NSG3160 | NSG3160 Health Assessment Exam 2
Version 3 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. When assessing the amplitude of a peripheral pulse, the nurse documents a grade
of ‘2+’. Which interpretation of this finding is correct?
A. The pulse is absent and non-palpable.
B. The pulse is weak, thready, and easily obliterated.
C. The pulse is normal and easily palpable.
D. The pulse is bounding and does not disappear with pressure.
Correct Answer: C
Expert Explanation: A pulse grade of 2+ represents a normal, expected finding in a
healthy adult. This grading indicates that the blood flow is sufficient and the vessel
is easily felt with moderate pressure. In contrast, 0 is absent, 1+ is weak, and 3+ or
4+ is bounding depending on the scale used. Nurses must consistently apply this
standardized scale to ensure accurate communication within the healthcare team.
Establishing this baseline allows for early detection of changes in the patient’s
circulatory status.
2. A nurse is performing the Modified Allen test on a patient. What is the primary
purpose of this assessment technique?
A. To assess the patency of the ulnar artery before arterial blood gas sampling.
,B. To evaluate the presence of deep vein thrombosis in the lower extremities.
C. To measure the degree of pitting edema in the upper arms.
D. To determine the extent of lymphatic drainage in the axillary region.
Correct Answer: A
Expert Explanation: The Modified Allen test is specifically designed to evaluate
collateral circulation through the ulnar artery. By compressing both radial and ulnar
arteries and then releasing the ulnar side, the nurse checks if the hand flushes
within 2 to 5 seconds. This ensures that if the radial artery is damaged during a
procedure, the hand will still receive adequate blood supply. A negative result
suggests insufficient collateral flow, necessitating the use of a different site for
arterial puncture. This technique is a critical safety measure used to prevent
ischemic injury to the hand.
3. The nurse notes that a patient has deep pitting edema in the lower extremities that
remains for a short time after pressure is released. How should the nurse document
this finding?
A. 1+ Edema
B. 2+ Edema
C. 4+ Edema
D. 3+ Edema
,Correct Answer: D
Expert Explanation: 3+ edema is characterized by a deep pit that remains for a
short time and noticeably swollen legs. The grading system typically ranges from 1+
for mild pitting to 4+ for very deep pitting that lasts a long time. This specific finding
suggests a significant accumulation of interstitial fluid that requires further clinical
investigation. Assessment should include checking for symmetry and identifying
potential underlying causes such as heart failure or venous insufficiency. Accurate
documentation of edema grade is vital for monitoring the effectiveness of diuretic
therapy or other interventions.
4. Which clinical finding is most characteristic of chronic arterial insufficiency?
A. Brownish discoloration of the skin around the ankles.
B. Painless ulcers located on the medial malleolus.
C. Cool skin temperature and diminished or absent pulses.
D. Heavy, aching pain that is relieved by leg elevation.
Correct Answer: C
Expert Explanation: Chronic arterial insufficiency leads to decreased blood flow,
which results in cool skin and weak or absent peripheral pulses. Unlike venous
issues, arterial pain (claudication) is usually aggravated by exercise and relieved by
rest or dangling the legs. Physical signs often include thin, shiny skin, loss of hair on
, the lower legs, and thickened nails. The lack of oxygenated blood flow to the tissues
is the primary driver of these clinical manifestations. Nurses must prioritize
assessing for these signs to prevent complications like tissue necrosis or gangrene.
5. A patient reports experiencing sharp, cramping pain in the calves while walking that
disappears after resting for a few minutes. The nurse recognizes this as:
A. Venous stasis
B. Deep vein thrombosis
C. Intermittent claudication
D. Lymphedema
Correct Answer: C
Expert Explanation: Intermittent claudication is a classic symptom of peripheral
artery disease caused by ischemia during physical activity. The muscles require
more oxygen during movement, which the narrowed arteries cannot provide,
leading to pain. Once the patient rests, the oxygen demand decreases and the pain
subsides, confirming the arterial nature of the problem. This condition is often
quantified by the distance a patient can walk before pain occurs. Identifying this
symptom early is crucial for implementing lifestyle changes and medical
management to improve circulation. Nurses should educate patients on the
importance of supervised walking programs to increase collateral circulation.
