NURS 190 | NURS190 Exam 4: Physical Assessment
- WCU Updated and Latest Questions and Correct
Answers with Rationale
1. When documenting a patient’s physical assessment, which of the following statements
represents objective data?
A. Abdomen is soft, non-tender, with active bowel sounds in all quadrants.
B. Patient reports feeling nauseous after eating breakfast today.
C. Patient states they have a sharp pain in the left lower quadrant.
D. Patient mentions they have a history of hypertension for ten years.
Correct Answer: A
Rationale: Objective data consists of observable and measurable information obtained
through the physical examination. The description of the abdomen being soft and non-
tender is a finding identified by the nurse during palpation and auscultation. Subjective
data includes feelings, perceptions, and concerns provided solely by the patient during the
history-taking process. Accurate documentation requires a clear distinction between what
the nurse sees versus what the patient says. This ensures that clinical reasoning is based on
verifiable clinical evidence rather than self-reported symptoms alone.
2. The nurse is performing a respiratory assessment and hears high-pitched, musical sounds
primarily during expiration. How should this be documented?
A. Coarse crackles
B. Stridor
C. Pleural friction rub
D. Wheezes
Correct Answer: D
Rationale: Wheezing is characterized by high-pitched, musical sounds caused by air
flowing through narrowed or obstructed airways. This finding is commonly associated with
conditions like asthma or chronic obstructive pulmonary disease. It is most frequently
heard during expiration but can also occur during inspiration in severe cases.
Documentation must include the timing within the respiratory cycle and the specific
location where the sound was heard. Proper identification of adventitious sounds is crucial
for determining the appropriate pharmacological intervention for the patient.
3. Which sequence should the nurse follow when conducting an abdominal assessment to
avoid altering bowel sounds?
A. Inspection, Palpation, Percussion, Auscultation
, B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: B
Rationale: The standard sequence for abdominal assessment is inspection followed
immediately by auscultation. Percussion and palpation are deferred until after auscultation
because they can stimulate bowel activity and falsely increase bowel sounds. Starting with
inspection allows the nurse to visualize any visible masses, pulsations, or symmetry issues
without interference. This standardized approach ensures that the data collected during
the exam is accurate and not influenced by the physical manipulation of the organs.
Adhering to this specific order is a fundamental competency in advanced physical
assessment integration.
4. A nurse assesses a patient’s lower extremities and notes that a 4mm indentation remains
for several seconds after pressure is released. How should this edema be graded?
A. 1+
B. 4+
C. 3+
D. 2+
Correct Answer: D
Rationale: Pitting edema is graded on a scale of 1+ to 4+ based on the depth of the
indentation and the time it takes to return. A 2+ grade corresponds to a 4mm indentation
that subsides fairly quickly after the pressure is removed. Assessing edema is vital for
patients with heart failure or renal issues to monitor fluid volume status. The nurse must
apply firm pressure over a bony prominence like the tibia to get an accurate reading.
Consistent grading across the healthcare team allows for better monitoring of the patient’s
clinical progression or regression.
5. During a neurological assessment, the nurse asks the patient to stick out their tongue.
Which cranial nerve is being evaluated?
A. Cranial Nerve IX (Glossopharyngeal)
B. Cranial Nerve XII (Hypoglossal)
C. Cranial Nerve X (Vagus)
D. Cranial Nerve VII (Facial)
Correct Answer: B
- WCU Updated and Latest Questions and Correct
Answers with Rationale
1. When documenting a patient’s physical assessment, which of the following statements
represents objective data?
A. Abdomen is soft, non-tender, with active bowel sounds in all quadrants.
B. Patient reports feeling nauseous after eating breakfast today.
C. Patient states they have a sharp pain in the left lower quadrant.
D. Patient mentions they have a history of hypertension for ten years.
Correct Answer: A
Rationale: Objective data consists of observable and measurable information obtained
through the physical examination. The description of the abdomen being soft and non-
tender is a finding identified by the nurse during palpation and auscultation. Subjective
data includes feelings, perceptions, and concerns provided solely by the patient during the
history-taking process. Accurate documentation requires a clear distinction between what
the nurse sees versus what the patient says. This ensures that clinical reasoning is based on
verifiable clinical evidence rather than self-reported symptoms alone.
2. The nurse is performing a respiratory assessment and hears high-pitched, musical sounds
primarily during expiration. How should this be documented?
A. Coarse crackles
B. Stridor
C. Pleural friction rub
D. Wheezes
Correct Answer: D
Rationale: Wheezing is characterized by high-pitched, musical sounds caused by air
flowing through narrowed or obstructed airways. This finding is commonly associated with
conditions like asthma or chronic obstructive pulmonary disease. It is most frequently
heard during expiration but can also occur during inspiration in severe cases.
Documentation must include the timing within the respiratory cycle and the specific
location where the sound was heard. Proper identification of adventitious sounds is crucial
for determining the appropriate pharmacological intervention for the patient.
3. Which sequence should the nurse follow when conducting an abdominal assessment to
avoid altering bowel sounds?
A. Inspection, Palpation, Percussion, Auscultation
, B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: B
Rationale: The standard sequence for abdominal assessment is inspection followed
immediately by auscultation. Percussion and palpation are deferred until after auscultation
because they can stimulate bowel activity and falsely increase bowel sounds. Starting with
inspection allows the nurse to visualize any visible masses, pulsations, or symmetry issues
without interference. This standardized approach ensures that the data collected during
the exam is accurate and not influenced by the physical manipulation of the organs.
Adhering to this specific order is a fundamental competency in advanced physical
assessment integration.
4. A nurse assesses a patient’s lower extremities and notes that a 4mm indentation remains
for several seconds after pressure is released. How should this edema be graded?
A. 1+
B. 4+
C. 3+
D. 2+
Correct Answer: D
Rationale: Pitting edema is graded on a scale of 1+ to 4+ based on the depth of the
indentation and the time it takes to return. A 2+ grade corresponds to a 4mm indentation
that subsides fairly quickly after the pressure is removed. Assessing edema is vital for
patients with heart failure or renal issues to monitor fluid volume status. The nurse must
apply firm pressure over a bony prominence like the tibia to get an accurate reading.
Consistent grading across the healthcare team allows for better monitoring of the patient’s
clinical progression or regression.
5. During a neurological assessment, the nurse asks the patient to stick out their tongue.
Which cranial nerve is being evaluated?
A. Cranial Nerve IX (Glossopharyngeal)
B. Cranial Nerve XII (Hypoglossal)
C. Cranial Nerve X (Vagus)
D. Cranial Nerve VII (Facial)
Correct Answer: B
