BSN 246 HESI Health Assessment V1
1. The nurse is performing a thoracic assessment on a client
with chronic asthma and hyperinflation of the lungs. Which
finding should be expected for this client?: Barrel chest
2. The nurse is assessing bowel sounds for a hospitalized
client. The nurse has heard bowel sounds in the right upper
quadrant. What action should the nurse take next?: Note the
character and frequency of bowel sounds
3. During inspection of a client's mouth and pharynx, the
nurse places a tongue blade on the back of the tongue which
causes the client to gag. After removing the tongue blade,
what action should the nurse take?: Document an intact gag
reflex.
4. When teaching a client how to perform a monthly breast self-
assessment, the nurse should tell the client that it is most
important to assess which part of the breast more closely for
changes?: Upper outer quadrant.
,5. The nurse is assessing a postmenopausal client who has a
BMI of 32. The client has a chest measurement of 42 inches,
waist measurement of 45 inches, and hip measurement of 50
inches. What important message should the nurse explain to
the client to promote health promotion?: A waist circumference
is greater than 35 inches in women puts you at higher risk for type
2 diabetes and heart disease."
6. The nurse performs a physical assessment on an older
female client. Which change from the prior exam may be an
indication of osteoporosis?: Height reduction of 1.5 inches.
7. While conducting an interview to obtain a health history,
the nurse notices that the client pauses frequently and looks
at the nurse expectantly. Which response is best for the
nurse to provide?: Sit quietly to allow the client to respond
comfortably.
8. A client is in the clinical for a yearly physical examination.
Which action should the nurse take when preparing to
, examine the client's abdomen?: Ask the client to urinate before
beginning the examination.
9. Which respiratory condition should the nurse document
after measuring a respiratory rate of 8 breaths/minute?:
Bradypnea.
10. Which procedure should the nurse use to assessfor a
pulse deficit?: Mea- sure the apical pulse and compare it to the
peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse
at the point of maximal impulse and the radial pulse palpated at
the wrist.
11. A client has been diagnosed with bilateral lower lobe
atelectasis. What percussion sound should the nurse expect
to hear when percussing over the client's lower lobes?: Dull,
thud-like.
12. A client is being assessed upon admission to the
medical-surgical unit. The nurse is preparing to complete a
1. The nurse is performing a thoracic assessment on a client
with chronic asthma and hyperinflation of the lungs. Which
finding should be expected for this client?: Barrel chest
2. The nurse is assessing bowel sounds for a hospitalized
client. The nurse has heard bowel sounds in the right upper
quadrant. What action should the nurse take next?: Note the
character and frequency of bowel sounds
3. During inspection of a client's mouth and pharynx, the
nurse places a tongue blade on the back of the tongue which
causes the client to gag. After removing the tongue blade,
what action should the nurse take?: Document an intact gag
reflex.
4. When teaching a client how to perform a monthly breast self-
assessment, the nurse should tell the client that it is most
important to assess which part of the breast more closely for
changes?: Upper outer quadrant.
,5. The nurse is assessing a postmenopausal client who has a
BMI of 32. The client has a chest measurement of 42 inches,
waist measurement of 45 inches, and hip measurement of 50
inches. What important message should the nurse explain to
the client to promote health promotion?: A waist circumference
is greater than 35 inches in women puts you at higher risk for type
2 diabetes and heart disease."
6. The nurse performs a physical assessment on an older
female client. Which change from the prior exam may be an
indication of osteoporosis?: Height reduction of 1.5 inches.
7. While conducting an interview to obtain a health history,
the nurse notices that the client pauses frequently and looks
at the nurse expectantly. Which response is best for the
nurse to provide?: Sit quietly to allow the client to respond
comfortably.
8. A client is in the clinical for a yearly physical examination.
Which action should the nurse take when preparing to
, examine the client's abdomen?: Ask the client to urinate before
beginning the examination.
9. Which respiratory condition should the nurse document
after measuring a respiratory rate of 8 breaths/minute?:
Bradypnea.
10. Which procedure should the nurse use to assessfor a
pulse deficit?: Mea- sure the apical pulse and compare it to the
peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse
at the point of maximal impulse and the radial pulse palpated at
the wrist.
11. A client has been diagnosed with bilateral lower lobe
atelectasis. What percussion sound should the nurse expect
to hear when percussing over the client's lower lobes?: Dull,
thud-like.
12. A client is being assessed upon admission to the
medical-surgical unit. The nurse is preparing to complete a
