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University of Pennsylvania Pass the 2025 HESI
Physical Assessment Exam with 120 These
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1. Which of the following techniques is used to assess muscle strength in a patient? A. Apply an opposing force or resistance. ✅ B. Observe the patient at rest. C. Percuss the muscle. D. Palpate the muscle. Correct Answer: A. Apply an opposing force or resistance. Rationale: Assessing muscle strength involves asking the patient to contract a muscle while the examiner applies opposing resistance. This determines the patient's ability to overcome force, a key part of strength grading. Observation, palpation, and percussion help in assessment but do not evaluate strength directly. 2. What does a goniometer measure? A. Muscle strength B. Joint stability C. Cranial nerve function D. Angles of extension and flexion ✅ Correct Answer: D. Angles of extension and flexion Rationale: A goniometer is an instrument used to measure the range of motion (ROM) in joints. It helps assess limitations in movement by providing an exact angle of flexion and extension, which is useful in musculoskeletal evaluations. 3. Neck flexion and extension should be:
A. 90 degrees B. 70 degrees C. 30 degrees D. 45 degrees ✅ Correct Answer: D. 45 degrees Rationale: Normal range of motion for both neck flexion and extension is about 45 degrees. Any significant deviation may suggest issues with musculoskeletal alignment, neurological impairment, or soft tissue injury.
4. Which of the following findings in a musculoskeletal assessment would be considered abnormal? A. Nodules B. Bogginess C. Symmetry D. Both A and B ✅ Correct Answer: D. Both A and B Rationale: Nodules and bogginess are abnormal findings. Nodules may suggest arthritis or gout, and bogginess can be indicative of inflammation or joint effusion. Symmetry, in contrast, is a normal finding. 5. What is an increased thoracic curvature, common in older adults, called? A. Scoliosis B. Lordosis C. Kyphosis ✅ D. Swayback Correct Answer: C. Kyphosis Rationale: Kyphosis is a forward rounding of the back, typically in the thoracic spine, commonly seen in older adults due to degenerative changes, osteoporosis, or poor posture. 6. Which finding in a preschooler during a cardiovascular system examination is abnormal? 1. Heart rate of 106 beats/min 2. Failure to gain weight because of fatigue while eating ✅
✅ Correct Answer: C. Cranial Nerve XI (Spinal Accessory) Rationale: CN XI controls the sternocleidomastoid and trapezius muscles, which are responsible for head rotation and shoulder elevation. Testing includes asking the patient to shrug shoulders against resistance.
10. When percussing over bone, the expected sound is: A. Dull B. Tympanic C. Flat ✅ D. Resonant ✅ Correct Answer: C. Flat Rationale: Percussion over a bone produces a flat sound due to its solid density. Resonance is heard over normal lung tissue, dullness over organs, and tympany over air-filled structures like the stomach. 11. What is a common cause of lordosis in children? A. Pregnancy B. Osteoporosis C. Muscular dystrophy D. Weak abdominal muscles ✅ ✅ Correct Answer: D. Weak abdominal muscles Rationale: In children, lordosis (exaggerated lumbar curve) often results from weak core muscles and tight lower back muscles. In adults, pregnancy or obesity can also contribute. 12. What is the most accurate method to assess edema in the lower extremities? A. Palpate for warmth B. Inspect for color changes C. Press firmly over a bony prominence for pitting ✅ D. Ask the patient if their shoes feel tight Correct Answer: C. Press firmly over a bony prominence for pitting Rationale: Edema is best assessed by applying pressure over areas like the tibia or ankle to check for indentation (pitting). This helps grade the severity on a scale from 1+ to 4+.
