Health Assessment Nursing Exam – Weight Monitoring, Fracture
Identification, Reflex Testing, and Cardiac Palpation (Q&A)
LATEST UPDATED 2025
Major Keywords: health assessment nursing questions, weight loss monitoring in obese patients, fracture pain vs muscle pain, gag reflex testing, pharyngeal
reflex assessment, apical pulse location, cardiac assessment in nursing, pediatric post-op care, NCLEX health assessment prep, nursing clinical skills
questions.
The nurse is caring for an obese client on a weight loss program. Which method would the nurse use to
most accurately assess the program's effectiveness?
a) Monitor client's weight.
b) Monitor client's intake & output.
c) Calculate client's daily caloric intake.
d) Frequently check client's serum protein levels.
a
The most accurate measurement of weight loss is weighing of the client. This needs to be done at the same time
of the day, in the same clothes, & using the same scale.
The other options measure nutrition & hydration status but are not associated with the effectiveness of the
weight loss program.
Tip: Clothing & shoes affect the obtained weight measurement. It is important to make a notation about any
clothing, shoes, accessories (heavy jewelry), or other items such as casts or braces worn by the client while
obtaining the weight.
A client has fallen & sustained a leg injury. Which question would the nurse ask to help determine if the
client sustained a fracture?
a) "Is the pain a dull ache?"
b) "Is the pain sharp & continuous?"
c) "Does the discomfort feel like a cramp?"
d) "Does the pain feel like the muscle was stretched?"
b
Fracture pain in generally described as sharp, continuous, & increasing in frequency.
Bone pain is often described as a dull, deep ache. Muscle injury is often described as an aching or cramping
pain, or soreness. Strains result from trauma to a muscle body or the attachment of a tendon from overstretching
or overextension.
Tip: Some fractures can be identified on inspection & exhibit manifestations such as an obvious deformity,
edema, & ecchymosis (bruising); other are detected only on x-ray examination.
What action would the nurse take to assess the pharyngeal reflex on a child prescribed liquids post-
appendectomy?
, a) Ask client to swallow.
b) Pull down the lower eyelid.
c) Shine a light toward the bridge of the nose.
d) Stimulate the back of the throat with a tongue depressor.
d
The pharyngeal (gag) reflex is tested by touching the back of the throat with an object, such as a tongue
depressor. A positive response to this reflex is considered normal.
Asking the client to swallow assess for the swallowing reflex. The nurse would pull down the lower eyelid to
assess the palpebral conjunctiva. The corneal light reflex is tested by shining a penlight toward the bridge of the
nose at a distance of 12-15 inches. The light's reflection should be symmetric in both corneas.
Tip: If a client receives a local throat anesthetic for a diagnostic or other procedure, the client must remain NPO
until the gag reflex returns.
As a part of cardiac assessment, to palpate the apical pulse, the nurse places the fingertips at which
location?
a) At the left midclavicular line at the fifth intercostal space.
b) At the left midclavicular line at the third intercostal space.
c) To the right of the left midclavicular line at the fifth intercostal space.
d) To the right of the left midclavicular line at the third intercostal space.
a
The PMI (point of maximal impulse), where the apical pulse is palpated, is normally located at the fourth or
fifth intercostal space, at the left midclavicular line.
Tip: The apical impulse may not be palpable in obese clients or clients with thick chest walls.
After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, the nurse
documents that the bowel sounds are normal. How would the nurse describe these findings?
a) Waves of loud gurgles auscultated in all four quadrants.
b) Soft gurgling or clicking sounds auscultated in all four quadrants.
c) Low-pitched swishing sounds auscultated in one or two quadrants.
d) Very high-pitched loud rushes auscultated, especially in one or two quadrants.
b
Although frequency & intensity of bowel sounds will vary depending on the phase of digestion, normal bowel
sounds are relatively soft gurgling or clicking sounds that occur irregularly 5-35 time per minute.
Loud gurgles (borborygmi) indicate hyper-peristalsis (described as hyperactive bowel sounds). A swishing or
bussing sounds represents turbulent blood flow associated with a bruit. No aortic bruits should be heard. Bowel
sounds will be higher pitched & loud when the intestines are under tension, such as a bowel obstruction.
Tip: Murphy's sign (the client cannot take a deep breath when the nurse's fingers are passed below the hepatic
margin because of pain) is an indicator of cholecystitis (inflamed gallbladder).
