NURS 3120 HEALTH ASSESSMENT
FINAL QUESTIONS AND ANSWERS
100% CORRECT
The nurse places the nondominant hand over the costovertebral angle (CVA) and
strikes it with the dominant hand. This tests for tenderness in which organ? - ANSWER-
Kidney
The nurse auscultates for bowel sounds. What is the normal frequency of bowel
sounds? - ANSWER-Every 5 to 15 seconds
The nurse also attempts to elicit rebound tenderness. Which of the following indicates
positive rebound tenderness? - ANSWER-Pain upon sudden withdrawal of fingers after
deep palpation
The abdomen should be auscultated for at least 5 minutes before determining that
bowel sounds are absent. - ANSWER-True
When taking the health history of a patient who presents with acute abdominal pain, the
nurse should first: - ANSWER-Postpone an in-depth history to take vital signs.
What factor explains the protruding abdomen of an infant? - ANSWER-Weak abdominal
muscles
While performing a head-to-toe assessment of a client the nurse hears dullness over
the left upper quadrant during percussion. What would be the next assessment the
nurse should perform? - ANSWER-Palpation of the area
While palpating the client's abdomen the nurse notes the client wince in pain and
assesses involuntary contraction of the abdominal muscles. The nurse would document
which of the following findings? - ANSWER-Guarding
The LUQ contains the: - ANSWER-spleen
The patient reports that he has not had a bowel movement in several days. You
auscultate the abdomen for bowel sounds. What characteristics are you assessing?
Select all that apply. - ANSWER-Frequency, absence of bowel sounds, quality.
A patient comes to the emergency room complaining that he has been vomiting for the
past 24 hours with black vomitus/emesis. You know that black vomitus may indicate: -
ANSWER-Blood acted on by gastric digestion
, A patient presents with complaints of feeling bloated. You percuss all four quadrants of
the abdomen. A high-pitched, hollow-quality, drum-like sound that is heard over air-filled
viscera is called: - ANSWER-Tympany
A patient comes to the urgent care center stating that today he noticed bright red blood
in his stool. He denies abdominal pain, nausea, or vomiting. He states that he had a
similar episode that occurred last week. Bright red blood usually indicates: - ANSWER-
Bleeding low in the colon or rectum.
Joe Keller, age 70, is brought to the emergency room with the chief complaint of chest
pain for the past hour. Which question would be most useful in eliciting Mr. Keller's chief
complaint? - ANSWER-What does the pain feel like?
Murmurs greater than a grade 3 are usually significant of pathology. - ANSWER-True
When the healthy adult is in the sitting position, no jugular pulsations are visible. -
ANSWER-True
Which of the following characteristics should be noted when assessing pulses? Select
all that apply. - ANSWER-Amplitude
During a cardiovascular assessment the nurse notes that the client has a heart rhythm
with a pause after each beat and a skip every third beat. What is the appropriate
interpretation of this finding? - ANSWER-Regularly irregular
The precordium is: - ANSWER-the area on the anterior chest overlying the heart and
great vessels.
When auscultating the heart, your first step is to: - ANSWER-identify S1 & S2
A murmur heard after S1 and before S2 is classified as: - ANSWER-systolic
While reviewing a medical record, a notation of 4+ edema of the right leg is noted. The
best description of this type of edema is: - ANSWER-very deep pitting, indentation lasts
a long time
Atrophic skin changes that occur with peripheral arterial insufficiency include: -
ANSWER-thin, shiny skin with loss of hair
When auscultating heart sounds S1 and S2, the nurse should do which of the following?
- ANSWER-Use the diaphragm of the stethoscope.
Which of the following is a normal capillary refill time? - ANSWER-Less than 3 seconds
Which setting is the best place to gather data for a health history? - ANSWER-Patient's
room
FINAL QUESTIONS AND ANSWERS
100% CORRECT
The nurse places the nondominant hand over the costovertebral angle (CVA) and
strikes it with the dominant hand. This tests for tenderness in which organ? - ANSWER-
Kidney
The nurse auscultates for bowel sounds. What is the normal frequency of bowel
sounds? - ANSWER-Every 5 to 15 seconds
The nurse also attempts to elicit rebound tenderness. Which of the following indicates
positive rebound tenderness? - ANSWER-Pain upon sudden withdrawal of fingers after
deep palpation
The abdomen should be auscultated for at least 5 minutes before determining that
bowel sounds are absent. - ANSWER-True
When taking the health history of a patient who presents with acute abdominal pain, the
nurse should first: - ANSWER-Postpone an in-depth history to take vital signs.
What factor explains the protruding abdomen of an infant? - ANSWER-Weak abdominal
muscles
While performing a head-to-toe assessment of a client the nurse hears dullness over
the left upper quadrant during percussion. What would be the next assessment the
nurse should perform? - ANSWER-Palpation of the area
While palpating the client's abdomen the nurse notes the client wince in pain and
assesses involuntary contraction of the abdominal muscles. The nurse would document
which of the following findings? - ANSWER-Guarding
The LUQ contains the: - ANSWER-spleen
The patient reports that he has not had a bowel movement in several days. You
auscultate the abdomen for bowel sounds. What characteristics are you assessing?
Select all that apply. - ANSWER-Frequency, absence of bowel sounds, quality.
A patient comes to the emergency room complaining that he has been vomiting for the
past 24 hours with black vomitus/emesis. You know that black vomitus may indicate: -
ANSWER-Blood acted on by gastric digestion
, A patient presents with complaints of feeling bloated. You percuss all four quadrants of
the abdomen. A high-pitched, hollow-quality, drum-like sound that is heard over air-filled
viscera is called: - ANSWER-Tympany
A patient comes to the urgent care center stating that today he noticed bright red blood
in his stool. He denies abdominal pain, nausea, or vomiting. He states that he had a
similar episode that occurred last week. Bright red blood usually indicates: - ANSWER-
Bleeding low in the colon or rectum.
Joe Keller, age 70, is brought to the emergency room with the chief complaint of chest
pain for the past hour. Which question would be most useful in eliciting Mr. Keller's chief
complaint? - ANSWER-What does the pain feel like?
Murmurs greater than a grade 3 are usually significant of pathology. - ANSWER-True
When the healthy adult is in the sitting position, no jugular pulsations are visible. -
ANSWER-True
Which of the following characteristics should be noted when assessing pulses? Select
all that apply. - ANSWER-Amplitude
During a cardiovascular assessment the nurse notes that the client has a heart rhythm
with a pause after each beat and a skip every third beat. What is the appropriate
interpretation of this finding? - ANSWER-Regularly irregular
The precordium is: - ANSWER-the area on the anterior chest overlying the heart and
great vessels.
When auscultating the heart, your first step is to: - ANSWER-identify S1 & S2
A murmur heard after S1 and before S2 is classified as: - ANSWER-systolic
While reviewing a medical record, a notation of 4+ edema of the right leg is noted. The
best description of this type of edema is: - ANSWER-very deep pitting, indentation lasts
a long time
Atrophic skin changes that occur with peripheral arterial insufficiency include: -
ANSWER-thin, shiny skin with loss of hair
When auscultating heart sounds S1 and S2, the nurse should do which of the following?
- ANSWER-Use the diaphragm of the stethoscope.
Which of the following is a normal capillary refill time? - ANSWER-Less than 3 seconds
Which setting is the best place to gather data for a health history? - ANSWER-Patient's
room
