HESI HEALTH ASSESSMENT NIGHTINGALE COLLEGE | ACTUAL EXAM
QUESTIONS AND ANSWERS, (WITH EVERYTHING YOU NEED) LATEST
UPDATED 2025
Question 1
A 29-year-old client tells the nurse, "I can't seem to get rid of this body-wracking dry cough that
has been hanging around for the last six weeks." How should the nurse document this client's
chief complaint?
A) Client complains of a chronic cough.
B) Client states, "I think I have lung cancer."
C) Reports having a "body-wracking dry cough" of 6 weeks duration.
D) Patient has a 6-week history of a non-productive cough.
Correct Answer: C) Describe having a "body-wracking dry cough" of 6 weeks duration.
Rationale: The chief complaint should be documented, whenever possible, using the client's
own words. This captures the client's perception of their problem accurately and avoids
premature diagnostic interpretation by the nurse.
Question 2
A 75-year-old client with a history of a cerebrovascular accident (CVA) has right hemiparesis.
When testing the deep tendon reflexes on the right side, the nurse elicits a 4+ response. This
finding indicates a(n):
A) Normal response for an older adult.
B) Diminished response consistent with a lower motor neuron disorder.
C) Hyperactive response consistent with an upper motor neuron disorder.
D) Expected finding in a client with hemiparesis.
Correct Answer: C) Hyperactive response consistent with an upper motor neuron disorder.
Rationale: A CVA (stroke) is an upper motor neuron lesion. This type of lesion disrupts the
inhibitory signals from the brain to the spinal cord, leading to hyperreflexia (exaggerated
reflexes, graded as 4+) and spasticity on the affected side.
Question 3
While examining a client's abdomen, which finding would be considered abnormal when
palpating the spleen?
A) The spleen is non-palpable.
B) A firm mass is palpated at the bottom of the left rib cage.
C) The client reports no tenderness on palpation.
D) Tympany is percussed over the splenic area.
Correct Answer: B) Firm mass palpated at bottom of left rib cage.
Rationale: A normal, healthy spleen is not palpable in an adult. If the spleen can be felt
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below the left costal margin, it indicates splenomegaly (enlargement), which is an abnormal
finding associated with various medical conditions like infection or liver disease.
Question 4
To auscultate for the presence of a carotid artery bruit, where should the nurse place the bell of
the stethoscope?
A) Directly over the angle of the jaw.
B) At the base of the neck, just above the clavicle.
C) Over the anterior neck, along the medial border of the sternocleidomastoid muscle.
D) On the posterior neck, lateral to the cervical spine.
Correct Answer: C) Place bell of stethoscope over carotid artery
Rationale: The carotid artery runs up the neck along the sternocleidomastoid muscle. A
bruit is a low-pitched sound of turbulent blood flow, so the bell of the stethoscope should be
placed over the artery in three locations: at the angle of the jaw, the mid-cervical area, and
the base of the neck.
Question 5
A client is being seen for a follow-up after treatment for pneumonia. Which technique should the
nurse use to best assess for adventitious lung sounds?
A) Place the bell of the stethoscope lightly on the skin.
B) Ask the client to take rapid, shallow breaths.
C) Press the stethoscope's diaphragm firmly on the skin over each lung field.
D) Have the client hold their breath while listening.
Correct Answer: C) Press the stethoscope's diaphragm firmly on the skin over each lung
field.
Rationale: Lung sounds are high-pitched, so the diaphragm of the stethoscope is the
appropriate tool. It must be pressed firmly against the skin to create a good seal and to
effectively transmit the sounds for a clear and accurate auscultation.
Question 6
A client with a diagnosed streptococcal pharyngitis now reports a high fever, severe unilateral
throat pain, difficulty swallowing, and a "hot potato" or muffled voice. The nurse should suspect
which complication?
A) Epiglottitis
B) A retropharyngeal abscess
C) Ludwig's angina
D) A peritonsillar abscess
Correct Answer: D) Peritonsillar abscess.
