NSG 100 Assessment- Nursing Practice and Patient
Assessment with Complete Solutions
Q1. During a patient interview, the nurse notices the patient avoids eye contact and
gives short answers. What is the most appropriate nursing action?
A1. Use open-ended questions and therapeutic silence to encourage the patient to
share more, while maintaining a nonjudgmental presence.
Q2. A nurse is assessing a patient’s respiratory status. Which finding requires
immediate intervention?
A2. Respiratory rate of 8 breaths per minute with cyanosis around the lips.
Q3. When performing a physical assessment, why should the nurse proceed from least
invasive to most invasive techniques?
A3. To build patient trust, reduce anxiety, and promote cooperation during the exam.
Q4. A patient reports chest pain rated 8/10. What is the nurse’s priority assessment?
A4. Assess vital signs and oxygen saturation immediately, then gather details about
pain onset, location, duration, and characteristics.
Q5. Which statement best reflects subjective data in a nursing assessment?
A5. “I feel dizzy when I stand up.”
Q6. A nurse documents: “Skin warm, dry, intact; capillary refill <2 seconds.” This is an
example of what type of data?
A6. Objective data.
Q7. A patient with diabetes presents with a foot ulcer. What is the nurse’s first step in
assessment?
A7. Inspect the wound for size, depth, drainage, and signs of infection.
Q8. Which tool is most appropriate for assessing a patient’s risk of falls?
A8. Morse Fall Scale.
Q9. A nurse is assessing pain in a nonverbal patient. Which scale is most appropriate?
A9. FLACC scale (Face, Legs, Activity, Cry, Consolability).
Q10. During a head-to-toe assessment, the nurse notes jugular vein distension. What
condition does this most likely indicate?
A10. Right-sided heart failure.
Q11. Which vital sign is most sensitive to early blood loss?
A11. Heart rate (tachycardia often appears before blood pressure drops).
, Q12. A nurse palpates the dorsalis pedis pulse. What is being assessed?
A12. Peripheral circulation in the lower extremities.
Q13. Which cranial nerve is tested when a patient is asked to smile and frown?
A13. Cranial nerve VII (Facial nerve).
Q14. A patient reports sudden shortness of breath. What is the nurse’s immediate
action?
A14. Assess airway, breathing, and circulation (ABC).
Q15. Which assessment finding indicates dehydration?
A15. Poor skin turgor and dry mucous membranes.
Q16. When auscultating lung sounds, crackles are most commonly associated with
what condition?
A16. Pulmonary edema or pneumonia.
Q17. A nurse notes unequal pupil sizes. What is the correct term?
A17. Anisocoria.
Q18. Which position is best for assessing jugular vein distension?
A18. Semi-Fowler’s position (30–45 degrees).
Q19. A patient’s blood pressure is 90/60 mmHg. What is the priority nursing
assessment?
A19. Assess for dizziness, confusion, or signs of hypoperfusion.
Q20. Which tool is used to assess a patient’s level of consciousness after head injury?
A20. Glasgow Coma Scale (GCS).
Q21. A nurse observes clubbing of the fingers. What condition is this often linked to?
A21. Chronic hypoxia (e.g., COPD, congenital heart disease).
Q22. Which sound is expected when percussing over the lungs?
A22. Resonance.
Q23. A patient reports numbness in the hands. Which system should be assessed
further?
A23. Neurological system.
Q24. Which finding is considered normal in an older adult’s cardiovascular assessment?
A24. Slightly increased systolic blood pressure due to arterial stiffness.
Q25. A nurse palpates the abdomen and notes guarding. What does this suggest?
A25. Possible peritoneal irritation or abdominal pain.
Assessment with Complete Solutions
Q1. During a patient interview, the nurse notices the patient avoids eye contact and
gives short answers. What is the most appropriate nursing action?
A1. Use open-ended questions and therapeutic silence to encourage the patient to
share more, while maintaining a nonjudgmental presence.
Q2. A nurse is assessing a patient’s respiratory status. Which finding requires
immediate intervention?
A2. Respiratory rate of 8 breaths per minute with cyanosis around the lips.
Q3. When performing a physical assessment, why should the nurse proceed from least
invasive to most invasive techniques?
A3. To build patient trust, reduce anxiety, and promote cooperation during the exam.
Q4. A patient reports chest pain rated 8/10. What is the nurse’s priority assessment?
A4. Assess vital signs and oxygen saturation immediately, then gather details about
pain onset, location, duration, and characteristics.
Q5. Which statement best reflects subjective data in a nursing assessment?
A5. “I feel dizzy when I stand up.”
Q6. A nurse documents: “Skin warm, dry, intact; capillary refill <2 seconds.” This is an
example of what type of data?
A6. Objective data.
Q7. A patient with diabetes presents with a foot ulcer. What is the nurse’s first step in
assessment?
A7. Inspect the wound for size, depth, drainage, and signs of infection.
Q8. Which tool is most appropriate for assessing a patient’s risk of falls?
A8. Morse Fall Scale.
Q9. A nurse is assessing pain in a nonverbal patient. Which scale is most appropriate?
A9. FLACC scale (Face, Legs, Activity, Cry, Consolability).
Q10. During a head-to-toe assessment, the nurse notes jugular vein distension. What
condition does this most likely indicate?
A10. Right-sided heart failure.
Q11. Which vital sign is most sensitive to early blood loss?
A11. Heart rate (tachycardia often appears before blood pressure drops).
, Q12. A nurse palpates the dorsalis pedis pulse. What is being assessed?
A12. Peripheral circulation in the lower extremities.
Q13. Which cranial nerve is tested when a patient is asked to smile and frown?
A13. Cranial nerve VII (Facial nerve).
Q14. A patient reports sudden shortness of breath. What is the nurse’s immediate
action?
A14. Assess airway, breathing, and circulation (ABC).
Q15. Which assessment finding indicates dehydration?
A15. Poor skin turgor and dry mucous membranes.
Q16. When auscultating lung sounds, crackles are most commonly associated with
what condition?
A16. Pulmonary edema or pneumonia.
Q17. A nurse notes unequal pupil sizes. What is the correct term?
A17. Anisocoria.
Q18. Which position is best for assessing jugular vein distension?
A18. Semi-Fowler’s position (30–45 degrees).
Q19. A patient’s blood pressure is 90/60 mmHg. What is the priority nursing
assessment?
A19. Assess for dizziness, confusion, or signs of hypoperfusion.
Q20. Which tool is used to assess a patient’s level of consciousness after head injury?
A20. Glasgow Coma Scale (GCS).
Q21. A nurse observes clubbing of the fingers. What condition is this often linked to?
A21. Chronic hypoxia (e.g., COPD, congenital heart disease).
Q22. Which sound is expected when percussing over the lungs?
A22. Resonance.
Q23. A patient reports numbness in the hands. Which system should be assessed
further?
A23. Neurological system.
Q24. Which finding is considered normal in an older adult’s cardiovascular assessment?
A24. Slightly increased systolic blood pressure due to arterial stiffness.
Q25. A nurse palpates the abdomen and notes guarding. What does this suggest?
A25. Possible peritoneal irritation or abdominal pain.