Identification, Reflex Testing, and Cardiac Palpation (Q&A)
LATEST UPDATED 2025
Major Keywords: health assessment nursing questions, weight loss monitoring in obese patients, fracture pain vs muscle pain, gag reflex testing, pharyngeal
reflex assessment, apical pulse location, cardiac assessment in nursing, pediatric post-op care, NCLEX health assessment prep, nursing clinical skills
questions.
The nurse is caring for an obese client on a weight loss program. Which method would the nurse use to
most accurately assess the program's effectiveness?
a) Monitor client's weight.
b) Monitor client's intake & output.
c) Calculate client's daily caloric intake.
d) Frequently check client's serum protein levels.
a
The most accurate measurement of weight loss is weighing of the client. This needs to be done at the same time
of the day, in the same clothes, & using the same scale.
The other options measure nutrition & hydration status but are not associated with the effectiveness of the
weight loss program.
Tip: Clothing & shoes affect the obtained weight measurement. It is important to make a notation about any
clothing, shoes, accessories (heavy jewelry), or other items such as casts or braces worn by the client while
obtaining the weight.
A client has fallen & sustained a leg injury. Which question would the nurse ask to help determine if the
client sustained a fracture?
a) "Is the pain a dull ache?"
b) "Is the pain sharp & continuous?"
c) "Does the discomfort feel like a cramp?"
d) "Does the pain feel like the muscle was stretched?"
b
Fracture pain in generally described as sharp, continuous, & increasing in frequency.
Bone pain is often described as a dull, deep ache. Muscle injury is often described as an aching or cramping
pain, or soreness. Strains result from trauma to a muscle body or the attachment of a tendon from overstretching
or overextension.
Tip: Some fractures can be identified on inspection & exhibit manifestations such as an obvious deformity,
edema, & ecchymosis (bruising); other are detected only on x-ray examination.
What action would the nurse take to assess the pharyngeal reflex on a child prescribed liquids post-
appendectomy?
, a) Ask client to swallow.
b) Pull down the lower eyelid.
c) Shine a light toward the bridge of the nose.
d) Stimulate the back of the throat with a tongue depressor.
d
The pharyngeal (gag) reflex is tested by touching the back of the throat with an object, such as a tongue
depressor. A positive response to this reflex is considered normal.
Asking the client to swallow assess for the swallowing reflex. The nurse would pull down the lower eyelid to
assess the palpebral conjunctiva. The corneal light reflex is tested by shining a penlight toward the bridge of the
nose at a distance of 12-15 inches. The light's reflection should be symmetric in both corneas.
Tip: If a client receives a local throat anesthetic for a diagnostic or other procedure, the client must remain NPO
until the gag reflex returns.
As a part of cardiac assessment, to palpate the apical pulse, the nurse places the fingertips at which
location?
a) At the left midclavicular line at the fifth intercostal space.
b) At the left midclavicular line at the third intercostal space.
c) To the right of the left midclavicular line at the fifth intercostal space.
d) To the right of the left midclavicular line at the third intercostal space.
a
The PMI (point of maximal impulse), where the apical pulse is palpated, is normally located at the fourth or
fifth intercostal space, at the left midclavicular line.
Tip: The apical impulse may not be palpable in obese clients or clients with thick chest walls.
After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, the nurse
documents that the bowel sounds are normal. How would the nurse describe these findings?
a) Waves of loud gurgles auscultated in all four quadrants.
b) Soft gurgling or clicking sounds auscultated in all four quadrants.
c) Low-pitched swishing sounds auscultated in one or two quadrants.
d) Very high-pitched loud rushes auscultated, especially in one or two quadrants.
b
Although frequency & intensity of bowel sounds will vary depending on the phase of digestion, normal bowel
sounds are relatively soft gurgling or clicking sounds that occur irregularly 5-35 time per minute.
Loud gurgles (borborygmi) indicate hyper-peristalsis (described as hyperactive bowel sounds). A swishing or
bussing sounds represents turbulent blood flow associated with a bruit. No aortic bruits should be heard. Bowel
sounds will be higher pitched & loud when the intestines are under tension, such as a bowel obstruction.
Tip: Murphy's sign (the client cannot take a deep breath when the nurse's fingers are passed below the hepatic
margin because of pain) is an indicator of cholecystitis (inflamed gallbladder).
