Final Exam: NSG 316/ NSG316 (NEW
2026/ 2027 Update) Health Assessment
Review| Questions & Answers| Grade A|
100% Correct (Accurate Solutions)- GCU
What components should be assessed and asked about when completing a cultural assessment?
Heritage, health practices, communication, family roles & social orientation, nutrition,
pregnancy, spirituality/religion, death, and role of health providers
What are the four sources of pain? (Provide some examples for each) 1. Visceral pain =
large interior organs (e.g., appendicitis, gallstones)
2. Deep somatic pain = blood vessels, joints, tendons, muscles, and bone injury (e.g., sprain,
broken bone)
3. Cutaneous pain = skin surface and subcutaneous tissues (e.g., paper cut)
4. Referred pain = felt at a particular site but originates from another location (e.g., left arm
hurting during an MI although the issue is with the heart)
A patient is crying and says, "Please get me something to relieve this pain." What should the
nurse do next?
a. Verify that the patient has an order for pain medications and administer order as directed
b. Assess the level of pain and ask patient what usually works for his or her pain, administer pain
medication as needed, then reassess pain level
c. Assess the level of pain and give medications according to pain level, and then reassess pain
d. Reposition the patient, then reassess the pain after intervention Answer: B
Answers A, C, and D are incorrect because pain management should be collaborative, and the
patient is not part of the decision making process in these answers.
Pain is always ____? Subjective!
A patient with a severe muscle cramp tells the nurse, "The pain is a little better when I massage
the muscle or apply a cold pack." Which criterion of the PQRST method of pain assessment is
addressed in the patient's statement?
a. Severity Scale
b. Quality/Quantity
c. Region/Radiation
d. Provocation/Palliation Answer: d
PQRST is a pain assessment scale; it stands for Provocation/Palliation, Quality/Quantity,
Region/Radiation, Severity Scale, and Timing. Because the patient is describing methods that
, provide comfort and relieve the pain, it indicates that the patient is addressing
Provocation/Palliation. If the patient reports about severity of pain on a scale of 0 to 10, then it
indicates that the patient is addressing Severity. When addressing the Quality/Quantity of the
pain, the patient describes the pain felt. If the patient reports about the site of pain, then the
patient is addressing Region/Radiation.
Stages of Edema 1+ mild, slight indentation, no perceptible swelling
2+ moderate, indentation subsides rapidly (seconds)
3+ deep, indentation remains for short time (minutes), appears swollen
4+ very deep, indentation lasts long time (hours), appears very swollen
Skin assessment for a head-to-toe assessment 1. Check skin for temperature w/ back of
hands and inspect
- skin is warm, dry, intact, color is consistent throughout, no lesins, scars, tattoos noted on
exposed skin
2. Skin turgor - appropriate B/L, no tenting noted
3. Upper body edema
4. Radial pulses - strong, palpable, equal, and approximately 2+
5. Capillary refill -
<2 sec B/L
Test for CN V CN V (trigeminal) - clench jaw, use cotton ball to touch different areas of the face
while patient has eyes closed
Test for CN VII CN VII (facial) - raise eyebrows, close eyes, puff out cheeks, smile, frown
Test for CN III, IV, VI CN III (oculomotor) IV (trochlear) VI (abducens) - six cardinal
fields of gaze; follow penlight w/o moving head
Test for CN XI CN XI (spinal accessory) - ROM of neck is equal and strength in
shoulders is equal w/ and w/o resistance
HEENMT - Head is normocephalic, face is symmetrical, neck is proportionate to head and
face, and hair distribution is normal
- Pupils are equal, round, reactive to light (direct and consensual), and accommodated.
Convergence is noted B/L, pupil size, no drainage or jaundice, symmetrical, sclera white,
conjunctive pink
- Ears are symmetrical, intact, skin color is consistent with exposed skin, pinna (pull up) and
tragus (push in) are mobile and nontender
- Nose is midline, nares are symmetrical and patent
- Tongue and buccal mucosa are pink, moist, and w/o lesions, dentition intact
- Trachea is midline
Test for CN IX CN IX (glossopharyngeal) - say "ahhh"; uvula rises w/ phonation
Test for CN XII CN XII (hypoglossal) - Say "light, tight, dynamite"
2026/ 2027 Update) Health Assessment
Review| Questions & Answers| Grade A|
100% Correct (Accurate Solutions)- GCU
What components should be assessed and asked about when completing a cultural assessment?
