BSN 246 HESI
Health Assessment V2 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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### 1. Where should the nurse place the bell of the stethoscope when auscultating for a carotid artery bruit?
Answer Choices:
- Over mid-chest above the heart.
- Posterior neck at the nape of the neck.
- Lateral neck, just under the mandible towards lymph nodes.
- Directly over the trachea in the suprasternal notch.
Correct Answer: C
Expert Rationale:
The carotid artery runs laterally beside the trachea, under the mandible, near lymph nodes. Using the stethoscope bell here allows detection of low- pitched sounds like bruits, indicating turbulent blood $low. The chest, nape, or trachea are inappropriate locations.
--- ### 2. For assessing adventitious lung sounds after pneumonia treatment, which technique should the nurse use?
Answer Choices:
- Use bell over lower lobes.
- Have client lie $lat while listening anterior chest.
- Press diaphragm $irmly on skin over each lung $ield.
- Shave chest hair before auscultation.
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Correct Answer: C
Expert Rationale:
The diaphragm, pressed $irmly against the skin, best transmits high-pitched lung sounds, including adventitious sounds. All lung $ields should be auscultated systematically, side to side, anteriorly and posteriorly. The bell is not ideal for lung sounds; shaving chest hair is unnecessary.
### 3. A 29-year-old male client presents reporting a persistent dry cough for 6 weeks and expresses concern about “maybe lung cancer.” Which documentation best captures the client’s chief complaint?
Answer Choices:
- Presents with a hacking non-productive cough of 6 weeks duration.
- Describe having a "body-wracking dry cough" of 6 weeks duration.
- Expresses concern of "lung cancer" symptoms for last 6 weeks.
- Young adult male presents with fears that he has "lung cancer": Describe
having a "body-wracking dry cough" of 6 weeks duration.
Correct Answer: B
Expert Rationale:
The chief complaint (CC) should directly re$lect the patient’s own description of their symptoms, not include interpretations or diagnoses (e.g., "lung cancer"). Option B captures the verbatim symptom in the patient’s words ("body-wracking dry cough") and duration, which is essential for accurate 3 / 4
and objective documentation. Documenting fears or diagnostic concerns belongs in the psychosocial or review of systems but not in the CC.
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### 4. A 75-year-old client post-CVA with right hemiparesis shows a brisk 4+ deep tendon re1lex on the right side. What does this 1inding indicate?
Answer Choices:
- A normal re$lex response.
- Absent or sluggish response consistent with a lower motor neuron lesion.
- Flaccid paralysis.
- Hyperactive response consistent with an upper motor neuron disorder.
Correct Answer: D
Expert Rationale:
A brisk 4+ re$lex indicates hyperre$lexia, usually seen in upper motor neuron lesions such as stroke (CVA). This $inding shows abnormal increased re$lex activity on the affected side, consistent with central nervous system impairment. Lower motor neuron lesions typically cause diminished or absent re$lexes; $laccid paralysis is a clinical $inding, not a re$lex description.
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