13. What cardiovascular finding is commonly seen in healthy older adults? A. Bounding peripheral pulses B. A loud S3 heart sound C. Increased systolic blood pressure ✅ D. Carotid bruits ✅ Correct Answer: C. Increased systolic blood pressure Rationale: Aging causes decreased arterial elasticity, leading to higher systolic pressures. An S3 is often abnormal in older adults, whereas bruits suggest atherosclerosis. The nurse observes symmetric chest excursion. What action should the nurse take? Ask the client to cough before repeating the assessment. This action is not necessary. Document the normal finding on the assessment record. Because chest excursion should be symmetric, i.e., equal on both sides, the nurse should document this normal finding on the assessment record. No additional intervention is warranted. If the chest excursion is asymmetric, the nurse should take further action to determine the cause of the asymmetry. Question the client about a recent history of rib fractures. This action is not necessary. Stop the assessment and measure the client's vital signs. This action is not necessary. - - correct ans- - Document the normal finding on the assessment record. Because chest excursion should be symmetric, i.e., equal on both sides, the nurse should document this normal finding on the assessment record. No additional
Vocal fremitus is assessed systematically, but the location of the posterior axillary line is not necessary. Assist the client to lie back in the bed. Because vocal fremitus can be assessed posteriorly, as well as anteriorly, there is no need to assist the client to lie back in the bed. Ask the client to repeat a phrase aloud. Vocal fremitus is assessed by palpating for vibrations on the thoracic wall beginning at the apex and ending at the base of the lungs while the client repeats a word or phrase aloud. - - correct ans- - Ask the client to repeat a phrase aloud. Vocal fremitus is assessed by palpating for vibrations on the thoracic wall beginning at the apex and ending at the base of the lungs while the client repeats a word or phrase aloud. In order to percuss the client's thorax posteriorly beginning at the apex of the right lung, how should the nurse begin? Palpate the space directly below the clavicle. The clavicles are located anteriorly and are not a useful landmark for posterior thoracic assessment. Place one finger pad over the first rib. Percussion over boney areas, such as the ribs, will not provide useful assessment data because the elicited sound will always be dull. Locate the client's first intercostal space. Percussion should be performed systematically, percussing in the intercostal spaces to avoid the ribs and scapulae. Find the space directly above the diaphragm.
The diaphragm is not a useful landmark to begin this assessment. - - correct ans- - Locate the client's first intercostal space. Percussion should be performed systematically, percussing in the intercostal spaces to avoid the ribs and scapulae. What follow-up action should the nurse implement Compare this finding with the location of the client's pneumonia seen on x-ray. Dullness upon percussion should be anticipated over areas of abnormal density, including pneumonia. The nurse can confirm this assessment finding by reviewing the location of the client's pneumonia found on x-ray. Review the client's medical history to determine how long he has had emphysema. Overly inflated alveoli found in clients with emphysema may cause hyperresonance upon percussion, rather than dullness. Document this normal assessment finding in the client's admission assessment. Resonance upon percussion is the predominant sound in healthy adult lung tissue. Notify the healthcare provider (HCP) that the client may have developed a pneumothorax. A pneumothorax may cause hyperresonance upon percussion rather than dullness. - - correct ans- - Compare this finding with the location of the client's pneumonia seen on x-ray. Dullness upon percussion should be anticipated over areas of abnormal density, including pneumonia. The nurse can confirm this assessment finding by reviewing the location of the client's pneumonia found on x-ray. After listening in this area, how should the nurse proceed? Move the diaphragm across to the apex of the right lung posteriorly.
Auscultate the lower lung fields to determine the presence of any adventitious sounds. Since vesicular breath sounds are normally heard in the peripheral lung fields, the nurse should continue to auscultate the remaining lung fields, listening for any abnormal, or adventitious, sounds. - - correct ans- - Auscultate the lower lung fields to determine the presence of any adventitious sounds. Since vesicular breath sounds are normally heard in the peripheral lung fields, the nurse should continue to auscultate the remaining lung fields, listening for any abnormal, or adventitious, sounds. What action should the nurse take? Document the presence of wheezes in the upper lobes and complete the assessment. Wheezes may be present in clients with chronic emphysema when diffuse airway obstruction occurs. Immediately assist the client to lean forward to reduce his respiratory effort. Leaning forward will not impact these breath sounds. Note the location of these bronchial breath sounds before completing the assessment. Bronchial, or tracheal, breath sounds are normal breath sounds heard as a harsh, hollow tubular sound over the trachea and larynx. Wait to assess these heart sounds until the respiratory assessment is complete. These high-pitched musical sounds are not heart sounds. - - correct ans- - Document the presence of wheezes in the upper lobes and complete the assessment. Wheezes may be present in clients with chronic emphysema when diffuse airway obstruction occurs. What action should the nurse take? Reassure the client that his lung sounds are improving.
