BSN 246 HESI Health Assessment Exam V1 (Latest 2025/ 2026 Update)
Questions & Answers| Grade A| 100% Correct (Verified Solutions)-
Nightingale
Question 1
When assessing a client with shoulder pain, which physical examination finding is the most
reliable indicator of a rotator cuff tear?
A) The client reports a popping sensation with movement.
B) The shoulder appears visibly deformed and swollen.
C) The client is unable to slowly lower the arm after it is abducted.
D) Pain is elicited when the client shrugs their shoulders against resistance.
E) The client has a limited passive range of motion.
Correct Answer: C) The client is unable to slowly lower the arm after it is abducted.
Rationale: This is known as the "drop arm test." A positive result, where the client is unable
to smoothly and slowly lower their arm from an abducted position, is a classic sign of a
significant rotator cuff tear, as the muscles are unable to control the arm's descent.
Question 2
During cardiac auscultation at the second left intercostal space, the nurse hears a split second
heart sound (S2). To further investigate this finding, what is the nurse's best action?
A) Ask the client to hold their breath for 15 seconds.
B) Palpate the client's carotid pulse simultaneously.
C) Listen to the sound while observing the client's respirations.
D) Have the client perform the Valsalva maneuver.
E) Immediately notify the healthcare provider of a pathological finding.
Correct Answer: C) Listen to the sound while observing the client's respirations.
Rationale: A physiologic split S2 is a normal finding where the aortic and pulmonic valves
close at slightly different times, often becoming more apparent during inspiration. By
observing the client's respirations, the nurse can determine if the split widens with
inspiration and disappears with expiration, which would confirm it as a normal physiologic
split.
Question 3
An 82-year-old client has returned to the surgical unit following a hip replacement. When
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assessing the client's pain level, which pain assessment scale is most appropriate to use?
A) The FACES scale
B) A numeric rating scale (0-10)
C) A verbal descriptor scale
D) The CRIES scale
E) The FLACC scale
Correct Answer: C) A verbal descriptor scale
Rationale: The verbal descriptor scale uses simple words like "no pain," "mild pain,"
"moderate pain," and "severe pain" to describe the intensity. This scale is often easier for
older adults, especially those with some cognitive impairment, to understand and use
compared to assigning a number to their pain.
Question 4
While assessing a client's abdomen, the nurse observes visible peristaltic waves in the left lower
quadrant. What is the nurse's next assessment step?
A) Deeply palpate the area to assess for a mass.
B) Auscultate for bowel sounds in all four quadrants.
C) Percuss the abdomen to check for tympany.
D) Observe the direction of the peristaltic movement.
E) Ask the client if they are experiencing nausea.
Correct Answer: D) Observe the direction of the peristaltic movement.
Rationale: Visible peristaltic waves can be a sign of an intestinal obstruction. Observing the
direction of the movement can help identify the location of the potential blockage. This is a
critical observation to make before proceeding with other assessment techniques like
palpation, which could be painful or harmful.
Question 5
To accurately auscultate for breath sounds in the right middle lobe of the lung, where should the
nurse place the stethoscope?
A) At the second intercostal space, right of the sternum.
B) At the fourth intercostal space, in the right midclavicular line.
C) On the posterior chest, near the right scapular line.
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D) At the sixth intercostal space, in the right midaxillary line.
E) Directly over the xiphoid process.
Correct Answer: B) At the fourth intercostal space, in the right midclavicular line.
Rationale: The right middle lobe is best auscultated on the anterior chest wall. The
landmark for the right middle lobe is the fourth intercostal space at the right midclavicular
line. Placing the stethoscope here allows for the clearest assessment of air movement in this
specific lobe.
Question 6
A female registered nurse (RN) is attempting to perform a respiratory assessment on a Muslim
male client, but he refuses to allow her to listen to his breath sounds. How should the RN
respond?
A) Explain that the assessment is medically necessary and must be completed.
B) Document the client's refusal and skip that part of the assessment.
C) Ask a female family member to be present during the examination.
D) Request a male nurse or healthcare provider to perform the exam.
E) Reassure the client that the assessment will be performed quickly.
Correct Answer: D) Request a male nurse or healthcare provider to perform the exam.