Rationale: A peritonsillar abscess is a collection of pus that forms behind one of the tonsils.
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It is a common complication of tonsillitis or severe pharyngitis. The classic signs are severe
unilateral pain, fever, a muffled voice, and trismus (difficulty opening the mouth).
Question 7
When obtaining a health history from a client scheduled for surgery, how should the nurse
approach asking about the use of illegal drugs and alcohol?
A) Ask, "You don't use any illegal drugs, do you?"
B) Document "denies substance use" if the client does not volunteer the information.
C) Use a non-judgmental, direct approach, asking specifically about alcohol, marijuana, and
other common substances.
D) Ask the client's family members about their substance use in private.
Correct Answer: C) Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts.
Rationale: To build rapport and obtain an accurate history, the nurse should use a direct,
matter-of-fact, and non-judgmental questioning style. Asking about specific substances and
amounts is more effective than using vague terms like "drugs" and communicates that this
is a routine and important part of the health assessment.
Question 8
A client reports pain in the lower abdomen. The nurse applies pressure to the area, and the client
feels no pain, but when the pressure is quickly released, the client reports sharp pain. What is the
nurse's priority action?
A) Document the finding as normal.
B) Apply a warm compress to the area.
C) Notify the healthcare provider of the rebound tenderness.
D) Continue to palpate the area to confirm the finding.
Correct Answer: C) Notify the healthcare provider of the rebound tenderness.
Rationale: Rebound tenderness is a classic sign of peritoneal inflammation (peritonitis),
which can be caused by a serious condition like appendicitis or a perforated organ. It is a
significant abnormal finding that requires immediate notification of the provider for
further evaluation.
Question 9
The nurse is assessing an ulcer on a client's lower leg to determine if it is caused by venous or
arterial insufficiency. Which of the following findings would be most characteristic of a venous
ulcer?
A) The ulcer is located on the tips of the toes.
B) The ulcer has a "punched-out" appearance with well-defined edges.
C) The surrounding skin is thin, shiny, and hairless.
D) The ulcer is located on the inner lower leg (medial malleolus) and has an irregular shape.
QUESTIONS AND ANSWERS, (WITH EVERYTHING YOU NEED) LATEST
UPDATED 2025
Question 1
A 29-year-old client tells the nurse, "I can't seem to get rid of this body-wracking dry cough that
has been hanging around for the last six weeks." How should the nurse document this client's
chief complaint?
A) Client complains of a chronic cough.
B) Client states, "I think I have lung cancer."
C) Reports having a "body-wracking dry cough" of 6 weeks duration.
D) Patient has a 6-week history of a non-productive cough.
Correct Answer: C) Describe having a "body-wracking dry cough" of 6 weeks duration.
Rationale: The chief complaint should be documented, whenever possible, using the client's
own words. This captures the client's perception of their problem accurately and avoids
premature diagnostic interpretation by the nurse.
Question 2
A 75-year-old client with a history of a cerebrovascular accident (CVA) has right hemiparesis.
When testing the deep tendon reflexes on the right side, the nurse elicits a 4+ response. This
finding indicates a(n):
A) Normal response for an older adult.
B) Diminished response consistent with a lower motor neuron disorder.
C) Hyperactive response consistent with an upper motor neuron disorder.
D) Expected finding in a client with hemiparesis.
Correct Answer: C) Hyperactive response consistent with an upper motor neuron disorder.
Rationale: A CVA (stroke) is an upper motor neuron lesion. This type of lesion disrupts the
inhibitory signals from the brain to the spinal cord, leading to hyperreflexia (exaggerated
reflexes, graded as 4+) and spasticity on the affected side.
Question 3
While examining a client's abdomen, which finding would be considered abnormal when
palpating the spleen?
A) The spleen is non-palpable.
B) A firm mass is palpated at the bottom of the left rib cage.
C) The client reports no tenderness on palpation.
D) Tympany is percussed over the splenic area.
Correct Answer: B) Firm mass palpated at bottom of left rib cage.