Version 3 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. When assessing the amplitude of a peripheral pulse, the nurse documents a grade
of ‘2+’. Which interpretation of this finding is correct?
A. The pulse is absent and non-palpable.
B. The pulse is weak, thready, and easily obliterated.
C. The pulse is normal and easily palpable.
D. The pulse is bounding and does not disappear with pressure.
Correct Answer: C
Expert Explanation: A pulse grade of 2+ represents a normal, expected finding in a
healthy adult. This grading indicates that the blood flow is sufficient and the vessel
is easily felt with moderate pressure. In contrast, 0 is absent, 1+ is weak, and 3+ or
4+ is bounding depending on the scale used. Nurses must consistently apply this
standardized scale to ensure accurate communication within the healthcare team.
Establishing this baseline allows for early detection of changes in the patient’s
circulatory status.
2. A nurse is performing the Modified Allen test on a patient. What is the primary
purpose of this assessment technique?
A. To assess the patency of the ulnar artery before arterial blood gas sampling.
,B. To evaluate the presence of deep vein thrombosis in the lower extremities.
C. To measure the degree of pitting edema in the upper arms.
D. To determine the extent of lymphatic drainage in the axillary region.
Correct Answer: A
Expert Explanation: The Modified Allen test is specifically designed to evaluate
collateral circulation through the ulnar artery. By compressing both radial and ulnar
arteries and then releasing the ulnar side, the nurse checks if the hand flushes
within 2 to 5 seconds. This ensures that if the radial artery is damaged during a
procedure, the hand will still receive adequate blood supply. A negative result
suggests insufficient collateral flow, necessitating the use of a different site for
arterial puncture. This technique is a critical safety measure used to prevent
ischemic injury to the hand.
3. The nurse notes that a patient has deep pitting edema in the lower extremities that
remains for a short time after pressure is released. How should the nurse document
this finding?
A. 1+ Edema
B. 2+ Edema
C. 4+ Edema
D. 3+ Edema
,Correct Answer: D
Expert Explanation: 3+ edema is characterized by a deep pit that remains for a
short time and noticeably swollen legs. The grading system typically ranges from 1+
for mild pitting to 4+ for very deep pitting that lasts a long time. This specific finding
suggests a significant accumulation of interstitial fluid that requires further clinical
investigation. Assessment should include checking for symmetry and identifying
potential underlying causes such as heart failure or venous insufficiency. Accurate
documentation of edema grade is vital for monitoring the effectiveness of diuretic
therapy or other interventions.
4. Which clinical finding is most characteristic of chronic arterial insufficiency?
A. Brownish discoloration of the skin around the ankles.
B. Painless ulcers located on the medial malleolus.
C. Cool skin temperature and diminished or absent pulses.
D. Heavy, aching pain that is relieved by leg elevation.
Correct Answer: C
Expert Explanation: Chronic arterial insufficiency leads to decreased blood flow,
which results in cool skin and weak or absent peripheral pulses. Unlike venous
issues, arterial pain (claudication) is usually aggravated by exercise and relieved by
rest or dangling the legs. Physical signs often include thin, shiny skin, loss of hair on
, the lower legs, and thickened nails. The lack of oxygenated blood flow to the tissues
is the primary driver of these clinical manifestations. Nurses must prioritize
assessing for these signs to prevent complications like tissue necrosis or gangrene.
5. A patient reports experiencing sharp, cramping pain in the calves while walking that
disappears after resting for a few minutes. The nurse recognizes this as:
A. Venous stasis
B. Deep vein thrombosis
C. Intermittent claudication
D. Lymphedema
Correct Answer: C
Expert Explanation: Intermittent claudication is a classic symptom of peripheral
artery disease caused by ischemia during physical activity. The muscles require
more oxygen during movement, which the narrowed arteries cannot provide,
leading to pain. Once the patient rests, the oxygen demand decreases and the pain
subsides, confirming the arterial nature of the problem. This condition is often
quantified by the distance a patient can walk before pain occurs. Identifying this
symptom early is crucial for implementing lifestyle changes and medical
management to improve circulation. Nurses should educate patients on the
importance of supervised walking programs to increase collateral circulation.