Rationale: This response demonstrates cultural sensitivity and respect for the client's beliefs
and modesty. The nurse's priority is to provide care that is both medically necessary and
culturally congruent. Finding a male provider to perform the assessment is the most
appropriate action to meet the client's needs.
Question 7
A nurse is preparing a discharge plan for a client from a different cultural background. Which of
the following is a priority cultural issue for the nurse to assess?
A) The client's preference for hospital food.
B) The client's primary language and education level.
C) The number of visitors the client had during their stay.
D) The client's favorite television shows.
E) The client's typical bedtime.
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Correct Answer: B) The client's primary language and education level.
Rationale: To ensure a safe and effective discharge, the nurse must be able to provide
instructions that the client can understand. Assessing the client's primary language is
crucial for determining if an interpreter is needed, and assessing the education level helps
the nurse tailor the teaching materials and methods to ensure comprehension.
Question 8
A client is admitted with suspected peptic ulcer disease (PUD). Which of the following
assessment findings are consistent with this diagnosis?
A) Steatorrhea and frequent urination.
B) Hematemesis, gastric pain, and intolerance of spicy foods.
C) Rebound tenderness and a rigid abdomen.
D) Jaundice and right upper quadrant pain.
E) Aortic bruit and constipation.
Correct Answer: B) Hematemesis, gastric pain, and intolerance of spicy foods.
Rationale: PUD is characterized by erosion of the GI mucosa. This can lead to epigastric
pain (often described as burning or gnawing), which may be exacerbated by certain foods
like spices. If the ulcer erodes into a blood vessel, it can cause bleeding, which may present
as hematemesis (vomiting blood).
Question 9
Which of the following is a common complication of systemic lupus erythematosus (SLE) that
should be monitored for during assessment?
A) Bradycardia
B) Weight gain
C) Hypertension
D) Breaks in tissue integrity
E) Hyperactive bowel sounds
Correct Answer: D) Breaks in tissue integrity
Rationale: SLE is a systemic autoimmune disease that frequently affects the skin. Clients
can develop various rashes (like the characteristic butterfly rash), photosensitivity, and
Questions & Answers| Grade A| 100% Correct (Verified Solutions)-
Nightingale
Question 1
When assessing a client with shoulder pain, which physical examination finding is the most
reliable indicator of a rotator cuff tear?
A) The client reports a popping sensation with movement.
B) The shoulder appears visibly deformed and swollen.
C) The client is unable to slowly lower the arm after it is abducted.
D) Pain is elicited when the client shrugs their shoulders against resistance.
E) The client has a limited passive range of motion.
Correct Answer: C) The client is unable to slowly lower the arm after it is abducted.
Rationale: This is known as the "drop arm test." A positive result, where the client is unable
to smoothly and slowly lower their arm from an abducted position, is a classic sign of a
significant rotator cuff tear, as the muscles are unable to control the arm's descent.
Question 2
During cardiac auscultation at the second left intercostal space, the nurse hears a split second
heart sound (S2). To further investigate this finding, what is the nurse's best action?
A) Ask the client to hold their breath for 15 seconds.
B) Palpate the client's carotid pulse simultaneously.
C) Listen to the sound while observing the client's respirations.
D) Have the client perform the Valsalva maneuver.
E) Immediately notify the healthcare provider of a pathological finding.
Correct Answer: C) Listen to the sound while observing the client's respirations.
Rationale: A physiologic split S2 is a normal finding where the aortic and pulmonic valves
close at slightly different times, often becoming more apparent during inspiration. By
observing the client's respirations, the nurse can determine if the split widens with
inspiration and disappears with expiration, which would confirm it as a normal physiologic
split.
Question 3
An 82-year-old client has returned to the surgical unit following a hip replacement. When
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assessing the client's pain level, which pain assessment scale is most appropriate to use?
A) The FACES scale
B) A numeric rating scale (0-10)
C) A verbal descriptor scale
D) The CRIES scale
E) The FLACC scale
Correct Answer: C) A verbal descriptor scale
Rationale: The verbal descriptor scale uses simple words like "no pain," "mild pain,"
"moderate pain," and "severe pain" to describe the intensity. This scale is often easier for
older adults, especially those with some cognitive impairment, to understand and use
compared to assigning a number to their pain.
