BSN 246 HESI Health Assessment Exam V1
Verified Questions Answers Rationales Nursing
Physical Assessment Guide Nightingale A+
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? - answer-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? - answer-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? - answer-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? - answer-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? - answer-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? - answer-Height reduction of 1.5 inches.
1
, 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? - answer-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? - answer-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? - answer-Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit? - answer-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? - answer-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? - answer-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? -
answer-Deep palpation above and to the left of the umbilicus.
2
Verified Questions Answers Rationales Nursing
Physical Assessment Guide Nightingale A+
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? - answer-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? - answer-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? - answer-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? - answer-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? - answer-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? - answer-Height reduction of 1.5 inches.
1
, 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? - answer-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? - answer-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? - answer-Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit? - answer-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? - answer-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? - answer-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? -
answer-Deep palpation above and to the left of the umbilicus.
2
