BSN 246 HESI
Health Assessment V1 EXAM
Nightingale College
Actual Qs & Verified Ans to Pass the Exam
This Hesi test contains:
passing score Guarantee
Format Set of Multiple-choice
questions with incorporating Next
Generation NCLEX (NGN) and Case scenarios
questions
Expert-Verified Explanations & Solutions
,### Scenario 1:
Question: To assess a client's pupillary reaction to accommodation,
what action should the nurse take?
- A) Use an ophthalmoscope for detailed examination
- B) Shine a penlight in each eye
- C) Observe pupil size when focusing on a near object and then a far object
- D) Measure the pupil diameter in centimeters
Correct Answer: C) Observe pupil size when focusing on a near object and
then a far object
Expert Rationale: Assessing a pupillary reaction to accommodation involves
observing how the pupils change size when a patient focuses on a near
object and then on a distant object. This tests the function of cranial nerves
II and III, important for visual acuity and ocular health.
---
### Scenario 2:
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?
- A) Administer NSAIDs as prescribed
- B) Maintain the client on a regular diet
- C) NPO (nothing by mouth)
,- D) Perform a rectal examination immediately
Correct Answer: C) NPO (nothing by mouth)
Expert Rationale: The client exhibiting pain and guarding during palpation
suggests possible acute abdomen or a surgical emergency. Keeping the client
NPO is critical to prepare for any necessary surgical interventions or imaging
studies, as well as to prevent the risk of aspiration.
---
### Scenario 3:
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?
- A) Engages in regular physical activity
- B) Takes an oral anticoagulant
- C) Reports a recent fall
- D) Has a history of hypertension
Correct Answer: B) Takes an oral anticoagulant
Expert Rationale: The presence of ecchymosis combined with the use of
anticoagulants raises concerns about potential bleeding disorders or
inadequate coagulation management. This necessitates further inquiry to
evaluate the need for adjustments in medication or assessment of liver
function.
---
, ### Scenario 4:
Question: While performing a physical assessment, the nurse is unable
to palpate the client's pedal pulses. Which action should the nurse
take?
- A) Reposition the patient's legs and attempt palpation again
- B) Use a Doppler ultrasonic stethoscope
- C) Document that pulses are not palpable
- D) Refer the client for a vascular consult
Correct Answer: B) Use a Doppler ultrasonic stethoscope
Expert Rationale: If pedal pulses are not palpable, using a Doppler allows
for non-invasive con7irmation of blood 7low in the arteries of the foot.
Documenting 7indings accurately and further investigating with the Doppler
is essential for evaluating potential vascular compromise.
### Scenario 5:
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?
- A) Impaired thinking
- B) Insightful observation
- C) A misunderstanding of idiomatic expressions
- D) Normal cognitive functioning
Correct Answer: A) Impaired thinking
Health Assessment V1 EXAM
Nightingale College
Actual Qs & Verified Ans to Pass the Exam
This Hesi test contains:
passing score Guarantee
Format Set of Multiple-choice
questions with incorporating Next
Generation NCLEX (NGN) and Case scenarios
questions
Expert-Verified Explanations & Solutions
,### Scenario 1:
Question: To assess a client's pupillary reaction to accommodation,
what action should the nurse take?
- A) Use an ophthalmoscope for detailed examination
- B) Shine a penlight in each eye
- C) Observe pupil size when focusing on a near object and then a far object
- D) Measure the pupil diameter in centimeters
Correct Answer: C) Observe pupil size when focusing on a near object and
then a far object
Expert Rationale: Assessing a pupillary reaction to accommodation involves
observing how the pupils change size when a patient focuses on a near
object and then on a distant object. This tests the function of cranial nerves
II and III, important for visual acuity and ocular health.
---
### Scenario 2:
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?
- A) Administer NSAIDs as prescribed
- B) Maintain the client on a regular diet
- C) NPO (nothing by mouth)
,- D) Perform a rectal examination immediately
Correct Answer: C) NPO (nothing by mouth)
Expert Rationale: The client exhibiting pain and guarding during palpation
suggests possible acute abdomen or a surgical emergency. Keeping the client
NPO is critical to prepare for any necessary surgical interventions or imaging
studies, as well as to prevent the risk of aspiration.
---
### Scenario 3:
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?
- A) Engages in regular physical activity
- B) Takes an oral anticoagulant
- C) Reports a recent fall
- D) Has a history of hypertension
Correct Answer: B) Takes an oral anticoagulant
Expert Rationale: The presence of ecchymosis combined with the use of
anticoagulants raises concerns about potential bleeding disorders or
inadequate coagulation management. This necessitates further inquiry to
evaluate the need for adjustments in medication or assessment of liver
function.
---
, ### Scenario 4:
Question: While performing a physical assessment, the nurse is unable
to palpate the client's pedal pulses. Which action should the nurse
take?
- A) Reposition the patient's legs and attempt palpation again
- B) Use a Doppler ultrasonic stethoscope
- C) Document that pulses are not palpable
- D) Refer the client for a vascular consult
Correct Answer: B) Use a Doppler ultrasonic stethoscope
Expert Rationale: If pedal pulses are not palpable, using a Doppler allows
for non-invasive con7irmation of blood 7low in the arteries of the foot.
Documenting 7indings accurately and further investigating with the Doppler
is essential for evaluating potential vascular compromise.
### Scenario 5:
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?
- A) Impaired thinking
- B) Insightful observation
- C) A misunderstanding of idiomatic expressions
- D) Normal cognitive functioning
Correct Answer: A) Impaired thinking
