BSN 246 HESI HEALTH ASSESSMENT
EXAM V2 LATEST 2025 QUESTIONS AND
VERIFIED ANSWERS |100% CORRECT|
GRADE A- NIGHTINGALE
The nurse is conducting a physical assessment of a young
adult. Which information provides the best indication of the
individual's nutritional status?
A. Status of current appetite.
B. A 24-hour diet history.
C. History of a recent weight loss.
D. Condition of hair, nails, and skin. Correct Answer
Correct Answer is D. Hair, nail, and skin are the most
important reflection of nutritional status.
The nurse is assessing a healthy adult male during an
annual physical examination. The nurse auscultates the
client's abdomen and hears gurgling sound every ten
seconds. What action should the nurse take in response to
this finding?
A. Document this normal bowel sound activity in the
record.
B. Encourage increased consumption of fiber in the diet.
C. Observe the next bowel movement for signs of
bleeding.
D. Report the hyperactivity to the healthcare provider.
Correct Answer Correct Answer is A. Normal Bowel sound
consist of clicks and gurgles and 5-30 per minute. An
,occasional borborygmus (Loud prolonged gurgle) may be
hear.
In observing a client's face, which assessment finding
requires the most immediate intervention by the nurse?
A. Eyelids are matted and crusted.
B. Cornea are jaundiced.
C. Oral mucosa is cyanotic.
D. Face is flushed and diaphoretic. Correct Answer
Answer is C. Blue lips occur when the skin on the lips
takes on a bluish tint or color. This generally is due to
either a lock of oxygen in the blood or to extremely cold
temperatures. When the skin becomes a bluish color, the
symptom is called cyanosis. Most commonly, blue lips are
caused by a lack of oxygen in the blood. Most causes of
cyanosis are serious and symptom of your body not
getting enough oxygen. Over time, this condition will
become life-threatening. It can lead to respiratory failure,
heart failure, and even death, if left untreated.
While obtaining a health history, a male client tells the
nurse that he sometimes experiences shortness of breath.
The nurse determines that the client's respirators are
regular and deep, and his respiratory rate is 14
breaths/minutes. What is the best nursing action?
A. Ask the client to perform light exercise and observe the
respiratory effect.
B. Document "dyspnea on exertion" in the client's medical
record.
C. Ask the client to describe the episodes of dyspnea in
more detail.
,D. Explain to the client the possible causes of dyspnea or
"shortness of breath." Correct Answer Correct Answer is
C. Both respiratory rate and breath sounds are normal.
Further assessment is needed by asking the client to
describe his SOB
When assessing a male client's respiratory status, which
technique should the nurse use to assess his anterior-
posterior (AP) chest diameter? A. Auscultation. B.
Percussion. C. Palpation. D. Observation. Correct Answer
Correct Answer is D. Observation is the way to detect
barrel chest which is associated with COPD
Which assessment finding supports the client statement,
"My feet swell all the time?" A. 2+ pitting edema of ankles
bilaterally. B. Capillary refill both feet > 3 seconds. C.
Pedal pulses weak and thread. D. Positive Homan's sign
bilaterally. Correct Answer Correct Answer is A. 2+ pitting
edema indicate swelling in the lower extremities.
Homans's sign is often used in the diagnosis of deep
venous thrombosis of the leg. A positive Homans's sign
(calf pain at dorsiflexion of the foot) is thought to be
associated with the presence of thrombosis.
The nurse is performing a cranial nerve exam on an 87-
year-old client. The nurse notes that the client has a
reduced upward gaze, a decreased corneal reflex, a high
frequency hearing loss, and a 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 Correct Answer is C. Full
cranial nurses assessment should be completed before
considering the other options.
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 Correct Answer is A.
"Pupils Equal, Round, and Reactive to Light".
