellum. Difficulty performing the task could suggest cerebellar dysfunction.
16. A nurse is assessing a client’s skin for signs of cyanosis. Where would the nurse most
likely notice cyanosis first?
Answer: Lips and nail beds
Rationale: Cyanosis is best observed in areas with high vascularization, such as the lips and
nail beds, where oxygen saturation issues are more readily visible.
17. When assessing a client’s pulse, the nurse notes that the pulse is irregular. What is the
priority action?
Answer: Check for an apical pulse
Rationale: An irregular pulse may suggest arrhythmias. To confirm the rhythm and rate, the
apical pulse should be checked for a full minute.
18. Which finding during a lung assessment suggests pleural effusion?
Answer: Dullness to percussion over the affected area
Rationale: Pleural effusion is the accumulation of fluid in the pleural space, causing dullness to
percussion and decreased breath sounds.
19. During assessment, the nurse notes the client has a decreased gag reflex. Which cranial
nerve(s) might be involved?
, Answer: Cranial nerves IX (Glossopharyngeal) and X (Vagus)
Rationale: The gag reflex involves the glossopharyngeal (IX) and vagus (X) nerves. A
decreased reflex suggests dysfunction in these nerves.
20. A nurse is assessing a client for signs of jaundice. What is the first area the nurse should
inspect?
Answer: Sclera of the eyes
Rationale: Jaundice first appears in the sclera, due to bilirubin accumulation. It’s often the
earliest and most noticeable sign in the eyes.
21. A nurse assesses a client’s radial pulse and notes it is weak and thready. What is the
most likely cause of this finding?
Answer: Decreased cardiac output
Rationale: A weak, thready pulse often indicates hypotension, shock, or decreased cardiac
output due to inadequate perfusion.
22. What is the correct technique for assessing for rebound tenderness?
Answer: Press gently on the abdomen and then quickly release
Rationale: Rebound tenderness is a sign of peritoneal irritation. Pain upon quick release of
pressure suggests appendicitis or other abdominal pathology.
23. When performing an abdominal assessment, which action should the nurse take first?
Answer: Inspect the abdomen
Rationale: Inspection precedes palpation and auscultation to avoid altering bowel sounds or
causing discomfort.
24. A client’s pupils constrict in response to light, but do not constrict when looking at a
near object. What is this indicative of?
Answer: Accommodation reflex failure
Rationale: Failure to constrict when focusing on a near object suggests dysfunction of the
oculomotor nerve (CN III), impacting the accommodation reflex.
25. During a physical exam, the nurse notes a bruit over the carotid artery. What is the
significance of this finding?
