BSN 246 HESI
Health Assessment V2
EXAM
Nightingale College
Actual Qs & Verified Ans to Pass the Exam
, THIS DOCUMENT CONTAINS THE FOLLOWING:
passing score Guarantee
Format Set of Multiple-choice
questions with incorporating Next Generation NCLEX
(NGN) and Case scenarios questions
Expert-Verified Explanations & Solutions
, BSN 246 HESI HEALTH ASSESMENT V2 EXAM
002
1. The nurse is performing a cranial nerve exam on an 87-year-old client. The nurse notes
reduced upward gaze, decreased corneal reflex, high-frequency hearing loss, and reduced
gag reflex. What action should the nurse take next?
- A. Review past history for any episodes of a cerebral cortex lesion.
- B. Implement neuro vital signs every 2 hours to detect Cushing's Triad.
- C. Continue the assessment to the next pairs of cranial nerves.
- D. Assess the spinal reflexes for demyelination symptoms.
Correct Answer: C. Continue the assessment to the next pairs of cranial nerves.
Expert Rationale: A complete assessment is necessary to identify all cranial nerve function before making
any conclusions about neurological status.
---
2. When performing a neurologic assessment on an alert client, the nurse observes that the
client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation
should the nurse use when documenting the assessment?
- A. PERRL.
- B. GCS of 15.
- C. PERLA.
- D. Neuro status intact.
Correct Answer: A. PERRL.
Expert Rationale: PERRL stands for "Pupils Equal, Round, Reactive to Light," which succinctly describes
the findings satisfactorily.
---
3. . Which assessment technique provides the nurse with the best data related to the client's
level of peripheral perfusion?
- A. Blood pressure measurement.
- B. Capillary refill test.
- C. Coolness of extremities.
- D. Skin turgor assessment.
Correct Answer: B. Capillary refill test.
Expert Rationale: The capillary refill test offers quick insight into peripheral perfusion and circulatory
status.
, ---
4. The nurse is assessing a female client who states that her hemorrhoids are inflamed and
hurt constantly. Which intervention is best for the nurse to complete a focused
assessment?
- A. Ask the client how long she has experienced discomfort related to hemorrhoids.
- B. Place the client in a standing position, leaning over the exam bed for inspection.
- C. Determine if the client uses any over-the-counter preparation for hemorrhoids.
- D. Position the client in the left lateral position to inspect the perianal area for fissures or sacs.
Correct Answer: D. Position the client in the left lateral position to inspect the perianal area for fissures or
sacs.
Expert Rationale: This position allows for optimal visualization and assessment of the perianal area,
critical in evaluating hemorrhoids.
---
5. The nurse is performing an initial assessment of a client who has an expressionless facial
affect, slurred speech, and red conjunctiva. What question should the nurse ask first?
- A. Have you been depressed lately?
- B. Had everything to eat in the last 24 hours?
- C. Ever had problems with your blood sugar?
- D. Been sleeping well?
Correct Answer: D. Been sleeping well?
Expert Rationale: Asking about sleep can help identify acute behavioral changes; lack of sleep can relate
to the symptoms noted.
---
6. After checking a client's pupillary response to light, the practical nurse (PN) tells the nurse
that the client's pupils are constricted with minimal response to light. Before verifying the
PN's findings, which action should the nurse take?
- A. Brighten the light in the client's room.
- B. Assess the client's visual fields.
- C. Review the client's medication list.
- D. Administer PRN saline eye solution.
Correct Answer: B. Assess the client's visual fields.
Expert Rationale: Evaluation of visual fields can provide further insights into pupillary response and
possible neurological issues.
---
Health Assessment V2
EXAM
Nightingale College
Actual Qs & Verified Ans to Pass the Exam
, THIS DOCUMENT CONTAINS THE FOLLOWING:
passing score Guarantee
Format Set of Multiple-choice
questions with incorporating Next Generation NCLEX
(NGN) and Case scenarios questions
Expert-Verified Explanations & Solutions
, BSN 246 HESI HEALTH ASSESMENT V2 EXAM
002
1. The nurse is performing a cranial nerve exam on an 87-year-old client. The nurse notes
reduced upward gaze, decreased corneal reflex, high-frequency hearing loss, and reduced
gag reflex. What action should the nurse take next?
- A. Review past history for any episodes of a cerebral cortex lesion.
- B. Implement neuro vital signs every 2 hours to detect Cushing's Triad.
- C. Continue the assessment to the next pairs of cranial nerves.
- D. Assess the spinal reflexes for demyelination symptoms.
Correct Answer: C. Continue the assessment to the next pairs of cranial nerves.
Expert Rationale: A complete assessment is necessary to identify all cranial nerve function before making
any conclusions about neurological status.
---
2. When performing a neurologic assessment on an alert client, the nurse observes that the
client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation
should the nurse use when documenting the assessment?
- A. PERRL.
- B. GCS of 15.
- C. PERLA.
- D. Neuro status intact.
Correct Answer: A. PERRL.
Expert Rationale: PERRL stands for "Pupils Equal, Round, Reactive to Light," which succinctly describes
the findings satisfactorily.
---
3. . Which assessment technique provides the nurse with the best data related to the client's
level of peripheral perfusion?
- A. Blood pressure measurement.
- B. Capillary refill test.
- C. Coolness of extremities.
- D. Skin turgor assessment.
Correct Answer: B. Capillary refill test.
Expert Rationale: The capillary refill test offers quick insight into peripheral perfusion and circulatory
status.
, ---
4. The nurse is assessing a female client who states that her hemorrhoids are inflamed and
hurt constantly. Which intervention is best for the nurse to complete a focused
assessment?
- A. Ask the client how long she has experienced discomfort related to hemorrhoids.
- B. Place the client in a standing position, leaning over the exam bed for inspection.
- C. Determine if the client uses any over-the-counter preparation for hemorrhoids.
- D. Position the client in the left lateral position to inspect the perianal area for fissures or sacs.
Correct Answer: D. Position the client in the left lateral position to inspect the perianal area for fissures or
sacs.
Expert Rationale: This position allows for optimal visualization and assessment of the perianal area,
critical in evaluating hemorrhoids.
---
5. The nurse is performing an initial assessment of a client who has an expressionless facial
affect, slurred speech, and red conjunctiva. What question should the nurse ask first?
- A. Have you been depressed lately?
- B. Had everything to eat in the last 24 hours?
- C. Ever had problems with your blood sugar?
- D. Been sleeping well?
Correct Answer: D. Been sleeping well?
Expert Rationale: Asking about sleep can help identify acute behavioral changes; lack of sleep can relate
to the symptoms noted.
---
6. After checking a client's pupillary response to light, the practical nurse (PN) tells the nurse
that the client's pupils are constricted with minimal response to light. Before verifying the
PN's findings, which action should the nurse take?
- A. Brighten the light in the client's room.
- B. Assess the client's visual fields.
- C. Review the client's medication list.
- D. Administer PRN saline eye solution.
Correct Answer: B. Assess the client's visual fields.
Expert Rationale: Evaluation of visual fields can provide further insights into pupillary response and
possible neurological issues.
---
