EXAM BSN 246 VERSION 4 WITH 200

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2024/2025 HESI HEALTH ASSESSMENT

EXAM BSN 246 VERSION 4 WITH 200

QUESTIONS AND CORRECT VERIFIED

ANSWERS/ BSN 246 HESI HEALTH

ASSESSMENT EXAM 2025 NIGHTINGALE

The nurse is assessing an ulcer on a Client lower extremity which is likely the result of either venous or arterial insufficiency which assessment techniques should the differentiate thé pathology causing the ulcer

• observe the specific location and appearance of the ulceration
• note any change in the color of the ulcer when leg is moved
• compare the skin turgor of the upper and lower leg
• measure the degree of joint range of motion in the extremity
• observe the specific location and appearance of the ulceration

The nurse is assessing the perianalvare of a female client who states she has chronic constipation and has bright red blood on the toilet paper after having a bowel which finding the nurse report that is most consistent with ct complaints

• flabby skin sac around anal orifice that is painless
• anus is moist hairless and has pigmented sphincter folds
• presence of dried brown stool around the perianal area
• shiny blue skin sac around anal opening and a linear split
• shiny blue skin sac around anal opening and a linear split

The nurse observed that a client is experiencing melena. What serum laboratory test should the nurse monitor in repose to this finding?

• Blood Urea Nitrogen test (BUN)
• Platelets

C. CBC

D. ALT 1 / 4

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• Blood Urea Nitrogen test (BUN)

In obtaining a client's health history related to smoking cigarettes, the nurse plans to determine the client's smoking pack years. What information should the nurse obtain for this calculation? SATA

• Age when the client started smoking
• Number of years the client smoked
• Packs of cigarettes smoked per day
• Number of attempts to quit smoking. E. Client's current age
• Number of years the client smoked
• Packs of cigarettes smoked per day

In assessing an adult client, the nurse calculates the BMI (body mass index) as 14 kg/m2. What nursing problem should be included in this client's plan of care?

• Fluid volume deficit.
• Unbalanced nutrition, less than body needs.
• Fluid volume excess
• Unbalanced nutrition, greater than body needs.
• Unbalanced nutrition, less than body needs.

The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating the spleen?

• Tip of spleen palpable when client is asked to forcefully exhale.
• Firm mass palpated at bottom of left rib cage.
• Rebound tenderness with compression over right upper quadrant.
• Pain noted when palpating McBurney's point.
• Firm mass palpated at bottom of left rib cage.

When assessing an older client with a history of cardiovascular disease, dyspnea, and peripheral edema, which method is best for the nurse to use?

• Auscultate the apical pulse at the point of maximal impulse.
• Palpate the radial pulses in both arms for a deficit.
• Feel the volume of the dorsalis pedis and posterior tibialis pulses.
• Use the stethoscope to listen over the 2 / 4

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• Feel the volume of the dorsalis pedis and posterior tibialis pulses.

When inspecting a client's skin, which finding requires the most immediate follow- up by the nurse?

• Plaque formation on elbows
• Thickened yellow nailbeds
• Diminished hair growth on legs
• Generalized truncal rash.
• Generalized truncal rash.

The nurse is assessing a female client who states that her hemorrhoids are inflamed and hurt constantly. Which intervention is best for the nurse implement to complete a focused assessment?

• Place the client in a standing position, leaning over the exam bed for inspection.
• Determine if the client uses any over- the-counter preparations for hemorrhoids.
• Ask the client how long she has experienced discomfort related to hemorrhoids.
• Position client in left lateral position to inspect perianal area for fissures or sacs.
• Position client in left lateral position to inspect perianal area for fissures or sacs.

When entering a client's room, the nurse observes that the client is using pursed-lip breathing. It is most important for the nurse to monitor the client for which problem

• Acute pain.
• Syncope
• Dyspnea
• Tetany.
• Dyspnea

A 19-year-old female client comes to the clinic complaining of breast tenderness before her menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take?

• Assure the client that her breasts are normal and advise annual evaluations.
• Explain to the client that an ultrasound of the breast will likely be necessary. 3 / 4

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• Request a return visit after her menstrual period for a breast exam re-check.
• Suggest that the client schedule a mammogram after her next menstrual period.
• Request a return visit after her menstrual period for a breast exam re-check.

When assessing a client's extraocular eye movement, what tool should the nurse use?

• Snellen chart.
• Pen light.
• One finger.
• Ophthalmoscope.
• One finger.

The nurse auscultation the precordium of a client who is diagnosed with mitral valve regulation and hears a grade IV systolic murmur. When documenting the comparison of systolic murmurs, which characteristics should the nurse use to support this systolic finding?

• Moderately loud, machine-like rumble not associated with a thrill.
• Loud, at the apex, associated with a palpable thrill. C. Very loud, with no

stethoscope, thrill easily palpable, heave visible.

• Soft, barely head-on auscultation in a quiet room
• Loud, at the apex, associated with a palpable thrill.

The nurse is assessing a client for goiter and is unable to observe the thyroid gland.Which action should the nurse take?

• Document that thyroid gland size is normal with no visible goiter.
• Palpate deeply and firmly over the location of the thyroid gland.
• Defer the thyroid exam and observe the client for signs of myxedema.
• Ask the client to swallow while palpating along the sides of the trachea.
• Ask the client to swallow while palpating along the sides of the trachea.

The nurse is performing a head-to-toe physical examination on known victim of intimate partner violence. The visual exam reveals several round, flat, pinpoint, red spots. How should the nurse document this finding?

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