Final Exam: NSG 316/ NSG316 (NEW 2026/ 2027 Update) Health Assessment Review| Questions & Answers| Grade A| 100% Correct (Accurate Solutions)- GCU

…. DLDD Final Exam: NSG 316/ NSG316 (NEW 2026/ 2027 Update) Health Assessment Review| Questions & Answers| Grade A| 100% Correct (Accurate Solutions)- GCU Q. What are the elements of a general survey and health assessment? ANSWERS Physical appearance, body structure, mobility, behavior, and measurement Q. What is the difference between subjective and objective data? ANSWERS Subjective data is what the patient say about themselves during the history taking. Objective data is observed when inspecting, percussing, palpating, and auscultating the patient during the physical exam. Q. What is the difference between a comprehensive assessment and a focused assessment? ANSWERS A comprehensive assessment includes the patient's history, physical exam, and VS; yearly health exams. A focused assessment is a more detailed assessment that related to a current medical condition/patient complaint; ER situations or after a diagnosis Q. A nurse is caring for a client who asks about measures the nurse takes to protect client privacy. Which of the following is an appropriate response by the nurse? a. "I will provide their information to anyone who requests it." b. "I will make sure my password to log into the system is the same one I use for everything else." c. "I will talk to my friends about the client in order to get advice." d. "I will log off the computer in between seeing clients." ANSWERS d HIPAA establishes national standards for the protection of certain health info. The privacy rule can be violated if a client's health info is on the computer screen and the nurse leaves it up while taking care of other clients. Q. What factors affect health promotion and disease prevention throughout the lifespan? ANSWERS Gender, genetics, education, socioeconomic status, ethnicity, lifestyle, chronic illness/disability, and race Q. Which of these are components of a functional assessment? (Select all that apply) a. vision and hearing b. mobility c. continence d. nutrition e. ADL-IADL ANSWERS Answer: all of them :) A functional assessment also includes mental status, affect, home environment, and social support! Q. What is the key to understanding cultural diversity? ANSWERS Being self-aware and having knowledge of one's own culture Q. FICA is an assessment tool used to determine a patient's spiritual history. What does FICA stand for? ANSWERS F = faith I = importance/influence C = community A = address/action Q. What components should be assessed and asked about when completing a cultural assessment? ANSWERS Heritage, health practices, communication, family roles & social orientation, nutrition, pregnancy, spirituality/religion, death, and role of health providers Q. What are the four sources of pain? (Provide some examples for each) ANSWERS 1. Visceral pain = large interior organs (e.g., appendicitis, gallstones) 2. Deep somatic pain = blood vessels, joints, tendons, muscles, and bone injury (e.g., sprain, broken bone) 3. Cutaneous pain = skin surface and subcutaneous tissues (e.g., paper cut) 4. Referred pain = felt at a particular site but originates from another location (e.g., left arm hurting during an MI although the issue is with the heart) Q. A patient is crying and says, "Please get me something to relieve this pain." What should the nurse do next? a. Verify that the patient has an order for pain medications and administer order as directed b. Assess the level of pain and ask patient what usually works for his or her pain, administer pain medication as needed, then reassess pain level c. Assess the level of pain and give medications according to pain level, and then reassess pain d. Reposition the patient, then reassess the pain after intervention ANSWERS B Answers A, C, and D are incorrect because pain management should be collaborative, and the patient is not part of the decision making process in these answers. Q. Pain is always ____? ANSWERS Subjective! Q. A patient with a severe muscle cramp tells the nurse, "The pain is a little better when I massage the muscle or apply a cold pack." Which criterion of the PQRST method of pain assessment is addressed in the patient's statement? a. Severity Scale b. Quality/Quantity c. Region/Radiation d. Provocation/Palliation ANSWERS d PQRST is a pain assessment scale; it stands for Provocation/Palliation, Quality/Quantity, Region/Radiation, Severity Scale, and Timing. Because the patient is describing methods that provide comfort and relieve the pain, it indicates that the patient is addressing Provocation/Palliation. If the patient reports about severity of pain on a scale of 0 to 10, then it indicates that the patient is addressing Severity. When addressing the Quality/Quantity of the pain, the patient describes the pain felt. If the patient reports about the site of pain, then the patient is addressing Region/Radiation. Q. Stages of Edema ANSWERS 1+ mild, slight indentation, no