This assessment does not reflect an improvement in the client's lung sounds. Document that the lung bases are clear upon auscultation. This is not accurate documentation of the findings. Chart what was heard both anteriorly and posteriorly. Although abnormal breath sounds in the lung bases may be heard only from the posterior, it is important to chart the sounds heard both anteriorly and posteriorly. Record only the location of the abnormal breath sounds. This does not provide the most complete documentation of the assessment findings. Recording the presence of normal breath sounds is also important. - - correct ans- - Chart what was heard both anteriorly and posteriorly. Although abnormal breath sounds in the lung bases may be heard only from the posterior, it is important to chart the sounds heard both anteriorly and posteriorly. Which assessment provides the most useful data related to the client's current nutritional status? Calculate the client's body mass index (BMI). Body mass index (BMI) is a marker of the client's optimal weight for his height and provides important data related to the client's current nutritional status. Ask the client about any recent changes in his appetite. This subjective data supports more specific and objective data related to the client's current nutritional status, but it is not the most important data to obtain. Assist the client to complete a 24-hour diet recall. This subjective data supports more specific and objective data related to the client's current nutritional status, but it is not the most important data to obtain.
This assessment will not provide the most useful information at this time. Auscultate breath sounds bilaterally. Thick, purulent sputum is a sign of an infectious process. The nurse should auscultate the client's lungs to determine if a change from the previous assessment has occurred, reflecting a worsening of the client's condition. Observe the thoracic diameter ratio. This assessment will not change from the initial assessment. Percuss for diaphragmatic excursion. This assessment will not provide the most useful information at this time. - - correct ans- - Auscultate breath sounds bilaterally. Thick, purulent sputum is a sign of an infectious process. The nurse should auscultate the client's lungs to determine if a change from the previous assessment has occurred, reflecting a worsening of the client's condition. Which data is most important for the nurse to obtain before contacting the HCP? Pedal pulse volume. The volume of the pedal pulses is not the highest priority assessment at this time. Orientation to situation. The client may be assessed for orientation to person, place, time, and situation. However, another assessment takes priority at this time. White blood cell count. Since there has been a change in the client's breath sounds, indicating a worsening in the client's pneumonia, it is important to note any increase in the client's white blood cell count. However, another assessment takes priority at this time.
Respiratory effort. Confusion may be an indicator of decreasing oxygenation, especially in the older person. Based on the client's signs of worsening pneumonia coupled with the confusion, his respiratory rate and effort along with his oxygen saturation level should be obtained before the nurse contacts t - - correct ans- - Respiratory effort. Confusion may be an indicator of decreasing oxygenation, especially in the older person. Based on the client's signs of worsening pneumonia coupled with the confusion, his respiratory rate and effort along with his oxygen saturation level should be obtained before the nurse contacts the HCP. When recording the change in the client's assessment findings, how should the nurse document the breath sounds Adventitious breath sounds present in the middle and lower lungs bilaterally. This documentation does not provide the most complete assessment data. Client's posterior breath sounds have worsened from the earlier assessment. This documentation does not provide the most complete assessment data. Crackles heard bilaterally in the middle and lower lung fields posteriorly. This documentation provides a clear, concise picture of the current assessment findings. Bilateral normal breath sounds heard only in the upper lobes posteriorly. This documentation does not provide the most complete assessment data. - - correct ans- - Crackles heard bilaterally in the middle and lower lung fields posteriorly. This documentation provides a clear, concise picture of the current assessment findings. How should the nurse report the assessment data?
A slightly curved nail surface is a normal finding. The normal nail base angle is 160 degrees. Since these findings are within normal parameters, the nurse should continue the assessment by observing the color of the nail surface. Use a pulse oximeter to measure the oxygen saturation. The assessment findings do not indicate a problem with oxygenation. Assess for crepitus underneath and around the nail surface. Crepitus, a crackling or clicking noise, would not be heard under or around nail surfaces. - - correct ans- - Continue the assessment, noting the color of the nail surface. A slightly curved nail surface is a normal finding. The normal nail base angle is 160 degrees. Since these findings are within normal parameters, the nurse should continue the assessment by observing the color of the nail surface While assessing the client's nails, it is most important for the nurse to follow-up on which assessment finding? Brittle nail surface. Brittle or ridged nail surfaces may be the result of iron deficiency. This finding warrants follow-up assessment related to the client's nutritional status. Ragged cuticles. Ragged cuticles may indicate that the client chews her cuticles. Another finding is of higher priority for further assessment by the nurse. Firm nail base. A firm nail base is a normal finding. A spongy nail base is abnormal, and may be found if nailbed clubbing is present. Irregular nail edges.
