BSN 246 HESI Health Assessment V1 || All Answers are Flawless.
The nurse is performing a thoracic assessment on a client with chronic asthma and hyperinflation
of the lungs. Which finding should be expected for this client? correct answers Barrel chest
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel sounds
in the right upper quadrant. What action should the nurse take next? correct answers Note the
character and frequency of bowel sounds
During inspection of a client's mouth and pharynx, the nurse places a tongue blade on the back of
the tongue which causes the client to gag. After removing the tongue blade, what action should
the nurse take? correct answers Document an intact gag reflex.
When teaching a client how to perform a monthly breast self-assessment, the nurse should tell
the client that it is most important to assess which part of the breast more closely for changes?
correct answers Upper outer quadrant.
The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a chest
measurement of 42 inches, waist measurement of 45 inches, and hip measurement of 50 inches.
What important message should the nurse explain to the client to promote health promotion?
correct answers A waist circumference is greater than 35 inches in women puts you at higher risk
for type 2 diabetes and heart disease."
The nurse performs a physical assessment on an older female client. Which change from the
prior exam may be an indication of osteoporosis? correct answers Height reduction of 1.5 inches.
While conducting an interview to obtain a health history, the nurse notices that the client pauses
frequently and looks at the nurse expectantly. Which response is best for the nurse to provide?
correct answers Sit quietly to allow the client to respond comfortably.
A client is in the clinical for a yearly physical examination. Which action should the nurse take
when preparing to examine the client's abdomen? correct answers Ask the client to urinate before
beginning the examination.
, Which respiratory condition should the nurse document after measuring a respiratory rate of 8
breaths/minute? correct answers Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit? correct answers Measure the
apical pulse and compare it to the peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point of maximal impulse
and the radial pulse palpated at the wrist.
A client has been diagnosed with bilateral lower lobe atelectasis. What percussion sound should
the nurse expect to hear when percussing over the client's lower lobes? correct answers Dull,
thud-like.
A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing to
complete a head-to-toe assessment and will begin at the head of the client. Which technique
should the nurse use to begin the assessment? correct answers Inspect the hair and skin.
The nurse is assessing a healthy young adult during an annual physical examination. Which
assessment technique should the nurse implement when palpating the abdominal aorta? correct
answers Deep palpation above and to the left of the umbilicus.
The nurse is conducting a family history as part of the assessment interview. Which action
should the nurse take to ensure that sufficient information about the client's blood relatives is
obtained? correct answers Document at least 3 generations of the client's family medical history.
The nurse is testing the client's shoulders for range of motion. What should the nurse document
to record normal internal rotation? correct answers Range of 90 degrees when the hands are
placed at the small of the back.
The nurse is performing a thoracic assessment on a client with chronic asthma and hyperinflation
of the lungs. Which finding should be expected for this client? correct answers Barrel chest
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel sounds
in the right upper quadrant. What action should the nurse take next? correct answers Note the
character and frequency of bowel sounds
During inspection of a client's mouth and pharynx, the nurse places a tongue blade on the back of
the tongue which causes the client to gag. After removing the tongue blade, what action should
the nurse take? correct answers Document an intact gag reflex.
When teaching a client how to perform a monthly breast self-assessment, the nurse should tell
the client that it is most important to assess which part of the breast more closely for changes?
correct answers Upper outer quadrant.
The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a chest
measurement of 42 inches, waist measurement of 45 inches, and hip measurement of 50 inches.
What important message should the nurse explain to the client to promote health promotion?
correct answers A waist circumference is greater than 35 inches in women puts you at higher risk
for type 2 diabetes and heart disease."
The nurse performs a physical assessment on an older female client. Which change from the
prior exam may be an indication of osteoporosis? correct answers Height reduction of 1.5 inches.
While conducting an interview to obtain a health history, the nurse notices that the client pauses
frequently and looks at the nurse expectantly. Which response is best for the nurse to provide?
correct answers Sit quietly to allow the client to respond comfortably.
A client is in the clinical for a yearly physical examination. Which action should the nurse take
when preparing to examine the client's abdomen? correct answers Ask the client to urinate before
beginning the examination.
, Which respiratory condition should the nurse document after measuring a respiratory rate of 8
breaths/minute? correct answers Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit? correct answers Measure the
apical pulse and compare it to the peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point of maximal impulse
and the radial pulse palpated at the wrist.
A client has been diagnosed with bilateral lower lobe atelectasis. What percussion sound should
the nurse expect to hear when percussing over the client's lower lobes? correct answers Dull,
thud-like.
A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing to
complete a head-to-toe assessment and will begin at the head of the client. Which technique
should the nurse use to begin the assessment? correct answers Inspect the hair and skin.
The nurse is assessing a healthy young adult during an annual physical examination. Which
assessment technique should the nurse implement when palpating the abdominal aorta? correct
answers Deep palpation above and to the left of the umbilicus.
The nurse is conducting a family history as part of the assessment interview. Which action
should the nurse take to ensure that sufficient information about the client's blood relatives is
obtained? correct answers Document at least 3 generations of the client's family medical history.
The nurse is testing the client's shoulders for range of motion. What should the nurse document
to record normal internal rotation? correct answers Range of 90 degrees when the hands are
placed at the small of the back.