Question 4
While assessing a client's abdomen, the nurse observes visible peristaltic waves in the left lower
quadrant. What is the nurse's next assessment step?
A) Deeply palpate the area to assess for a mass.
B) Auscultate for bowel sounds in all four quadrants.
C) Percuss the abdomen to check for tympany.
D) Observe the direction of the peristaltic movement.
E) Ask the client if they are experiencing nausea.
Correct Answer: D) Observe the direction of the peristaltic movement.
Rationale: Visible peristaltic waves can be a sign of an intestinal obstruction. Observing the
direction of the movement can help identify the location of the potential blockage. This is a
critical observation to make before proceeding with other assessment techniques like
palpation, which could be painful or harmful.
Question 5
To accurately auscultate for breath sounds in the right middle lobe of the lung, where should the
nurse place the stethoscope?
A) At the second intercostal space, right of the sternum.
B) At the fourth intercostal space, in the right midclavicular line.
C) On the posterior chest, near the right scapular line.
,[Type here]
D) At the sixth intercostal space, in the right midaxillary line.
E) Directly over the xiphoid process.
Correct Answer: B) At the fourth intercostal space, in the right midclavicular line.
Rationale: The right middle lobe is best auscultated on the anterior chest wall. The
landmark for the right middle lobe is the fourth intercostal space at the right midclavicular
line. Placing the stethoscope here allows for the clearest assessment of air movement in this
specific lobe.
Question 6
A female registered nurse (RN) is attempting to perform a respiratory assessment on a Muslim
male client, but he refuses to allow her to listen to his breath sounds. How should the RN
respond?
A) Explain that the assessment is medically necessary and must be completed.
B) Document the client's refusal and skip that part of the assessment.
C) Ask a female family member to be present during the examination.
D) Request a male nurse or healthcare provider to perform the exam.
E) Reassure the client that the assessment will be performed quickly.
Correct Answer: D) Request a male nurse or healthcare provider to perform the exam.
Rationale: This response demonstrates cultural sensitivity and respect for the client's beliefs
and modesty. The nurse's priority is to provide care that is both medically necessary and
culturally congruent. Finding a male provider to perform the assessment is the most
appropriate action to meet the client's needs.
Question 7
A nurse is preparing a discharge plan for a client from a different cultural background. Which of
the following is a priority cultural issue for the nurse to assess?
A) The client's preference for hospital food.
B) The client's primary language and education level.
C) The number of visitors the client had during their stay.
D) The client's favorite television shows.
E) The client's typical bedtime.
, [Type here]
Correct Answer: B) The client's primary language and education level.
Rationale: To ensure a safe and effective discharge, the nurse must be able to provide
instructions that the client can understand. Assessing the client's primary language is
crucial for determining if an interpreter is needed, and assessing the education level helps
the nurse tailor the teaching materials and methods to ensure comprehension.
Question 8
A client is admitted with suspected peptic ulcer disease (PUD). Which of the following
assessment findings are consistent with this diagnosis?
A) Steatorrhea and frequent urination.
B) Hematemesis, gastric pain, and intolerance of spicy foods.
C) Rebound tenderness and a rigid abdomen.
D) Jaundice and right upper quadrant pain.
E) Aortic bruit and constipation.
Correct Answer: B) Hematemesis, gastric pain, and intolerance of spicy foods.
Rationale: PUD is characterized by erosion of the GI mucosa. This can lead to epigastric
pain (often described as burning or gnawing), which may be exacerbated by certain foods
like spices. If the ulcer erodes into a blood vessel, it can cause bleeding, which may present
as hematemesis (vomiting blood).
Question 9
Which of the following is a common complication of systemic lupus erythematosus (SLE) that
should be monitored for during assessment?
A) Bradycardia
B) Weight gain
C) Hypertension
D) Breaks in tissue integrity
E) Hyperactive bowel sounds
Correct Answer: D) Breaks in tissue integrity
Rationale: SLE is a systemic autoimmune disease that frequently affects the skin. Clients
can develop various rashes (like the characteristic butterfly rash), photosensitivity, and