Heritage, health practices, communication, family roles & social orientation, nutrition,
pregnancy, spirituality/religion, death, and role of health providers
What are the four sources of pain? (Provide some examples for each) 1. Visceral pain =
large interior organs (e.g., appendicitis, gallstones)
2. Deep somatic pain = blood vessels, joints, tendons, muscles, and bone injury (e.g., sprain,
broken bone)
3. Cutaneous pain = skin surface and subcutaneous tissues (e.g., paper cut)
4. Referred pain = felt at a particular site but originates from another location (e.g., left arm
hurting during an MI although the issue is with the heart)
A patient is crying and says, "Please get me something to relieve this pain." What should the
nurse do next?
a. Verify that the patient has an order for pain medications and administer order as directed
b. Assess the level of pain and ask patient what usually works for his or her pain, administer pain
medication as needed, then reassess pain level
c. Assess the level of pain and give medications according to pain level, and then reassess pain
d. Reposition the patient, then reassess the pain after intervention Answer: B
Answers A, C, and D are incorrect because pain management should be collaborative, and the
patient is not part of the decision making process in these answers.
Pain is always ____? Subjective!
A patient with a severe muscle cramp tells the nurse, "The pain is a little better when I massage
the muscle or apply a cold pack." Which criterion of the PQRST method of pain assessment is
addressed in the patient's statement?
a. Severity Scale
b. Quality/Quantity
c. Region/Radiation
d. Provocation/Palliation Answer: d
PQRST is a pain assessment scale; it stands for Provocation/Palliation, Quality/Quantity,
Region/Radiation, Severity Scale, and Timing. Because the patient is describing methods that
, provide comfort and relieve the pain, it indicates that the patient is addressing
Provocation/Palliation. If the patient reports about severity of pain on a scale of 0 to 10, then it
indicates that the patient is addressing Severity. When addressing the Quality/Quantity of the
pain, the patient describes the pain felt. If the patient reports about the site of pain, then the
patient is addressing Region/Radiation.
Stages of Edema 1+ mild, slight indentation, no perceptible swelling
2+ moderate, indentation subsides rapidly (seconds)
3+ deep, indentation remains for short time (minutes), appears swollen
4+ very deep, indentation lasts long time (hours), appears very swollen
Skin assessment for a head-to-toe assessment 1. Check skin for temperature w/ back of
hands and inspect
- skin is warm, dry, intact, color is consistent throughout, no lesins, scars, tattoos noted on
exposed skin
2. Skin turgor - appropriate B/L, no tenting noted
3. Upper body edema
4. Radial pulses - strong, palpable, equal, and approximately 2+
5. Capillary refill -
<2 sec B/L
Test for CN V CN V (trigeminal) - clench jaw, use cotton ball to touch different areas of the face
while patient has eyes closed
Test for CN VII CN VII (facial) - raise eyebrows, close eyes, puff out cheeks, smile, frown
Test for CN III, IV, VI CN III (oculomotor) IV (trochlear) VI (abducens) - six cardinal
fields of gaze; follow penlight w/o moving head
Test for CN XI CN XI (spinal accessory) - ROM of neck is equal and strength in
shoulders is equal w/ and w/o resistance
HEENMT - Head is normocephalic, face is symmetrical, neck is proportionate to head and
face, and hair distribution is normal
- Pupils are equal, round, reactive to light (direct and consensual), and accommodated.
Convergence is noted B/L, pupil size, no drainage or jaundice, symmetrical, sclera white,
conjunctive pink
- Ears are symmetrical, intact, skin color is consistent with exposed skin, pinna (pull up) and
tragus (push in) are mobile and nontender
- Nose is midline, nares are symmetrical and patent
- Tongue and buccal mucosa are pink, moist, and w/o lesions, dentition intact
- Trachea is midline
Test for CN IX CN IX (glossopharyngeal) - say "ahhh"; uvula rises w/ phonation
Test for CN XII CN XII (hypoglossal) - Say "light, tight, dynamite"