Which assessment technique provides the nurse with the
best data related to the client's level of peripheral
perfusion? Correct Answer Correct Answer C. Capillary
refill test
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
client in left lateral position to inspect perianal area for
fissures or sacs. Correct Answer Correct Answer is D. A
focused assessment collects relevant information
EXAM V2 LATEST 2025 QUESTIONS AND
VERIFIED ANSWERS |100% CORRECT|
GRADE A- NIGHTINGALE
The nurse is conducting a physical assessment of a young
adult. Which information provides the best indication of the
individual's nutritional status?
A. Status of current appetite.
B. A 24-hour diet history.
C. History of a recent weight loss.
D. Condition of hair, nails, and skin. Correct Answer
Correct Answer is D. Hair, nail, and skin are the most
important reflection of nutritional status.
The nurse is assessing a healthy adult male during an
annual physical examination. The nurse auscultates the
client's abdomen and hears gurgling sound every ten
seconds. What action should the nurse take in response to
this finding?
A. Document this normal bowel sound activity in the
record.
B. Encourage increased consumption of fiber in the diet.
C. Observe the next bowel movement for signs of
bleeding.
D. Report the hyperactivity to the healthcare provider.
Correct Answer Correct Answer is A. Normal Bowel sound
consist of clicks and gurgles and 5-30 per minute. An
,occasional borborygmus (Loud prolonged gurgle) may be
hear.
In observing a client's face, which assessment finding
requires the most immediate intervention by the nurse?
A. Eyelids are matted and crusted.
B. Cornea are jaundiced.
C. Oral mucosa is cyanotic.
D. Face is flushed and diaphoretic. Correct Answer
Answer is C. Blue lips occur when the skin on the lips
takes on a bluish tint or color. This generally is due to
either a lock of oxygen in the blood or to extremely cold
temperatures. When the skin becomes a bluish color, the
symptom is called cyanosis. Most commonly, blue lips are
caused by a lack of oxygen in the blood. Most causes of
cyanosis are serious and symptom of your body not
getting enough oxygen. Over time, this condition will
become life-threatening. It can lead to respiratory failure,
heart failure, and even death, if left untreated.
While obtaining a health history, a male client tells the
nurse that he sometimes experiences shortness of breath.
The nurse determines that the client's respirators are
regular and deep, and his respiratory rate is 14
breaths/minutes. What is the best nursing action?
A. Ask the client to perform light exercise and observe the
respiratory effect.
B. Document "dyspnea on exertion" in the client's medical
record.
C. Ask the client to describe the episodes of dyspnea in
more detail.
,D. Explain to the client the possible causes of dyspnea or
"shortness of breath." Correct Answer Correct Answer is
C. Both respiratory rate and breath sounds are normal.
Further assessment is needed by asking the client to
describe his SOB
When assessing a male client's respiratory status, which
technique should the nurse use to assess his anterior-
posterior (AP) chest diameter? A. Auscultation. B.
Percussion. C. Palpation. D. Observation. Correct Answer
Correct Answer is D. Observation is the way to detect
barrel chest which is associated with COPD
Which assessment finding supports the client statement,
"My feet swell all the time?" A. 2+ pitting edema of ankles
bilaterally. B. Capillary refill both feet > 3 seconds. C.
Pedal pulses weak and thread. D. Positive Homan's sign
bilaterally. Correct Answer Correct Answer is A. 2+ pitting
edema indicate swelling in the lower extremities.
Homans's sign is often used in the diagnosis of deep
venous thrombosis of the leg. A positive Homans's sign
(calf pain at dorsiflexion of the foot) is thought to be
associated with the presence of thrombosis.
The nurse is performing a cranial nerve exam on an 87-
year-old client. The nurse notes that the client has a
reduced upward gaze, a decreased corneal reflex, a high
frequency hearing loss, and a 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 Correct Answer is C. Full
cranial nurses assessment should be completed before
considering the other options.
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 Correct Answer is A.
"Pupils Equal, Round, and Reactive to Light".
Which assessment technique provides the nurse with the
best data related to the client's level of peripheral
perfusion? Correct Answer Correct Answer C. Capillary
refill test
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
client in left lateral position to inspect perianal area for
fissures or sacs. Correct Answer Correct Answer is D. A
focused assessment collects relevant information