perceptible swelling 2+ moderate, indentation subsides rapidly (seconds) 3+ deep, indentation remains for short time (minutes), appears swollen 4+ very deep, indentation lasts long time (hours), appears very swollen Q. Skin assessment for a head-to-toe assessment ANSWERS 1. Check skin for temperature w/ back of hands and inspect - skin is warm, dry, intact, color is consistent throughout, no lesins, scars, tattoos noted on exposed skin 2. Skin turgor - appropriate B/L, no tenting noted 3. Upper body edema 4. Radial pulses - strong, palpable, equal, and approximately 2+ 5. Capillary refill - 2 sec B/L Q. Test for CN V ANSWERS CN V (trigeminal) - clench jaw, use cotton ball to touch different areas of the face while patient has eyes closed Q. Test for CN VII ANSWERS CN VII (facial) - raise eyebrows, close eyes, puff out cheeks, smile, frown Q. Test for CN III, IV, VI ANSWERS CN III (oculomotor) IV (trochlear) VI (abducens) - six cardinal fields of gaze; follow penlight w/o moving head Q. Test for CN XI ANSWERS CN XI (spinal accessory) - ROM of neck is equal and strength in shoulders is equal w/ and w/o resistance Q. If a patient presents equal anterior-posterior- to- traverse ratio, what would it be indicative of? a. pectus excavatum b. scoliosis c. kyphosis d. barrel chest ANSWERS d Q. What lung sounds would present as adventitious? (select all that apply) a. Stridor b. Wheezes c. Bronchi d. Rhonchi e. Rales ANSWERS a, b, d, e Q. Which of the following adventitious lung sounds are specifically classified as discontinuous? (Select all that apply) a. fine crackles b. atelectatic crackles c. coarse crackles d. sonorous rhonchi wheeze e. pleural friction rub ANSWERS a, b, c, e Q. Which of the following adventitious lung sounds are specifically classified as continuous? (Select all that apply) a. coarse crackles b. sonorous rhonchi wheeze c. stridor d. fine crackles e. sibilant wheeze ANSWERS b, c, e Q. How many blocks (stairs) does it take to produce this pain? ANSWERS Claudication distance Q. Which valves close in S1? (select all that apply) a. Pulmonic b. Tricuspid c. Mitral d. Aortic ANSWERS b & c - Tricuspid and Mitral are known as the AV valves Q. Which valves close in S2? (select all that apply) a. Aortic b. Pulmonic c. Tricuspid d. Mitral ANSWERS a & b - Aortic and Pulmonic are known as the semilunar valves Q. What are the characteristic(s) of heart sounds? (select all that apply) a. Intensity b. Duration c. Temperature d. Timing e. Vibrations ANSWERS a, b, d *There are 4 characteristics. Frequency is another one that involves the pitch (high pitch/low pitch) Q. What sound does a bruit make? What about a murmur? ANSWERS - A bruit makes a whooshing, swishing sound - A murmur makes a swooshing sound Which condition causes the stool to be gray in color? a. Use of iron medication b. Presence of jaundice or hepatitis c. Localized bleeding around the anus d. Presence of gastrointestinal bleeding Answer: b * Use of iron medications will cause the stool to look black and nontarry * Localized bleeding would result in red blood in the stool * GI bleed leads to black tarry stools If a nurse suspects an enlarged organ, such as a spleen, what should they do? The nurse should refer it to the HCP and avoid over palpating so that the fragile organ does not rupture Which term would the nurse use to document the palpation of a small fatty nodule through the linea alba on the abdomen when the patient is standing? a. diastasis recti b. incisional hernia c. epigastric hernia d. umbilical hernia Answer: c - Epigastric hernia = protrusion of the abdominal structures - Incisional hernia = bulge near an old operative scar - Umbilical hernia = protrusion of the intestine in the umbilical ring - Inguinal hernia is seen with discoloration of the umbilicus Which is present on the abdomen of a patient with ascites a. crusts and redness b. everted umbilicus c. bluish periumbilical color d. deeply sunken umbilicus Answer: b Which intervention is used to determine Murphy sign? a. Push both hands together in a "duck-bill" position at the patient's right flank b. Hold the hand perpendicular to the abdomen and push down slowly and deeply c. Push down the lower part of the right thigh while the patient tries to hold the leg up d. Ask the patient to take a deep breath while holding the fingers under the liver border Answer: d * Murphy got his gallbladder removed! What position would you place a client that is about to get a rectal exam? a. left lateral decubitus b. standing while leaning on the table c. prone d. fowler's Answer: a * Technically B is correct too but it is often more embarrassing for patients so A is a better answer What are the main causes of End Stage Renal Disease? HTN and Diabetes While completing a Testicular Self-Examination (TSE) the patient feels a firm but painless lump. What should they do next? a. Nothing, this is normal b. Call their physician for further check c. Put ice on it d. Take viagra Answer: b * Patients should also notify their physicians if they feel a hard area