BSN 246 HESI Health Assessment Exam Prep (Latest 2025/ 2026
Update) Questions & Answers| Grade A| 100% Correct (Verified
Solutions)- Nightingale
Question 1
When conducting a health history interview with a client, which of the following is an example
of an open-ended question?
A) "Are you allergic to any medications?"
B) "Can you tell me more about what your chest pain feels like?"
C) "Is your pain worse in the morning?"
D) "Have you ever had surgery before?"
E) "Do you take your blood pressure medicine every day?"
Correct Answer: B) "Can you tell me more about what your chest pain feels like?"
Rationale: An open-ended question is designed to elicit a narrative response and encourage
the client to share detailed information. This question invites the client to describe their
symptoms in their own words, which is more effective for gathering qualitative data than a
question that can be answered with a simple "yes" or "no."
Question 2
The nurse is performing a physical assessment. The technique of tapping the client's skin with
short, sharp strokes to assess underlying structures is known as:
A) Inspection
B) Palpation
C) Percussion
D) Auscultation
E) Manipulation
Correct Answer: C) Percussion
Rationale: Percussion is the physical examination technique that involves striking a part of
the body to elicit a sound or vibration. It is used to determine the size, density, and location
of underlying organs, as well as to detect the presence of fluid or air.
Question 3
A client's blood pressure is measured as 154/96 mmHg. The nurse should document this finding
as which stage of hypertension?
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A) Normal
B) Elevated
C) Stage 1 Hypertension
D) Stage 2 Hypertension
E) Hypertensive Crisis
Correct Answer: D) Stage 2 Hypertension
Rationale: According to the 2017 ACC/AHA guidelines, Stage 2 Hypertension is defined as a
systolic pressure of 140 mmHg or higher OR a diastolic pressure of 90 mmHg or higher.
This client's reading meets both criteria.
Question 4
When assessing the pupillary light reflex, the nurse shines a light into the client's left eye and
observes that the right pupil also constricts. This phenomenon is known as the:
A) Direct light reflex
B) Accommodation reflex
C) Consensual light reflex
D) Corneal light reflex
E) Red reflex
Correct Answer: C) Consensual light reflex
Rationale: The consensual light reflex is the simultaneous constriction of the pupil in the
opposite eye when a light is shone into one eye. This normal reflex indicates the integrity of
the neural pathways between the eyes and the brain.
Question 5
Which of the following findings is considered subjective data?
A) The client's temperature is 101.2°F.
B) The client's skin is pale and diaphoretic.
C) The client reports feeling nauseated.
D) The client's heart rate is 110 beats per minute.
E) A wound on the client's leg measures 3 cm in length.
,[Type here]
Correct Answer: C) The client reports feeling nauseated.
Rationale: Subjective data is information that is reported by the client and cannot be
directly observed or measured by the nurse. Nausea is a feeling or symptom that the client
experiences. All other options are objective data that the nurse can measure or observe.
Question 6
To accurately assess for jugular venous distention (JVD), the nurse should place the client in
which position?
A) Supine with the head of the bed flat.
B) Sitting upright at a 90-degree angle.
C) In a semi-Fowler's position, with the head of the bed elevated 30 to 45 degrees.
D) In a left lateral Sims' position.
E) In the Trendelenburg position.
Correct Answer: C) In a semi-Fowler's position, with the head of the bed elevated 30 to 45
degrees.
Rationale: This position is optimal for visualizing the jugular veins. If the client is lying flat,
the veins may be full and distended in a healthy person. If the client is sitting fully upright,
the veins may not be visible at all. The 30- to 45-degree angle allows for the accurate
assessment of venous pressure.
Question 7
The nurse auscultates a client's lung fields and hears a high-pitched, musical, squeaking sound,
primarily during expiration. This sound should be documented as:
A) Crackles (rales)
B) Rhonchi
C) Stridor
D) A wheeze
E) A pleural friction rub
Correct Answer: D) A wheeze
Rationale: A wheeze is a continuous, high-pitched musical sound caused by air being forced
through narrowed airways. It is the hallmark sound of bronchoconstriction and is a
characteristic finding in conditions like asthma and COPD.
, [Type here]
Question 8
When performing an abdominal assessment, the nurse should auscultate for bowel sounds:
A) After palpating the abdomen.
B) For at least one minute in each quadrant.
C) Before percussing or palpating the abdomen.
D) Using the bell of the stethoscope.
E) Only if the client reports abdominal pain.
Correct Answer: C) Before percussing or palpating the abdomen.
Rationale: The standard sequence for abdominal assessment is inspection, auscultation,
percussion, and then palpation. Auscultation is performed before palpation and percussion
because these techniques can stimulate the bowel and alter the frequency and character of
the bowel sounds, leading to an inaccurate assessment.
Question 9
A nurse is assessing a client's level of consciousness. The client is difficult to arouse and requires
vigorous shaking or a painful stimulus to respond. The nurse should document this level as:
A) Lethargic
B) Obtunded
C) Stuporous
D) Comatose
E) Alert
Correct Answer: C) Stuporous
Rationale: A stuporous client responds only to persistent and vigorous stimuli, such as
shaking or pain. When the stimulus is removed, the client immediately lapses back into a
state of unresponsiveness. This is a more profound level of unconsciousness than being
lethargic or obtunded.
Question 10
A nurse is assessing the skin of an older adult. The nurse gently pinches the skin below the
clavicle, and it remains tented for several seconds. This finding is an indicator of:
A) A normal aging change.
