ESTUDYR
BSN 246 HESI HEALTH ASSESSMENT V1 UPDATED EXAM WITH MOST
TESTED QUESTIONS AND ANSWERS | GRADED A+ | ASSURED SUCCESS
WITH DETAILED RATIONALES
1. The nurse is performing a thoracic assessment on a client with chronic asthma and
hyperinflation of the lungs. Which finding should be expected?
A. Pectus excavatum
B. Kyphosis
C. Barrel chest ✔
D. Funnel chest
Rationale: Chronic air trapping and hyperinflation in asthma cause increased anterior-posterior
diameter → barrel chest.
2. The nurse hears bowel sounds in the right upper quadrant. What should the nurse do next?
A. Immediately document “normal” and leave
B. Note the character and frequency of bowel sounds ✔
C. Palpate the left lower quadrant first
D. Call the physician for orders
Rationale: Hearing bowel sounds requires further characterization (e.g., active, hypoactive,
high-pitched).
3. During mouth/pharynx inspection, a tongue blade triggers gagging. After removing the blade,
the nurse should:
A. Repeatedly stimulate to test again
B. Document an intact gag reflex ✔
C. Notify physician of absent reflex
D. Suction the oropharynx immediately
Rationale: A normal gag response indicates intact cranial nerves IX and X — document it.
4. When teaching monthly breast self-examination, which area should be assessed most closely?
A. Nipple only
B. Lower inner quadrant
C. Periareolar area only
D. Upper outer quadrant ✔
Rationale: The upper outer quadrant contains much of the glandular tissue and is the most
common site of breast cancer.
,ESTUDYR
5. A postmenopausal client with BMI 32: waist 45", hips 50". What health promotion message is
most important?
A. "You need more fiber."
B. "Start strength training only."
C. "A waist circumference >35" increases risk for type 2 diabetes and heart disease." ✔
D. "BMI is the only risk factor."
Rationale: Central obesity (waist >35" in women) is strongly linked to cardiometabolic risk.
6. Which change from prior exams may indicate osteoporosis in an older female?
A. New hair loss
B. Decreased breath sounds
C. Height reduction of 1.5 inches ✔
D. Increased appetite
Rationale: Vertebral compression fractures and kyphosis cause measurable height loss.
7. If a client pauses and looks expectantly during an interview, the nurse should:
A. Fill the silence with more questions
B. Move to the next topic quickly
C. Sit quietly to allow the client to respond comfortably ✔
D. Repeat the question louder
Rationale: Therapeutic silence gives clients time to think and respond.
8. Before abdominal examination, the nurse should:
A. Ask the client to drink water
B. Perform deep palpation first
C. Ask the client to empty the bladder ✔
D. Measure height and weight at bedside
Rationale: A full bladder can obscure palpation and cause discomfort; voiding improves comfort
and accuracy.
9. A respiratory rate of 8 breaths/min should be documented as:
A. Tachypnea
B. Bradypnea ✔
C. Apnea
, ESTUDYR
D. Eupnea
Rationale: Bradypnea = respirations <12 breaths/min in adults.
10. To assess pulse deficit, the nurse should:
A. Compare radial to femoral pulses
B. Palpate both wrists simultaneously
C. Measure apical pulse and compare to peripheral (radial) pulse ✔
D. Use only an automatic BP monitor
Rationale: Pulse deficit = difference between apical and peripheral pulse rates (e.g., in atrial
fibrillation).
11. Bilateral lower-lobe atelectasis produces which percussion note?
A. Tympany
B. Hyperresonant
C. Dull, thud-like ✔
D. Flat only at apex
Rationale: Consolidation/atelectasis produces dullness on percussion due to increased tissue
density.
12. To begin a head-to-toe assessment at the head, the nurse should first:
A. Auscultate lung sounds
B. Inspect the abdomen
C. Inspect the hair and scalp and skin ✔
D. Perform cranial nerve testing
Rationale: Inspection is performed before palpation and percussion; start with visible structures
like hair and scalp.
13. When palpating the abdominal aorta in a healthy young adult, the nurse should:
A. Palpate only in the left lower quadrant
B. Deep palpation above and slightly left of the umbilicus ✔
C. Use only light palpation at the epigastrium
D. Palpate at the midclavicular line
Rationale: The aorta is palpated deep in the upper midline/just left of the midline above the
umbilicus.
