BSNl 246l HESIl Healthl Assessmentl Examl V4l (Latestl 2025/l 2026l Update)l Questionsl &l Answers|l Gradel A|l 100%l Correctl (Verifiedl Solutions)-l Nightingale
Q:l Thel nursel isl conductingl al physicall assessmentl ofl al youngl adult.l Whichl informationl providesl thel bestl indicationl ofl thel individual'sl nutritionall status?A.l Statusl ofl currentl appetite.l B.l Al 24-hourl dietl history.l C.l Historyl ofl al recentl weightl loss.l D.l Conditionl ofl hair,l nails,l andl skin.
Answer:
Correctl answerl isl D.l Hair,l nail,l andl skinl arel thel mostl importantl reflectionl ofl nutritionall status.
Q:l Thel nursel isl assessingl al healthyl adultl malel duringl anl annuall physicall examination.l Thel nursel auscultatesl thel client'sl abdomenl andl hearsl gurglingl soundl everyl tenl seconds.l Whatl actionl shouldl thel nursel takel inl responsel tol thisl finding?A.l Documentl thisl normall bowell soundl activityl inl thel record.l B.l Encouragel increasedl consumptionl ofl fiberl inl thel diet.l C.l Observel thel nextl bowell movementl forl signsl ofl bleeding.l D.l Reportl thel hyperactivityl tol thel healthcarel provider.
Answer:
Correctl answerl isl A.l Normall Bowell soundl consistl ofl clicksl andl gurglesl andl 5-30l perl minute.l Anl occasionall borborygmusl (Loudl prolongedl gurgle)l mayl bel hear.
Q:l Inl observingl al client'sl face,l whichl assessmentl findingl requiresl thel mostl immediatel interventionl byl thel nurse?A.l Eyelidsl arel mattedl andl crusted.B.l Corneal arel jaundiced.l C.l Orall mucosal isl cyanotic.l D.l Facel isl flushedl andl diaphoretic.
- / 3
Answer:
Answerl isl C.l Bluel lipsl occurl whenl thel skinl onl thel lipsl takesl onl al bluishl tintl orl color.l Thisl generallyl isl duel tol eitherl al lockl ofl oxygenl inl thel bloodl orl tol extremelyl coldl temperatures.l Whenl thel skinl becomesl al bluishl color,l thel symptoml isl calledl cyanosis.l Mostl commonly,l bluel lipsl arel causedl byl al lackl ofl oxygenl inl thel blood.l Mostl causesl ofl cyanosisl arel seriousl andl symptoml ofl yourl bodyl notl gettingl enoughl oxygen.l Overl time,l thisl conditionl willl becomel life-threatening.l Itl canl leadl tol respiratoryl failure,l heartl failure,l andl evenl death,l ifl leftl untreated.
Q:l Whilel obtainingl al healthl history,l al malel clientl tellsl thel nursel thatl hel sometimesl experiencesl shortnessl ofl breath.l Thel nursel determinesl thatl thel client'sl respiratorsl arel regularl andl deep,l andl hisl respiratoryl ratel isl 14l breaths/minutes.l Whatl isl thel bestl nursingl action?A.l Askl thel clientl tol performl lightl exercisel andl observel thel respiratoryl effect.l B.l Documentl "dyspneal onl exertion"l inl thel client'sl medicall record.l C.l Askl thel clientl tol describel thel episodesl ofl dyspneal inl morel detail.l D.l Explainl tol thel clientl thel possiblel causesl ofl dyspneal orl "shortnessl ofl breath."
Answer:
Correctl answerl isl C.l Bothl respiratoryl ratel andl breathl soundsl arel normal.l Furtherl assessmentl isl neededl byl askingl thel clientl tol describel hisl SOB
Q:l Whenl assessingl al malel client'sl respiratoryl status,l whichl techniquel shouldl thel nursel usel tol assessl hisl anterior-l posteriorl (AP)l chestl diameter?l A.l Auscultation.l B.l Percussion.l C.l Palpation.l D.l Observation.
Answer:
Correctl answerl isl D.l Observationl isl thel wayl tol detectl barrell chestl whichl isl associatedl withl COPD
Q:l Whichl assessmentl findingl supportsl thel clientl statement,l "Myl feetl swelll alll thel time?"l A.l 2+l pittingl edemal ofl anklesl bilaterally.l B.l Capillaryl refilll bothl feetl >l 3l seconds.l C.l Pedall pulsesl weakl andl thread.l D.l Positivel Homan'sl signl bilaterally.
Answer:
Correctl answerl isl A.l 2+l pittingl edemal indicatel swellingl inl thel lowerl extremities.l Homans'sl signl isl oftenl usedl inl thel diagnosisl ofl deepl venousl thrombosisl ofl thel leg.l Al 2 / 3
positivel Homans'sl signl (calfl painl atl dorsiflexionl ofl thel foot)l isl thoughtl tol bel associatedl withl thel presencel ofl thrombosis.
Q:l Thel nursel isl performingl al craniall nervel examl onl anl 87-year-oldl client.l Thel nursel notesl thatl thel clientl hasl al reducedl upwardl gaze,l al decreasedl corneall reflex,l al highl frequencyl hearingl loss,l andl al reducedl gagl reflex.l Whatl actionl shouldl thel nursel takel next?l A.l Reviewl pastl historyl forl anyl episodesl ofl al cerebrall cortexl lesion.l B.l Implementl neurol vitall signsl everyl 2l hoursl tol detectl Cushing'sl Triad.l C.l Continuel thel assessmentl tol thel nextl pairsl ofl craniall nerves.l D.l Assessl thel spinall reflexesl forl demyelinationl symptoms.
Answer:
Correctl answerl isl C.l Fulll craniall nursesl assessmentl shouldl bel completedl beforel consideringl thel otherl options.
Q:l Whenl performingl al neurologicl assessmentl onl anl alertl client,l thel nursel observesl thatl thel client'sl pupilsl arel bothl round,l 3l mml inl size,l andl respondl brisklyl tol light.l Whichl notationl shouldl thel nursel usel whenl documentingl thel assessment?l A.l PERRL.l B.l GCSl ofl 15.l C.l PERLA.l D.l Neurol statusl intact
Answer:
Correctl answerl isl A.l "Pupilsl Equal,l Round,l andl Reactivel tol Light".
Q:l Whichl assessmentl techniquel providesl thel nursel withl thel bestl datal relatedl tol thel client'sl levell ofl peripherall perfusion?
Answer:
correctl answerl C.l Capillaryl refilll test
Q:l Thel nursel isl assessingl al femalel clientl whol statesl thatl herl hemorrhoidsl arel inflamedl andl hurtl constantly.l Whichl interventionl isl bestl forl thel nursel tol completel al focusedl assessment?l A.l Askl thel clientl howl longl shel hasl experiencedl discomfortl relatedl tol hemorrhoids.l B.l Placel thel clientl inl al standingl position,l leaningl overl thel examl bedl forl inspection.l C.l Determinel ifl thel clientl usesl anyl over-the-counterl preparationl forl hemorrhoids.l D.l Positionl clientl inl leftl laterall positionl tol inspectl perianall areal forl fissuresl orl sacs.
- / 3