or an overall enlarged testicle While you screen a patient for an STI you notice abnormal vaginal discharge. What should be your next step? a. Teach the patient the different types of discharge b. Educate the patient about the importance of using condoms to prevent STI c. order a gonorrhea/chlamydia culture d. order bloodwork for HIV Answer: c Which statements would the nurse include when teaching an aging adult about prevention of constipation? (Select all that apply) a. "Include high-fat foot in the diet" b. "Include low-fiber foods in the diet" c. "Do not retain stool deliberately" d. "Participate in physical exercise" e. "Drink an adequate quantity of water" Answer: c, d, e What do you look for when taking the obstetric history of a woman? # of pregnancies, abortion, and miscarriages * Think obstetric = OB = baby What might a male nurse need if they are about to take objective data of a woman in relation to the GU system? A CHAPARONE!!! * Same goes with a female nurse entering a male patient's room What is the difference between true incontinence and urgency incontinence? - True incontinence = loss of urine W/O warning - Urgency incontinence = experience a strong sensation and urgency to pee What symptom is common between acute cystitis, prostatitis, and urethritis? Burning when urinating (dysuria) How long do you listen for bowel sounds before confirming that they are absent? 5 minutes How do you assess the kidneys? - Place one hand over the 12th rib at the costovertebral angle on the back - Placing hands together in a "duck-bill" position at person's right/left flank (side); have person take a deep breath and press firmly Borborygmus sound of hyperperistalsis Which instruction would the nurse give the patient in who carpal tunnel syndrome is suspected? a. "Touch your chin to your chest" b. "Open your mouth as widely as you can" c. "Raise each led with the knee extended" d. "Place your hands back to back and flex your wrists at a right angle" Answer: d * This is known as the Phalen Test and it reproduces numbness and burning in a person w/ Carpal Tunnel Syndrome The nurse performs the "get up and go test" on a geriatric patient to assess for which condition? a. risk of fall b. presence of lordosis c. risk of osteoporosis d. presence of abnormal gait Answer: a Which condition would the nurse expect in a patient who has been on bed rest for a month? a. adhesive capsulitis b. tear of rotator cuff c. dislocated shoulder d. subacromial bursitis Answer: a * adhesive capsulitis is also known as frozen shoulder and os associated w/ prolonged bed rest or shoulder immobility A patient with a history of a knee injury reports local pain in the knee. Which test would the nurse perform to further evaluate the knee? a. Phalen b. Thomas c. Bulge Sign d. McMurray Answer: d * The McMurray test is performed when a patient has reported a history of trauma followed by locking, giving way, or local knee pain * If you hear a "click" = McMurray test is positive for a torn meniscus How does the time of day affect rheumatoid arthritis, osteoarthritis, and tendinitis? - RA pain is worse in the morning - Osteoarthritis pain is worse later in the day - Tendinitis is worse in the morning but improves throughout the day The patient has been experiencing axial skeletal pain for 4 months and reports confusion, forgetfulness, insomnia, and fatigue. The nurse suspects which diagnosis? a. scoliosis b. achilles tenosynovitis c. fibromyalgia syndrome d. herniated nucleus pulposus Answer: c * Fibromyalgia may cause psychosocial distress leading to cognitive problems such as mental confusion and forgetfulness Genu varum bowlegs Genu valgum knock-knees The nurse appreciates a grating sound during joint manipulation of a patient with rheumatoid arthritis. Which term would the nurse use to document this finding? a. ankylosis b. crepitation c. dislocation d. subluxation Answer: b The older adult patient complains of stiffness in the right knee and severe pain with ambulation. Upon further assessment, the nurse notes a hard, bony protuberance on the right knee joint. The nurse suspects which diagnosis? a. osteoarthritis b. gouty arthritis c. ankylosing spondylitis d. subcutaneous nodule Answer: a * Osteoarthritis = noninflammatory, localized, progressive disorder involving deterioration of articular cartilage and subchondral bone; DEGENERATIVE!!! If you were to see a limitation such as swelling from arthritis in a patient, how would that affect testing their range of motion? If you see a limitation, gently attempt passive motion with the person's muscles relaxed while you move the body part. What conditions are caused by chronic rheumatoid arthritis? (Select all that apply) a. swan-neck b. boutonniere deformities c. ulnar deviation/drift d. degenerative joint disease e. osteoarthritis Answer: all of them How do you assess for temporomandibular joint dysfunction in a patient? TMJ → place the tips of your first two fingers in front of each ear and ask the person to open and close their mouth; note