Health Assessment V1 EXAM

BSN 246 HESI

Health Assessment V1 EXAM Nightingale College Actual Qs & Verified Ans to Pass the Exam

This Hesi test contains:

 passing score Guarantee  Format Set of Multiple-choice  questions with incorporating Next Generation NCLEX (NGN) and Case scenarios questions  Expert-Verified Explanations & Solutions

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### Scenario 1:

Question: To assess a client's pupillary reaction to accommodation,

what action should the nurse take?

• Use an ophthalmoscope for detailed examination
• Shine a penlight in each eye
• Observe pupil size when focusing on a near object and then a far object
• Measure the pupil diameter in centimeters

Correct Answer: C) Observe pupil size when focusing on a near object and

then a far object

Expert Rationale: Assessing a pupillary reaction to accommodation involves

observing how the pupils change size when a patient focuses on a near object and then on a distant object. This tests the function of cranial nerves II and III, important for visual acuity and ocular health.

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Scenario 2:

Question: During an abdominal assessment, a client with a temperature

of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

• Administer NSAIDs as prescribed
• Maintain the client on a regular diet
• NPO (nothing by mouth) 2 / 4

• Perform a rectal examination immediately

Correct Answer: C) NPO (nothing by mouth)

Expert Rationale: The client exhibiting pain and guarding during palpation

suggests possible acute abdomen or a surgical emergency. Keeping the client NPO is critical to prepare for any necessary surgical interventions or imaging studies, as well as to prevent the risk of aspiration.

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Scenario 3:

Question: When inspecting an adult woman's skin, the nurse observes

several areas of ecchymosis on her trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

• Engages in regular physical activity
• Takes an oral anticoagulant
• Reports a recent fall
• Has a history of hypertension

Correct Answer: B) Takes an oral anticoagulant

Expert Rationale: The presence of ecchymosis combined with the use of

anticoagulants raises concerns about potential bleeding disorders or inadequate coagulation management. This necessitates further inquiry to evaluate the need for adjustments in medication or assessment of liver function.

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Scenario 4:

Question: While performing a physical assessment, the nurse is unable

to palpate the client's pedal pulses. Which action should the nurse take?

• Reposition the patient's legs and attempt palpation again
• Use a Doppler ultrasonic stethoscope
• Document that pulses are not palpable
• Refer the client for a vascular consult

Correct Answer: B) Use a Doppler ultrasonic stethoscope

Expert Rationale: If pedal pulses are not palpable, using a Doppler allows

for non-invasive con7irmation of blood 7low in the arteries of the foot.Documenting 7indings accurately and further investigating with the Doppler is essential for evaluating potential vascular compromise.

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Scenario 5:

Question: The nurse asks a female client about the proverb "Glass

Houses," and she replies, "It will break the windows." Which conclusion should be documented about this client's response?

• Impaired thinking
• Insightful observation
• A misunderstanding of idiomatic expressions
• Normal cognitive functioning

Correct Answer: A) Impaired thinking

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