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BSN HESI 246 Health Assessment V1 Exam – 2025 (3 Version Exams) Actual Exam – Nightingale College
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Question 1: The nurse is assessing a patient’s cranial nerves. Which assessment finding indicates cranial nerve VII (Facial nerve) is intact? A. The patient can shrug shoulders symmetrically. B. The patient’s pupils constrict in response to light. C. The patient smiles and frowns symmetrically. D. The patient’s tongue protrudes midline.
Answer: C. The patient smiles and frowns symmetrically. Explanation: Cranial Nerve VII controls facial muscles used in expression. Symmetrical movement when smiling or frowning indicates it’s intact. A = CN XI (spinal accessory) B = CN III (oculomotor) D = CN XII (hypoglossal) Question 2: Which technique should the nurse use first when assessing the abdomen? A. Palpation B. Percussion C. Auscultation D. Inspection Answer: D. Inspection Explanation: Always begin with inspection when assessing the abdomen. Auscultation follows because palpation and percussion can alter bowel sounds. Question 3: A patient reports shortness of breath. What is the most appropriate nursing action? A. Ask about smoking history B. Perform a full head-to-toe assessment C. Raise the head of the bed and assess lung sounds
B. Left ventricular failure C. Pericarditis D. Atrial fibrillation Answer: B. Left ventricular failure Explanation: S3 in older adults is often a sign of heart failure. It occurs after S2 and reflects increased ventricular filling pressure. Question 6: During a skin assessment, the nurse notes a flat, nonpalpable lesion less than 1 cm in diameter. What is the correct documentation? A. Papule B. Macule C. Vesicle D. Nodule Answer: B. Macule Explanation: A macule is a flat, nonpalpable lesion. Examples include freckles and petechiae. Question 7: The nurse is assessing for jugular vein distension (JVD). What patient position is appropriate? A. Supine with head flat B. Sitting upright at 90° C. Supine with head of bed elevated 30–45° D. Left lateral position
Answer: C. Supine with head of bed elevated 30–45° Explanation: This position enhances visualization of the jugular veins for assessing JVD, which may indicate fluid overload or heart failure. Question 8: The nurse places a vibrating tuning fork on a patient's mastoid bone and then near the ear canal. The patient hears the sound longer by air conduction. What test is this, and is it normal? A. Rinne test; normal B. Weber test; abnormal C. Rinne test; abnormal D. Whisper test; normal Answer: A. Rinne test; normal Explanation: The Rinne test compares air vs. bone conduction. Normally, air conduction is heard longer. This indicates no conductive hearing loss. Question 9: Which technique best assesses tactile fremitus? A. Palpation using the fingertips B. Using the diaphragm of the stethoscope C. Placing the ulnar side of the hands on the chest wall D. Light percussion across intercostal spaces Answer: C. Placing the ulnar side of the hands on the chest wall
Which of the following lymph nodes are located just in front of the ear? A. Submental B. Preauricular C. Occipital D. Posterior cervical Answer: B. Preauricular Explanation: Preauricular nodes are located in front of the ear and may be palpable with infections like conjunctivitis or ear infections. Question 13: Which finding during a cardiovascular assessment requires immediate intervention? A. S1 louder than S2 at the apex B. Regular rate and rhythm C. A murmur heard at the left sternal border D. New onset of S4 sound in an elderly patient Answer: D. New onset of S4 sound in an elderly patient Explanation: An S4 sound often indicates stiff ventricles, as in left ventricular hypertrophy or MI, and requires further evaluation. Question 14: During a head-to-toe assessment, the nurse notes a lateral curvature of the thoracic spine. What is this condition called? A. Kyphosis
B. Scoliosis C. Lordosis D. Spina bifida Answer: B. Scoliosis Explanation: Scoliosis is a lateral deviation of the spine and may be congenital or acquired. Kyphosis is a forward curvature. Question 15: Which assessment technique is best for evaluating skin temperature? A. Palpation with fingertips B. Light percussion C. Palpation with the back of the hand D. Inspection under bright light Answer: C. Palpation with the back of the hand Explanation: The dorsal side of the hand is most sensitive to temperature variations. Question 16: The nurse percusses a patient’s lung fields and hears hyperresonance. What does this indicate? A. Normal lung tissue B. Pleural effusion C. Emphysema D. Pneumonia
Stage II involves epidermis and part of the dermis, appearing as a shallow open ulcer or blister. Question 19: The nurse asks a patient to say “ah” and observes the uvula and soft palate rising midline. Which cranial nerve is being assessed? A. CN IX (Glossopharyngeal) B. CN X (Vagus) C. CN XII (Hypoglossal) D. CN V (Trigeminal) Answer: B. CN X (Vagus) Explanation: CN X controls the rise of the soft palate and uvula. This checks motor function related to swallowing and speech. Question 20: Which statement describes correct technique for auscultating heart sounds? A. Use the bell of the stethoscope for high-pitched sounds. B. Listen over only the mitral area. C. Auscultate in a Z pattern across all valve areas. D. Perform percussion before auscultation. Answer: C. Auscultate in a Z pattern across all valve areas. Explanation: A Z pattern covers aortic, pulmonic, tricuspid, and mitral areas. Bell = low-pitched sounds
Diaphragm = high-pitched soundsQuestion 21: The nurse is assessing an older adult’s skin. Which finding is expected with aging? A. Increased skin turgor B. Presence of cherry angiomas C. Jaundice D. Thickened and oily skin Answer: B. Presence of cherry angiomas Explanation: Cherry angiomas are benign red lesions common with aging. Aging causes decreased turgor and dryness, not thick, oily skin. Jaundice is pathological, not age-related. Question 22: Which heart sound is heard just before S1 and is commonly associated with decreased ventricular compliance? A. S B. S C. Murmur D. S Answer: D. S Explanation: S4 occurs with atrial contraction into a stiff ventricle (e.g., in HTN, CAD), and is heard just before S1.