B) Dehydration.
Update) Questions & Answers| Grade A| 100% Correct (Verified
Solutions)- Nightingale
Question 1
When conducting a health history interview with a client, which of the following is an example
of an open-ended question?
A) "Are you allergic to any medications?"
B) "Can you tell me more about what your chest pain feels like?"
C) "Is your pain worse in the morning?"
D) "Have you ever had surgery before?"
E) "Do you take your blood pressure medicine every day?"
Correct Answer: B) "Can you tell me more about what your chest pain feels like?"
Rationale: An open-ended question is designed to elicit a narrative response and encourage
the client to share detailed information. This question invites the client to describe their
symptoms in their own words, which is more effective for gathering qualitative data than a
question that can be answered with a simple "yes" or "no."
Question 2
The nurse is performing a physical assessment. The technique of tapping the client's skin with
short, sharp strokes to assess underlying structures is known as:
A) Inspection
B) Palpation
C) Percussion
D) Auscultation
E) Manipulation
Correct Answer: C) Percussion
Rationale: Percussion is the physical examination technique that involves striking a part of
the body to elicit a sound or vibration. It is used to determine the size, density, and location
of underlying organs, as well as to detect the presence of fluid or air.
Question 3
A client's blood pressure is measured as 154/96 mmHg. The nurse should document this finding
as which stage of hypertension?
,[Type here]
A) Normal
B) Elevated
C) Stage 1 Hypertension
D) Stage 2 Hypertension
E) Hypertensive Crisis
Correct Answer: D) Stage 2 Hypertension
Rationale: According to the 2017 ACC/AHA guidelines, Stage 2 Hypertension is defined as a
systolic pressure of 140 mmHg or higher OR a diastolic pressure of 90 mmHg or higher.
This client's reading meets both criteria.
Question 4
When assessing the pupillary light reflex, the nurse shines a light into the client's left eye and
observes that the right pupil also constricts. This phenomenon is known as the:
A) Direct light reflex
B) Accommodation reflex
C) Consensual light reflex
D) Corneal light reflex
E) Red reflex
Correct Answer: C) Consensual light reflex
Rationale: The consensual light reflex is the simultaneous constriction of the pupil in the
opposite eye when a light is shone into one eye. This normal reflex indicates the integrity of
the neural pathways between the eyes and the brain.
Question 5
Which of the following findings is considered subjective data?
A) The client's temperature is 101.2°F.
B) The client's skin is pale and diaphoretic.
C) The client reports feeling nauseated.
D) The client's heart rate is 110 beats per minute.
E) A wound on the client's leg measures 3 cm in length.
,[Type here]
Correct Answer: C) The client reports feeling nauseated.
Rationale: Subjective data is information that is reported by the client and cannot be
directly observed or measured by the nurse. Nausea is a feeling or symptom that the client
experiences. All other options are objective data that the nurse can measure or observe.
Question 6
To accurately assess for jugular venous distention (JVD), the nurse should place the client in
which position?
A) Supine with the head of the bed flat.
B) Sitting upright at a 90-degree angle.
C) In a semi-Fowler's position, with the head of the bed elevated 30 to 45 degrees.
D) In a left lateral Sims' position.
E) In the Trendelenburg position.
Correct Answer: C) In a semi-Fowler's position, with the head of the bed elevated 30 to 45
degrees.
Rationale: This position is optimal for visualizing the jugular veins. If the client is lying flat,
the veins may be full and distended in a healthy person. If the client is sitting fully upright,
the veins may not be visible at all. The 30- to 45-degree angle allows for the accurate
assessment of venous pressure.
Question 7
The nurse auscultates a client's lung fields and hears a high-pitched, musical, squeaking sound,
primarily during expiration. This sound should be documented as:
A) Crackles (rales)
B) Rhonchi
C) Stridor
D) A wheeze
E) A pleural friction rub
Correct Answer: D) A wheeze
Rationale: A wheeze is a continuous, high-pitched musical sound caused by air being forced
through narrowed airways. It is the hallmark sound of bronchoconstriction and is a
characteristic finding in conditions like asthma and COPD.
, [Type here]
Question 8
When performing an abdominal assessment, the nurse should auscultate for bowel sounds:
A) After palpating the abdomen.
B) For at least one minute in each quadrant.
C) Before percussing or palpating the abdomen.
D) Using the bell of the stethoscope.
E) Only if the client reports abdominal pain.
Correct Answer: C) Before percussing or palpating the abdomen.
Rationale: The standard sequence for abdominal assessment is inspection, auscultation,
percussion, and then palpation. Auscultation is performed before palpation and percussion
because these techniques can stimulate the bowel and alter the frequency and character of
the bowel sounds, leading to an inaccurate assessment.
Question 9
A nurse is assessing a client's level of consciousness. The client is difficult to arouse and requires
vigorous shaking or a painful stimulus to respond. The nurse should document this level as:
A) Lethargic
B) Obtunded
C) Stuporous
D) Comatose
E) Alert
Correct Answer: C) Stuporous
Rationale: A stuporous client responds only to persistent and vigorous stimuli, such as
shaking or pain. When the stimulus is removed, the client immediately lapses back into a
state of unresponsiveness. This is a more profound level of unconsciousness than being
lethargic or obtunded.
Question 10
A nurse is assessing the skin of an older adult. The nurse gently pinches the skin below the
clavicle, and it remains tented for several seconds. This finding is an indicator of:
A) A normal aging change.
B) Dehydration.