BSN 246 HESI HEALTH ASSESSMENT V1 UPDATED EXAM WITH MOST
TESTED QUESTIONS AND ANSWERS | GRADED A+ | ASSURED SUCCESS
WITH DETAILED RATIONALES
1. The nurse is performing a thoracic assessment on a client with chronic asthma and
hyperinflation of the lungs. Which finding should be expected?
A. Pectus excavatum
B. Kyphosis
C. Barrel chest ✔
D. Funnel chest
Rationale: Chronic air trapping and hyperinflation in asthma cause increased anterior-posterior
diameter → barrel chest.
2. The nurse hears bowel sounds in the right upper quadrant. What should the nurse do next?
A. Immediately document “normal” and leave
B. Note the character and frequency of bowel sounds ✔
C. Palpate the left lower quadrant first
D. Call the physician for orders
Rationale: Hearing bowel sounds requires further characterization (e.g., active, hypoactive,
high-pitched).
3. During mouth/pharynx inspection, a tongue blade triggers gagging. After removing the blade,
the nurse should:
A. Repeatedly stimulate to test again
B. Document an intact gag reflex ✔
C. Notify physician of absent reflex
D. Suction the oropharynx immediately
Rationale: A normal gag response indicates intact cranial nerves IX and X — document it.
4. When teaching monthly breast self-examination, which area should be assessed most closely?
A. Nipple only
B. Lower inner quadrant
C. Periareolar area only
D. Upper outer quadrant ✔
Rationale: The upper outer quadrant contains much of the glandular tissue and is the most
common site of breast cancer.
,ESTUDYR
5. A postmenopausal client with BMI 32: waist 45", hips 50". What health promotion message is
most important?
A. "You need more fiber."
B. "Start strength training only."
C. "A waist circumference >35" increases risk for type 2 diabetes and heart disease." ✔
D. "BMI is the only risk factor."
Rationale: Central obesity (waist >35" in women) is strongly linked to cardiometabolic risk.
6. Which change from prior exams may indicate osteoporosis in an older female?
A. New hair loss
B. Decreased breath sounds
C. Height reduction of 1.5 inches ✔
D. Increased appetite
Rationale: Vertebral compression fractures and kyphosis cause measurable height loss.
7. If a client pauses and looks expectantly during an interview, the nurse should:
A. Fill the silence with more questions
B. Move to the next topic quickly
C. Sit quietly to allow the client to respond comfortably ✔
D. Repeat the question louder
Rationale: Therapeutic silence gives clients time to think and respond.
8. Before abdominal examination, the nurse should:
A. Ask the client to drink water
B. Perform deep palpation first
C. Ask the client to empty the bladder ✔
D. Measure height and weight at bedside
Rationale: A full bladder can obscure palpation and cause discomfort; voiding improves comfort
and accuracy.
9. A respiratory rate of 8 breaths/min should be documented as:
A. Tachypnea
B. Bradypnea ✔
C. Apnea
, ESTUDYR
D. Eupnea
Rationale: Bradypnea = respirations <12 breaths/min in adults.
10. To assess pulse deficit, the nurse should:
A. Compare radial to femoral pulses
B. Palpate both wrists simultaneously
C. Measure apical pulse and compare to peripheral (radial) pulse ✔
D. Use only an automatic BP monitor
Rationale: Pulse deficit = difference between apical and peripheral pulse rates (e.g., in atrial
fibrillation).
11. Bilateral lower-lobe atelectasis produces which percussion note?
A. Tympany
B. Hyperresonant
C. Dull, thud-like ✔
D. Flat only at apex
Rationale: Consolidation/atelectasis produces dullness on percussion due to increased tissue
density.
12. To begin a head-to-toe assessment at the head, the nurse should first:
A. Auscultate lung sounds
B. Inspect the abdomen
C. Inspect the hair and scalp and skin ✔
D. Perform cranial nerve testing
Rationale: Inspection is performed before palpation and percussion; start with visible structures
like hair and scalp.
13. When palpating the abdominal aorta in a healthy young adult, the nurse should:
A. Palpate only in the left lower quadrant
B. Deep palpation above and slightly left of the umbilicus ✔
C. Use only light palpation at the epigastrium
D. Palpate at the midclavicular line
Rationale: The aorta is palpated deep in the upper midline/just left of the midline above the
umbilicus.
