BSN 246 HESI Health Assessment Exam V1 - V4

pg. 1 BSN 246 HESI Health Assessment Exam (V1 - V4) Latest 2024 -2025 TEST BANK/ Complete 1000+ Real Exam Questions with Detailed Verified Answers (100% Correct Answers) Graded A+

• An adult patient presents to the E.D. with "vaginal bleeding" and dizziness. Level of

consciousness is decreased. The nurse prioritizes collecting which vital signs?

• Respiratory rate and temperature.
• Body mass index (BMI).
• Weight and oxygen saturation.
• Heart rate and blood pressure. - Correct Answer - D

• A 40 year-old patient with hypertension (HTN) presents to the internal medicine clinic

for an initial visit. When obtaining the patient's blood pressure (BP), how should the nurse proceed?

• Cuff should be inflated to the exact point at which the palpated pulse

disappeared.

• Cuff should be inflated to about 200 mmHg and then slowly deflated.
• Cuff should be inflated about 20-30 mmHg above the palpated systolic BP.
• Cuff should be inflated 30 mm Hg above the patient's pulse rate. - Correct

Answer - C

• The nurse is performing a head-to-toe assessment on a dark-skinned client

presenting with "fatigue." To best assess for pallor, the nurse should check which of these areas?

• Conjunctivae.
• Sclera. 1 / 4

pg. 2

• Middle ear.
• Hair. - Correct Answer - A-Pallor will be best seen in lesser pigmented areas such

as the oral mucosa and conjunctivae, which are normally pink in color.

• The nurse is examining a patient presenting with "severe headache." Which

assessment finding leads the nurse to suspect increased intracranial pressure?

• Enlarged and tender occipital lymph nodes.
• Red, bulging tympanic membrane.
• Blurred margins of the optic disc.
• Pupils are 4mm and reactive. - Correct Answer - C

• A 12 year-old child presents to the clinic complaining of "ear pain". The mother

accompanies the child. The nurse utilizes which technique?

• While inserting the otoscope, the nurse pulls the pinna up and back.
• The nurse examines the middle ear with the child in the prone position.
• The nurse percusses the mastoid process for dullness.
• The nurse pulls the pinna straight down and inspects the tympanic membrane

with the penlight. - Correct Answer - A

• During a general survey of a 20 year-old patient presenting with "ear pain", the nurse

observes ptosis and drooling from the left side of the mouth. The nurse suspects dysfunction of which cranial nerve (CN)?

A. CN II.

B. CN IV.

C. CN VII.

• CN V. - Correct Answer - C

• The nurse is examining a 68 year-old male with a "hearing problem." The client says

it started suddenly last week, is worse in the left ear, and it sounds like everyone is mumbling and whispering but it helps when they talk louder. Based on subjective data, what should the nurse do first?

• / 4

pg. 3

• Assess his mood and ask how the hearing loss is affecting his life.
• Assume the client is developing presbycusis and refer for audiometric testing.
• Perform an otoscopic examination of the external and middle ear.
• Suspect a sensorineural loss and assess the functions of the inner ear. - Correct

Answer - C

• During an examination of a 70 year-old client presenting with "rash", the nurse

notices small grouped vesicles along the left side of the client's chest. The client says it started earlier in the week and it is "very painful." The nurse suspects:

• Kaposi Sarcoma.
• Herpes zoster.
• Candidiasis.
• Allergic drug reaction. - Correct Answer - B

• The nurse is assessing an adult Black client presenting to the emergency department

with gastrointestinal bleeding. Interview reveals that the patient is on blood thinners.The nurse knows to observe for petechiae in which area?

• Genitalia.
• Oral mucosa.
• Scalp.
• Middle ear. - Correct Answer - B

• The nurse is caring for a client with a severe deficiency of thyroid hormone.

Examination reveals decreased vital signs, weakness, and nonpitting edema on the

face. The nurse documents:

• exophthalmos.
• anasarca.
• myxedema.
• scleroderma. - Correct Answer - C

• The nurse is examining a patient undergoing withdrawal from opiates. The

temperature is 102 degrees Fahrenheit. What other vital sign change does the nurse expect to find, in relation to the fever?

• Low oxygen saturation. 3 / 4

pg. 4

• Bradypnea.
• Elevated heart rate.
• Hypotension. - Correct Answer - C

• An adolescent male has been brought into the emergency department after a

motorized scooter accident. How should the nurse begin the mental status examination?

• Assess the patient's level of consciousness.
• Assess the patient's judgment.
• Assess the patient's recent memory.
• Determine if the patient has suicidal thoughts. - Correct Answer - A

• A mother brings her 6 year-old child in for "irritability." How should the nurse conduct

the mental status exam?

• The nurse can defer the mental status exam, as irritability is normal in a 6 year-

old child.

• The nurse should begin the exam by having the patient fill out the GAD-7 and

PHQ-9.

• The mini-mental state exam (MMSE) should be used to obtain a baseline for

cognitive ability.

• Appearance, behavior, cognition, and thought processes can be assessed with

special consideration for developmental milestones. - Correct Answer - D

• The RN is gathering the vital signs of an adult athlete and finds the following:

temperature-36.9° C; pulse-48 beats per minute; respirations-12 breaths per minute; blood pressure-104/58 mm Hg. What should the nurse do next?

• Continue with the exam; these are normal vitals for a healthy, athletic adult.
• Document "bradypnea" in the client's chart.
• Notify the physician of the pulse and blood pressure.
• Recheck all vital signs to confirm the findings. - Correct Answer - A
• / 4