any pain, clicking, or popping When using the scale for muscle testing what is considered normal? A scale of 5 where there is full ROM with and without resistance; 100% The nurse would ask a patient which question to test for recent memory? a. "In which country were you born?" b. "What time did you get up today?" c. "Can you write a sentence?" d. "Do you know today's date?" Answer: b * Although D might seem like a good answer as well that question is typically used for orientation The patient tells the nurse, "I often hear my dead grandfather's voice." Which abnormal mental health finding is the patient experiencing? a. illusions b. delusions c. flight of ideas d. hallucinations Answer: d * hallucinations can not only by visual but also auditory and olfactory Which tool is used to screen for depression? PHQ-9 Which screening tool is used for anxiety? GAD-7 Which maximum score can be given to a patient when using the Mini-Mental State Examination (MMSE)? What does this score indicate? a. 5 b. 20 c. 25 d. 30 Answer: d * A score of 30 indicates that the patient has good cognitive abilities and no sign of dementia or delirium Which patient behavior would be assessed when administering the Mini-Cog screening examination? a. Performing serial 7s b. Spelling "world" backward c. Intersecting two pentagons d. Drawing a clock face Answer: d * The patient is asked to draw the face of a clock and write the numbers on the clock face during the Mini-Cog screening examination. It is used to detect cognitive impairment in healthy older adults. The patient tells the nurse, "I am the almighty and your creator. You all must do as I say; I am your ruler." Which thought content abnormality would the patient exhibit? a. delusions b. obsessions c. compulsions d. hypochondriasis Answer: a Which of these is not a component of a mental status assessment? a. known illness/health problem b. cultural background c. current medications d. personal history Answer: b An older adult patient comes in due to his recent loss of his partner of 52 years. What is this patient at risk for and how does this loss impact him? He is at risk for depression, grief, and despair. This loss impacted his by having him question his purpose and independence due to his loss which also entailed the loss of his role as a husband. When is a full mental status exam necessary? Patients whose initial screening suggests anxiety disorder, depression, memory loss, inappropriate social interaction, trauma to the brain, tumor, CVA/stroke, aphasia, and acute onset of symptoms of a mental illness. Which of these health history factors can affect the interpretation of findings in a mental status assessment? (Select all that apply) a. Alcoholism b. Chronic Renal Disease c. Medications d. Educational/behavioral level e. Stress Answer: all of them While assessing a teenager you observe them expressing hopelessness and see signs of self harm. As a nurse what should you do if you are concerned and suspect suicide? a. Give them a hug b. Tell them it's going to be okay c. Share concerns with a mental health professional d. Share concerns with the patients guardians Answer: c * We as nurses, along with police and teachers, are mandated reports whenever we suspect self-harm, abuse, violence, or neglect tonsil grading scale 1+: visible 2+: halfway b/n tonsillar pillars and uvula 3+: touching uvula 4+: touching each other (1-2 in healthy people) normal contour of abdomen flat or rounded contour of the abdomen describes nutritional state how to auscultate bowel sounds use diaphragm of stethoscope, hold lightly against skin, begin in RLQ how long do you need to auscultate in each quadrant to determine bowel sounds are completely absent 5 minutes how to auscultate vascular sounds use the bell of the stethoscope, use firmer pressure over the arteries is there usually tenderness when palpating the sigmoid colon yes what can make organs enlarged trauma, injury, distention, infection abnormal findings in GI/GU system -thrills and bruits -obesity -ascites -cysts -tumor -hypo/hyperactive bowel sounds ethnic differences in the lips black people may have blue lips and a dark line on the gingival margin GI system changes in the aging adult -salivation decreases -dec sense of taste -delayed esophageal emptying and gastric acid secretion -dec liver size (normal liver functions) -dec drug metabolism -frequent constipation borborygmus hyperactive bowel sounds melena can be caused by taking iron meds bright red blood in the stool may be due to hemorrhoids developmental changes in men -testosterone decreases -pubic hair and penis size dec -testes dec in size/less firm 2 main causes of end stage renal disease HTN and diabetes true incontinence loss of urine without warning urgency incontinence sudden loss of urine, strong sensation and urge joints Areas where two or more bones join together flexion bending a joint extension Straightening of a joint abduction Movement away from the midline of the body adduction Movement toward the midline of the body