Irregular nail edges may indicate that the client chews her fingernails. Another finding is of higher priority for further assessment by the nurse. - - correct ans- - Brittle nail surface. Brittle or ridged nail surfaces may be the result of iron deficiency. This finding warrants follow-up assessment related to the client's nutritional status. Which assessment is most important for the nurse to complete? Ask the client how long she has colored her hair. Excessive use of artificial hair coloring may cause damage to the hair, but this is of less importance than another finding. Check the client's hair for split ends. Split ends indicate damage due to overheating or drying. Another finding is more significant as an indicator of the client's overall health. Observe the texture and distribution of hair growth on the scalp. Dull, dry, sparse hair may be the result of a nutrient deficiency, such as insufficient protein or zinc. These findings would support the nurse's concerns regarding Amanda's overall nutritional status. Note the pattern of hair growth around the client's forehead. The pattern of hair growth around the forehead is often hereditary and is unlikely to be a significant finding. - - correct ans- - Observe the texture and distribution of hair growth on the scalp. Dull, dry, sparse hair may be the result of a nutrient deficiency, such as insufficient protein or zinc. These findings would support the nurse's concerns regarding Amanda's overall nutritional status. Amanda tells the nurse that her scalp itches sometimes. The nurse observes white flecks on the client's shoulders. What action should the nurse take first?
Summarize the abusive events without directly quoting the client. This does not provide the most accurate documentation. Refrain from including information that might identify the alleged abuser. Information that identifies the alleged abuser is important to include in the documentation. - - correct ans- - Quote the client's responses to the questions as verbatim as possible. Documentation should be as verbatim as possible to provide the most detailed, accurate information. Which strategy should the nurse use to document the extent of the physical injuries? Complete the Abuse Assessment Screen. The Abuse Assessment Screen is useful to screen clients for possible abuse, but is not used to document the extent of physical injury. Prepare a detailed injury map. An injury map provides is a useful visual documentation of the locations of observable injuries along with descriptive progress notes and photographs of the injuries if the client gives consent to photograph the injuries. Include X-Rays in the client record. Including X-Rays will give a visual account of damage to bones but will not show the extent of injury to soft tissue. Use the numeric Braden scale. The Braden scale is an effective scale used to determine pressure ulcer risk. It is not useful in documenting physical injuries. - - correct ans- - Prepare a detailed injury map. An injury map provides is a useful visual documentation of the locations of observable injuries along with descriptive progress notes and photographs of the injuries if the client gives consent to photograph the injuries.
After expressing concern about the bruises on Amanda's abdomen, how should the nurse begin the abuse assessment? Determine if the client is sexually active. This information may be relevant later in the assessment, but it is not immediately relevant to the finding of abdominal bruising. Ask the client if someone else caused the injuries. It is appropriate to first ask a direct question to elicit information about possible abuse. If the client is reluctant to respond to a direct question about possible abuse, the nurse may then choose to use an indirect approach to encourage further verbalization. Encourage the client to describe her family structure. This information may be relevant later in the assessment, but it is not immediately relevant to the finding of abdominal bruising. Advise the client of her right to legal counsel during the interview. Since the client is not being accused or charged with any crimi - - correct ans- - Ask the client if someone else caused the injuries. It is appropriate to first ask a direct question to elicit information about possible abuse. If the client is reluctant to respond to a direct question about possible abuse, the nurse may then choose to use an indirect approach to encourage further verbalization. To gather data related to the frequency of abuse by Amanda's boyfriend, what action should the nurse take first? Instruct the client that there is no point in denying the pattern of abuse because of the varying colors of the bruises. Since this action may, or may not be necessary depending on the client's willingness to provide the information related to abuse frequency, another action should be taken first.
