NUR 3270/NUR3270 Exam 3 V3 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. When performing a physical assessment of the abdomen, in which order should the nurse
perform the techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: B
Expert Explanation: The correct sequence for abdominal assessment is inspection,
auscultation, percussion, and then palpation. This specific order is used because percussion
and palpation can increase peristalsis, which would give a false interpretation of bowel
sounds. By auscultating immediately after inspection, the nurse ensures the most accurate
assessment of the patient’s natural bowel activity.
2. A patient complains of pain in the Right Lower Quadrant (RLQ). Which organ is primarily
located in this area?
A. Liver
B. Spleen
,C. Sigmoid Colon
D. Appendix
Correct Answer: D
Expert Explanation: The Right Lower Quadrant (RLQ) contains the appendix, cecum, and
the right ovary/ureter. Pain in this area is a classic indicator of appendicitis. The liver is
primarily in the RUQ, the spleen is in the LUQ, and the sigmoid colon is in the LLQ.
3. To assess Cranial Nerve II (Optic Nerve), which tool should the nurse use?
A. Tuning Fork
B. Snellen Chart
C. Penlight
D. Reflex Hammer
Correct Answer: B
Expert Explanation: The Optic Nerve (CN II) is responsible for visual acuity and visual
fields. Using a Snellen chart allows the nurse to measure the distance vision of the patient.
This test is essential for evaluating the sensory function of the eyes during a neurological
exam.
4. The nurse asks the patient to shrug their shoulders against resistance. This maneuver tests
which cranial nerve?
A. CN XI (Spinal Accessory)
, B. CN X (Vagus)
C. CN IX (Glossopharyngeal)
D. CN XII (Hypoglossal)
Correct Answer: A
Expert Explanation: Cranial Nerve XI, the Spinal Accessory nerve, innervates the trapezius
and sternomastoid muscles. To test this nerve, the nurse asks the patient to shrug their
shoulders and turn their head against resistance. Equal strength on both sides indicates
that the nerve is intact and functioning properly.
5. During a musculoskeletal exam, the nurse asks the patient to move their arm away from
the midline of the body. This movement is called:
A. Adduction
B. Extension
C. Flexion
D. Abduction
Correct Answer: D
Expert Explanation: Abduction is the movement of a limb or other part away from the
midline of the body. Adduction is the opposite, moving toward the midline. Correct
terminology is vital for documenting Range of Motion (ROM) accurately in a clinical setting.
Health Assessment Q&A with Rationale |
William Paterson University
1. When performing a physical assessment of the abdomen, in which order should the nurse
perform the techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: B
Expert Explanation: The correct sequence for abdominal assessment is inspection,
auscultation, percussion, and then palpation. This specific order is used because percussion
and palpation can increase peristalsis, which would give a false interpretation of bowel
sounds. By auscultating immediately after inspection, the nurse ensures the most accurate
assessment of the patient’s natural bowel activity.
2. A patient complains of pain in the Right Lower Quadrant (RLQ). Which organ is primarily
located in this area?
A. Liver
B. Spleen
,C. Sigmoid Colon
D. Appendix
Correct Answer: D
Expert Explanation: The Right Lower Quadrant (RLQ) contains the appendix, cecum, and
the right ovary/ureter. Pain in this area is a classic indicator of appendicitis. The liver is
primarily in the RUQ, the spleen is in the LUQ, and the sigmoid colon is in the LLQ.
3. To assess Cranial Nerve II (Optic Nerve), which tool should the nurse use?
A. Tuning Fork
B. Snellen Chart
C. Penlight
D. Reflex Hammer
Correct Answer: B
Expert Explanation: The Optic Nerve (CN II) is responsible for visual acuity and visual
fields. Using a Snellen chart allows the nurse to measure the distance vision of the patient.
This test is essential for evaluating the sensory function of the eyes during a neurological
exam.
4. The nurse asks the patient to shrug their shoulders against resistance. This maneuver tests
which cranial nerve?
A. CN XI (Spinal Accessory)
, B. CN X (Vagus)
C. CN IX (Glossopharyngeal)
D. CN XII (Hypoglossal)
Correct Answer: A
Expert Explanation: Cranial Nerve XI, the Spinal Accessory nerve, innervates the trapezius
and sternomastoid muscles. To test this nerve, the nurse asks the patient to shrug their
shoulders and turn their head against resistance. Equal strength on both sides indicates
that the nerve is intact and functioning properly.
5. During a musculoskeletal exam, the nurse asks the patient to move their arm away from
the midline of the body. This movement is called:
A. Adduction
B. Extension
C. Flexion
D. Abduction
Correct Answer: D
Expert Explanation: Abduction is the movement of a limb or other part away from the
midline of the body. Adduction is the opposite, moving toward the midline. Correct
terminology is vital for documenting Range of Motion (ROM) accurately in a clinical setting.
