NUR 3270/NUR3270 Exam 1 V2 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. A nurse is conducting a health history on a new patient. Which of the following is
considered subjective data?
A. The patient’s report of a ‘throbbing’ headache.
B. A blood pressure reading of 140/90 mmHg.
C. A visible skin rash on the patient’s forearm.
D. The patient’s weight of 185 pounds.
Correct Answer: A
Expert Explanation: Subjective data consists of information that the patient tells the
nurse, such as their perceptions and feelings. In this case, a ‘throbbing’ headache is a
symptom that only the patient can experience and report. Objective data, like blood
pressure or a rash, are findings that can be observed or measured by the clinician.
2. During a physical exam, the nurse uses the diaphragm of the stethoscope to auscultate.
Which sounds is the nurse specifically listening for?
A. Low-pitched heart murmurs.
B. Third and fourth heart sounds (S3 and S4).
C. Vascular bruits.
,D. High-pitched sounds like breath and bowel sounds.
Correct Answer: D
Expert Explanation: The diaphragm of the stethoscope is designed to pick up high-pitched
sounds such as breath, bowel, and normal heart sounds. The bell of the stethoscope is
better suited for low-pitched sounds, including extra heart sounds or murmurs. Using the
correct side of the chest piece is essential for an accurate physical assessment.
3. When assessing an elderly patient’s skin, the nurse notes a decrease in skin turgor. Where
is the best place to assess this in an older adult?
A. The back of the hand.
B. The forearm.
C. Beneath the clavicle.
D. The abdomen.
Correct Answer: C
Expert Explanation: Skin turgor assessment helps determine a patient’s hydration status.
In older adults, the skin on the back of the hand is often loose and less elastic due to aging,
which can provide a false positive for dehydration. Assessing turgor over the sternum or
beneath the clavicle provides a more accurate reflection of hydration in this population.
4. A nurse is performing a general survey. Which component is part of this initial assessment?
A. Auscultating lung sounds.
, B. Observing the patient’s gait and posture.
C. Palpating the thyroid gland.
D. Measuring deep tendon reflexes.
Correct Answer: B
Expert Explanation: The general survey is a ‘snapshot’ of the patient’s overall health
status observed from the moment of meeting. It includes physical appearance, body
structure, mobility (such as gait and posture), and behavior. Detailed maneuvers like
auscultation or palpation are part of the specific system-by-system physical examination
that follows the general survey.
5. The nurse is using the PQRSTU mnemonic to assess a patient’s pain. What does the ‘Q’
represent?
A. Quantity of the pain.
B. Quickness of onset.
C. Quality or character of the pain.
D. Quaking or radiating nature.
Correct Answer: C
Expert Explanation: In the PQRSTU pain assessment tool, ‘Q’ stands for Quality or
Character. This involves asking the patient to describe how the pain feels, such as sharp,
Health Assessment Q&A with Rationale |
William Paterson University
1. A nurse is conducting a health history on a new patient. Which of the following is
considered subjective data?
A. The patient’s report of a ‘throbbing’ headache.
B. A blood pressure reading of 140/90 mmHg.
C. A visible skin rash on the patient’s forearm.
D. The patient’s weight of 185 pounds.
Correct Answer: A
Expert Explanation: Subjective data consists of information that the patient tells the
nurse, such as their perceptions and feelings. In this case, a ‘throbbing’ headache is a
symptom that only the patient can experience and report. Objective data, like blood
pressure or a rash, are findings that can be observed or measured by the clinician.
2. During a physical exam, the nurse uses the diaphragm of the stethoscope to auscultate.
Which sounds is the nurse specifically listening for?
A. Low-pitched heart murmurs.
B. Third and fourth heart sounds (S3 and S4).
C. Vascular bruits.
,D. High-pitched sounds like breath and bowel sounds.
Correct Answer: D
Expert Explanation: The diaphragm of the stethoscope is designed to pick up high-pitched
sounds such as breath, bowel, and normal heart sounds. The bell of the stethoscope is
better suited for low-pitched sounds, including extra heart sounds or murmurs. Using the
correct side of the chest piece is essential for an accurate physical assessment.
3. When assessing an elderly patient’s skin, the nurse notes a decrease in skin turgor. Where
is the best place to assess this in an older adult?
A. The back of the hand.
B. The forearm.
C. Beneath the clavicle.
D. The abdomen.
Correct Answer: C
Expert Explanation: Skin turgor assessment helps determine a patient’s hydration status.
In older adults, the skin on the back of the hand is often loose and less elastic due to aging,
which can provide a false positive for dehydration. Assessing turgor over the sternum or
beneath the clavicle provides a more accurate reflection of hydration in this population.
4. A nurse is performing a general survey. Which component is part of this initial assessment?
A. Auscultating lung sounds.
, B. Observing the patient’s gait and posture.
C. Palpating the thyroid gland.
D. Measuring deep tendon reflexes.
Correct Answer: B
Expert Explanation: The general survey is a ‘snapshot’ of the patient’s overall health
status observed from the moment of meeting. It includes physical appearance, body
structure, mobility (such as gait and posture), and behavior. Detailed maneuvers like
auscultation or palpation are part of the specific system-by-system physical examination
that follows the general survey.
5. The nurse is using the PQRSTU mnemonic to assess a patient’s pain. What does the ‘Q’
represent?
A. Quantity of the pain.
B. Quickness of onset.
C. Quality or character of the pain.
D. Quaking or radiating nature.
Correct Answer: C
Expert Explanation: In the PQRSTU pain assessment tool, ‘Q’ stands for Quality or
Character. This involves asking the patient to describe how the pain feels, such as sharp,
