NUR 3270/NUR3270 Final Exam V3 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing a patient’s abdomen, in which order should the nurse perform the
assessment techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: A
Expert Explanation: The standard sequence of physical assessment is modified for the
abdomen to avoid altering bowel sounds. Auscultation must be performed before
percussion and palpation because manual manipulation can stimulate peristalsis. This
ensures that the sounds heard during auscultation are a true reflection of the patient’s
bowel activity.
2. Which part of the hand is best suited for assessing the patient’s skin temperature?
A. Fingertips
B. Dorsal surface of the hand
C. Ulnar surface of the hand
,D. Palmar surface of the hand
Correct Answer: B
Expert Explanation: The dorsal surface or back of the hand is thinner and more sensitive
to temperature changes than the palms. Nurses use this area to check for symmetry in skin
temperature across different body parts. Using the fingertips is better for fine tactile
discrimination rather than temperature sensing.
3. A nurse is assessing a patient for pitting edema and notes a 6mm indentation that remains
for a short time. How should this be documented?
A. 1+
B. 2+
C. 4+
D. 3+
Correct Answer: D
Expert Explanation: Edema is graded on a scale of 1+ to 4+ based on the depth of the
indentation and how long it persists. A 6mm indentation corresponds to a 3+ grade, which
is considered deep pitting. Accurate documentation of edema is crucial for monitoring fluid
balance and cardiac function in patients.
4. Which cranial nerve is being tested when the nurse asks the patient to shrug their
shoulders against resistance?
A. Cranial Nerve VII (Facial)
, B. Cranial Nerve XI (Spinal Accessory)
C. Cranial Nerve X (Vagus)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: B
Expert Explanation: The Spinal Accessory nerve (CN XI) innervates the trapezius and
sternocleidomastoid muscles. Testing shoulder shrugging and neck rotation against
resistance evaluates the strength and integrity of this nerve. Weakness or asymmetry
during this test may indicate nerve damage or muscular pathology.
5. During a lung assessment, the nurse hears high-pitched, musical sounds primarily during
expiration. These are identified as:
A. Crackles
B. Wheezes
C. Rhonchi
D. Pleural friction rub
Correct Answer: B
Expert Explanation: Wheezes are continuous, high-pitched whistling sounds produced by
air flowing through narrowed or obstructed airways. They are commonly associated with
conditions like asthma or chronic obstructive pulmonary disease. Identifying the specific
type of adventitious breath sound is vital for determining the underlying respiratory issue.
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing a patient’s abdomen, in which order should the nurse perform the
assessment techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: A
Expert Explanation: The standard sequence of physical assessment is modified for the
abdomen to avoid altering bowel sounds. Auscultation must be performed before
percussion and palpation because manual manipulation can stimulate peristalsis. This
ensures that the sounds heard during auscultation are a true reflection of the patient’s
bowel activity.
2. Which part of the hand is best suited for assessing the patient’s skin temperature?
A. Fingertips
B. Dorsal surface of the hand
C. Ulnar surface of the hand
,D. Palmar surface of the hand
Correct Answer: B
Expert Explanation: The dorsal surface or back of the hand is thinner and more sensitive
to temperature changes than the palms. Nurses use this area to check for symmetry in skin
temperature across different body parts. Using the fingertips is better for fine tactile
discrimination rather than temperature sensing.
3. A nurse is assessing a patient for pitting edema and notes a 6mm indentation that remains
for a short time. How should this be documented?
A. 1+
B. 2+
C. 4+
D. 3+
Correct Answer: D
Expert Explanation: Edema is graded on a scale of 1+ to 4+ based on the depth of the
indentation and how long it persists. A 6mm indentation corresponds to a 3+ grade, which
is considered deep pitting. Accurate documentation of edema is crucial for monitoring fluid
balance and cardiac function in patients.
4. Which cranial nerve is being tested when the nurse asks the patient to shrug their
shoulders against resistance?
A. Cranial Nerve VII (Facial)
, B. Cranial Nerve XI (Spinal Accessory)
C. Cranial Nerve X (Vagus)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: B
Expert Explanation: The Spinal Accessory nerve (CN XI) innervates the trapezius and
sternocleidomastoid muscles. Testing shoulder shrugging and neck rotation against
resistance evaluates the strength and integrity of this nerve. Weakness or asymmetry
during this test may indicate nerve damage or muscular pathology.
5. During a lung assessment, the nurse hears high-pitched, musical sounds primarily during
expiration. These are identified as:
A. Crackles
B. Wheezes
C. Rhonchi
D. Pleural friction rub
Correct Answer: B
Expert Explanation: Wheezes are continuous, high-pitched whistling sounds produced by
air flowing through narrowed or obstructed airways. They are commonly associated with
conditions like asthma or chronic obstructive pulmonary disease. Identifying the specific
type of adventitious breath sound is vital for determining the underlying respiratory issue.