A. Excessive tearing B. Involuntary eye movement C. Drooping of the eyelid D. Misalignment of the eyes Answer: D. Misalignment of the eyes Explanation: Strabismus is a condition where the eyes do not properly align with each other. It can lead to amblyopia if untreated. Question 26: Which finding is considered abnormal during an ear exam using an otoscope? A. Pearly gray tympanic membrane B. Cone of light at 5 o'clock in right ear C. Visible malleus D. Bulging, red tympanic membrane Answer: D. Bulging, red tympanic membrane Explanation: A bulging, red TM suggests acute otitis media. Normal findings include a pearly gray membrane with a visible light reflex. Question 27: The nurse is palpating the posterior tibial pulse. Where is this located? A. Lateral to the Achilles tendon B. Behind the medial malleolus C. Dorsum of the foot
D. Popliteal fossa Answer: B. Behind the medial malleolus Explanation: The posterior tibial pulse is found just behind the medial malleolus, and is key in assessing circulation to the foot. Question 28: The nurse documents a lesion that is raised, fluid-filled, and smaller than 1 cm. What type of lesion is this? A. Bulla B. Macule C. Papule D. Vesicle Answer: D. Vesicle Explanation: Vesicles are small, fluid-filled lesions (e.g., chickenpox, herpes). Bullae are >1 cm Papules are solid Macules are flat Question 29: Which test is used to assess for carpal tunnel syndrome? A. McMurray’s test
Answer: B. Romberg test Explanation: The Romberg test evaluates balance and coordination, which are cerebellar functions. Babinski = corticospinal tract Pupillary reflex = cranial nerve function DTRs = spinal cord integrity Question 32: Which finding is most consistent with venous insufficiency? A. Intermittent claudication B. Cold, pale extremities C. Brown discoloration near the ankles D. Absent dorsalis pedis pulses Answer: C. Brown discoloration near the ankles Explanation: Chronic venous stasis leads to hemosiderin deposits, causing brown skin discoloration around the lower legs and ankles. Question 33: When assessing the thorax of a toddler, what is a normal finding? A. Lateral diameter greater than anteroposterior B. AP diameter = transverse diameter
C. Hyperresonance is abnormal D. Absent breath sounds in lower lobes Answer: B. AP diameter = transverse diameter Explanation: In toddlers, the chest appears more rounded with equal AP and transverse diameters. As they age, the thorax becomes more oval. Question 34: A patient reports pain when the nurse palpates the costovertebral angle. What organ is most likely involved? A. Liver B. Stomach C. Kidney D. Gallbladder Answer: C. Kidney Explanation: CVAT (costovertebral angle tenderness) suggests kidney inflammation or infection (e.g., pyelonephritis). Question 35: Which of the following is an expected change in the cardiovascular system during pregnancy? A. Decreased heart rate B. Decreased blood volume C. Systolic murmur D. Decreased cardiac output
B. Sign of acute infection C. Possible malignancy D. Indicates immune response Answer: C. Possible malignancy Explanation: Hard, fixed, and non-tender nodes, especially supraclavicular, may indicate cancer and require immediate evaluation. Question 38: When auscultating bowel sounds, how long should the nurse listen before declaring absent sounds? A. 30 seconds B. 1 minute C. 2 minutes D. 5 minutes Answer: D. 5 minutes Explanation: Bowel sounds must be absent for 5 continuous minutes in each quadrant before confirming absence. Question 39: Which of the following best describes crepitus during a musculoskeletal assessment? A. A soft clicking sound in the abdomen B. Audible crackling or popping with joint movement C. A firm mass over a muscle D. Muscle spasm with palpation
Answer: B. Audible crackling or popping with joint movement Explanation: Crepitus is a grating or crackling sensation produced by friction between bone and cartilage, common in arthritis. Question 40: What technique is used to test for hip dislocation in infants? A. Barlow and Ortolani maneuvers B. Allis test C. McMurray test D. Trendelenburg sign Answer: A. Barlow and Ortolani maneuvers Explanation: These tests assess for developmental dysplasia of the hip (DDH) in newborns. McMurray = knee meniscus Trendelenburg = gluteal weakness in walking child Question 41: Which cranial nerve is tested when the patient is asked to shrug the shoulders against resistance? A. CN V – Trigeminal B. CN VII – Facial C. CN XI – Spinal Accessory D. CN XII – Hypoglossal
