NSG121/NSG 121 Final Exam V1 | Health
Assessment Q&A with Rationale | Herzing
University
1. A nurse is preparing to perform a physical assessment on a new patient. Which technique
should the nurse use first for every body system except the abdomen?
A. Palpation
B. Percussion
C. Inspection
D. Auscultation
Correct Answer: C
Rationale: Inspection is always the first step in the physical assessment process because it
provides initial visual data about the patient’s condition. This step involves a deliberate and
focused observation of the patient’s body and behavior. By starting with inspection, the
nurse can identify visible abnormalities before touching the patient, which might alter
findings like heart rate or skin color.
2. During an abdominal assessment, in what order should the nurse perform the physical
examination techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Auscultation, Inspection, Palpation, Percussion
,C. Inspection, Palpation, Percussion, Auscultation
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: A
Rationale: The abdomen must be auscultated before percussion or palpation because
those physical maneuvers can stimulate bowel activity. Stimulating the bowel can result in
false recordings of bowel sounds that were not originally present. Following this sequence
ensures the accuracy of the gastrointestinal assessment by observing and listening in a
resting state first.
3. When assessing a patient’s risk for pressure injuries, the nurse utilizes the Braden Scale.
Which score would indicate the highest risk for skin breakdown?
A. 9
B. 15
C. 19
D. 23
Correct Answer: A
Rationale: The Braden Scale uses a scoring system where lower numbers correlate with a
higher risk of developing a pressure injury. A score of 9 indicates very high risk, while a
score of 23 represents the lowest possible risk. Understanding this inverse relationship is
critical for prioritizing preventative nursing interventions for vulnerable patients.
, 4. A patient presents with ‘the worst headache of my life.’ Which action should the nurse
take first?
A. Perform a comprehensive neurological exam.
B. Administer prescribed pain medication.
C. Ask the patient about their history of migraines.
D. Assess the patient’s vital signs and level of consciousness.
Correct Answer: D
Rationale: The phrase ‘worst headache of my life’ is a clinical ‘red flag’ for a potential
subarachnoid hemorrhage. The nurse must immediately assess vital signs and level of
consciousness to determine the patient’s stability. While history and pain management are
important, they are secondary to identifying a life-threatening neurological emergency.
5. While auscultating the lungs of a patient with asthma, the nurse hears high-pitched,
musical sounds primarily during expiration. How should the nurse document this finding?
A. Crackles
B. Pleural friction rub
C. Rhonchi
D. Wheezes
Correct Answer: D
Assessment Q&A with Rationale | Herzing
University
1. A nurse is preparing to perform a physical assessment on a new patient. Which technique
should the nurse use first for every body system except the abdomen?
A. Palpation
B. Percussion
C. Inspection
D. Auscultation
Correct Answer: C
Rationale: Inspection is always the first step in the physical assessment process because it
provides initial visual data about the patient’s condition. This step involves a deliberate and
focused observation of the patient’s body and behavior. By starting with inspection, the
nurse can identify visible abnormalities before touching the patient, which might alter
findings like heart rate or skin color.
2. During an abdominal assessment, in what order should the nurse perform the physical
examination techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Auscultation, Inspection, Palpation, Percussion
,C. Inspection, Palpation, Percussion, Auscultation
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: A
Rationale: The abdomen must be auscultated before percussion or palpation because
those physical maneuvers can stimulate bowel activity. Stimulating the bowel can result in
false recordings of bowel sounds that were not originally present. Following this sequence
ensures the accuracy of the gastrointestinal assessment by observing and listening in a
resting state first.
3. When assessing a patient’s risk for pressure injuries, the nurse utilizes the Braden Scale.
Which score would indicate the highest risk for skin breakdown?
A. 9
B. 15
C. 19
D. 23
Correct Answer: A
Rationale: The Braden Scale uses a scoring system where lower numbers correlate with a
higher risk of developing a pressure injury. A score of 9 indicates very high risk, while a
score of 23 represents the lowest possible risk. Understanding this inverse relationship is
critical for prioritizing preventative nursing interventions for vulnerable patients.
, 4. A patient presents with ‘the worst headache of my life.’ Which action should the nurse
take first?
A. Perform a comprehensive neurological exam.
B. Administer prescribed pain medication.
C. Ask the patient about their history of migraines.
D. Assess the patient’s vital signs and level of consciousness.
Correct Answer: D
Rationale: The phrase ‘worst headache of my life’ is a clinical ‘red flag’ for a potential
subarachnoid hemorrhage. The nurse must immediately assess vital signs and level of
consciousness to determine the patient’s stability. While history and pain management are
important, they are secondary to identifying a life-threatening neurological emergency.
5. While auscultating the lungs of a patient with asthma, the nurse hears high-pitched,
musical sounds primarily during expiration. How should the nurse document this finding?
A. Crackles
B. Pleural friction rub
C. Rhonchi
D. Wheezes
Correct Answer: D