pronation turning the palm downward supination movement that turns the palm up circumduction moving the arm in a circle around the shoulder inversion moves the sole of the foot inward eversion turning the sole of the foot outward rotation moving the head around a central axis protraction Moving a part forward retraction moving a part backward elevation raising a body part depression lowering a body part where can the spinous processes of C7 and T1 be found at base of neck musculoskeletal changes in the aging adult -bone resorption inc and deposition dec after 40 -dec height/kyphosis -loss of SQ fat -marked bony prominences scale for muscle testing 5: full ROM and resistance (normal) 4: full ROM and some resistance 3: full ROM with gravity 2: full ROM with no gravity (eliminated) 1: slight contraction 0: no contraction the Denver II test is used to screen fine and gross motor skills for children normal time for get up and go test 10 secs in 60yrs get up and go test measures mobility and stability inflammatory conditions Rheumatoid arthritis Ankylosing spondylitis degenerative conditions osteoarthritis and osteoporosis rheumatoid arthritis chronic autoimmune inflammatory disorder where there's destruction of lining of the joints. can cause deformities. pain experienced when waking up osteoarthritis caused by wear and tear. cartilage destruction. bone on bone osteoporosis bone becomes thin and brittle carpal tunnel syndrome characterized by weakness, pain, and disturbances of sensation in the hand and fingers conditions caused by chronic rheumatoid arthritis -swan neck and boutonniere deformities -ulnar deviation/drift -degenerative joint disease/osteoarthritis -syndactyly -polydactyly by what age does the fetus develop a skeleton of cartilage 3 months function assessment history questions for the aging adult includes loss of function, self care deficit and safety risks approaches to take during a physical exam head to toe, proximal to distal, midline outward correct order of examination for musculoskeletal system inspection, palpation, ROM, muscle testing local causes of referred pain in the shoulder hiatal hernia, cardiac and pleural conditions what measurement would indicate no true bone discrepancy 1cm abnormalities of the shoulder joint effusion, subacromial bursitis, atrophy abnormalities of the elbow Gouty arthritis, epicondylitis, tennis elbow, subcutaneous nodules abnormalities of the wrist and hand carpal tunnel syndrome, syndactyly, colles' fx abnormalities of the knee chrondomalacia patellae, menisci swelling, synovitis abnormalities of ankle/foot Chronic/acute gout Hallux valgus with bunion and hammer toes when to conduct a full mental status assessment when patients whose initial screening suggests anxiety disorder, depression, behavioral changes, brain lesions, aphasia, symptoms of psychiatric mental illness full mental status assessment includes LOC, language, mood and affect, attention, memory, abstract reasoning, thought process, thought content, perceptions how to assess mental status ABCT Appearance Behavior Cognition Thought processes cognitive functions orientation, attention span, recent memory, remote memory recent memory example 24 diet recall remote memory example ask verifiable past events normal response of the 4 unrelated words test 3-4 word recall for people 60 testing for people with aphasia word comprehension, reading, writing screening for suicidal thoughts should be conducted when person expresses feelings of sadness, hopelessness, despair. begin with general questions mini mental state exam Concentrates only on cognitive functioning; can differ between psychiatric mental illnesses; scores between 24-30 show no cognitive impairment mini-cog test tests cognitive impairment in healthy adults; consists of 3 item recall test and clock drawing test mental health care with aging adults check sensory status 1st and make sure they're wearing their hearing aids Glasgow Coma Scale tests consciousness in aging person where confusion is common; ranges 3-15 (15 is best) IPV screening -ask every woman if she's been abused by someone intimate -head to toe -CBC with platelet level, serum liver function, coagulation panel, urinalysis -suspect when client denies AAS danger assessment assesses risk for homicide. the more yes answers, the more serious the danger of the situation RRRR test in the past 12 months has your drinking caused -Risk of bodily harm -Relationship trouble -Role failure -Run ins with law AUDIT tool helps detect less severe alcohol problems; covers alcohol consumption, drinking behavior/dependence, adverse consequences from alcohol CAGE test tests for lifetime alcohol abuse/dependence -Cut down -Annoyed -Guilty -Eye opener TWEAK test alcohol risk in women (especially pregnant) -Tolerance -Worry -Eye opener -Amnesia -Kut down SMAST-G test screening in aging adults who report social/regular drinking CIWA-Ar score used to determine whether to treat alcohol withdrawal substance abuse documentation liver profile, CBC, breathalyzer, BAC