Rationale: A normal, healthy spleen is not palpable in an adult. If the spleen can be felt
,[Type here]
below the left costal margin, it indicates splenomegaly (enlargement), which is an abnormal
finding associated with various medical conditions like infection or liver disease.
Question 4
To auscultate for the presence of a carotid artery bruit, where should the nurse place the bell of
the stethoscope?
A) Directly over the angle of the jaw.
B) At the base of the neck, just above the clavicle.
C) Over the anterior neck, along the medial border of the sternocleidomastoid muscle.
D) On the posterior neck, lateral to the cervical spine.
Correct Answer: C) Place bell of stethoscope over carotid artery
Rationale: The carotid artery runs up the neck along the sternocleidomastoid muscle. A
bruit is a low-pitched sound of turbulent blood flow, so the bell of the stethoscope should be
placed over the artery in three locations: at the angle of the jaw, the mid-cervical area, and
the base of the neck.
Question 5
A client is being seen for a follow-up after treatment for pneumonia. Which technique should the
nurse use to best assess for adventitious lung sounds?
A) Place the bell of the stethoscope lightly on the skin.
B) Ask the client to take rapid, shallow breaths.
C) Press the stethoscope's diaphragm firmly on the skin over each lung field.
D) Have the client hold their breath while listening.
Correct Answer: C) Press the stethoscope's diaphragm firmly on the skin over each lung
field.
Rationale: Lung sounds are high-pitched, so the diaphragm of the stethoscope is the
appropriate tool. It must be pressed firmly against the skin to create a good seal and to
effectively transmit the sounds for a clear and accurate auscultation.
Question 6
A client with a diagnosed streptococcal pharyngitis now reports a high fever, severe unilateral
throat pain, difficulty swallowing, and a "hot potato" or muffled voice. The nurse should suspect
which complication?
A) Epiglottitis
B) A retropharyngeal abscess
C) Ludwig's angina
D) A peritonsillar abscess
Correct Answer: D) Peritonsillar abscess.
Rationale: A peritonsillar abscess is a collection of pus that forms behind one of the tonsils.
, [Type here]
It is a common complication of tonsillitis or severe pharyngitis. The classic signs are severe
unilateral pain, fever, a muffled voice, and trismus (difficulty opening the mouth).
Question 7
When obtaining a health history from a client scheduled for surgery, how should the nurse
approach asking about the use of illegal drugs and alcohol?
A) Ask, "You don't use any illegal drugs, do you?"
B) Document "denies substance use" if the client does not volunteer the information.
C) Use a non-judgmental, direct approach, asking specifically about alcohol, marijuana, and
other common substances.
D) Ask the client's family members about their substance use in private.
Correct Answer: C) Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts.
Rationale: To build rapport and obtain an accurate history, the nurse should use a direct,
matter-of-fact, and non-judgmental questioning style. Asking about specific substances and
amounts is more effective than using vague terms like "drugs" and communicates that this
is a routine and important part of the health assessment.
Question 8
A client reports pain in the lower abdomen. The nurse applies pressure to the area, and the client
feels no pain, but when the pressure is quickly released, the client reports sharp pain. What is the
nurse's priority action?
A) Document the finding as normal.
B) Apply a warm compress to the area.
C) Notify the healthcare provider of the rebound tenderness.
D) Continue to palpate the area to confirm the finding.
Correct Answer: C) Notify the healthcare provider of the rebound tenderness.
Rationale: Rebound tenderness is a classic sign of peritoneal inflammation (peritonitis),
which can be caused by a serious condition like appendicitis or a perforated organ. It is a
significant abnormal finding that requires immediate notification of the provider for
further evaluation.
Question 9
The nurse is assessing an ulcer on a client's lower leg to determine if it is caused by venous or
arterial insufficiency. Which of the following findings would be most characteristic of a venous
ulcer?
A) The ulcer is located on the tips of the toes.
B) The ulcer has a "punched-out" appearance with well-defined edges.
C) The surrounding skin is thin, shiny, and hairless.
D) The ulcer is located on the inner lower leg (medial malleolus) and has an irregular shape.
