NSG121/NSG 121 Exam 3 V1 | Health
Assessment Q&A with Rationale | Herzing
University
1. When assessing the abdomen, which sequence of assessment techniques should the nurse
follow to ensure accurate findings?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Palpation, Percussion, Auscultation, Inspection
D. Auscultation, Inspection, Palpation, Percussion
Correct Answer: A
Rationale: The correct order for abdominal assessment is inspection, auscultation,
percussion, and then palpation. Auscultation is performed second because percussion and
palpation can increase peristalsis, which would result in false bowel sound findings. This
sequence ensures that the nurse hears the patient’s baseline bowel activity before any
physical stimulation occurs.
2. A nurse is auscultating the heart at the 5th intercostal space, left midclavicular line. Which
heart sound is primarily heard at this location?
A. S1 sound (closure of mitral and tricuspid valves)
B. S2 sound (closure of aortic and pulmonic valves)
,C. S3 sound (ventricular gallop)
D. S4 sound (atrial gallop)
Correct Answer: A
Rationale: The 5th intercostal space at the left midclavicular line is the mitral area, where
S1 is heard loudest. S1 marks the beginning of systole and corresponds with the closure of
the atrioventricular valves. Correct identification of this sound is essential for determining
the heart rate and identifying the systolic phase of the cardiac cycle.
3. During a respiratory assessment, the nurse hears high-pitched, musical sounds primarily
during expiration. How should the nurse document this finding?
A. Wheezes
B. Course crackles
C. Fine crackles
D. Pleural friction rub
Correct Answer: A
Rationale: Wheezes are continuous, musical sounds caused by air squeezing through
narrowed or obstructed airways. They are commonly associated with conditions such as
asthma or chronic obstructive pulmonary disease. Documentation must include the timing
within the respiratory cycle and the pitch of the sound.
, 4. A nurse is testing a patient’s cranial nerve V (Trigeminal). Which action should the nurse
ask the patient to perform?
A. Clench the teeth while the nurse palpates the temporal and masseter muscles
B. Smile and show teeth
C. Shrug the shoulders against resistance
D. Stick out the tongue and move it from side to side
Correct Answer: A
Rationale: The trigeminal nerve (CN V) has both motor and sensory components, and
clenching teeth tests the motor function of the muscles of mastication. The nurse should
also assess sensory function by touching the face with a cotton wisp in three areas.
Evaluating this nerve is critical for patients with suspected neurological deficits or facial
trauma.
5. When grading peripheral pulses, the nurse notes that the pulse is ‘normal’ or ‘expected.’
Which numerical grade should be assigned?
A. 1+
B. 2+
C. 3+
D. 4+
Correct Answer: B
Assessment Q&A with Rationale | Herzing
University
1. When assessing the abdomen, which sequence of assessment techniques should the nurse
follow to ensure accurate findings?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Palpation, Percussion, Auscultation, Inspection
D. Auscultation, Inspection, Palpation, Percussion
Correct Answer: A
Rationale: The correct order for abdominal assessment is inspection, auscultation,
percussion, and then palpation. Auscultation is performed second because percussion and
palpation can increase peristalsis, which would result in false bowel sound findings. This
sequence ensures that the nurse hears the patient’s baseline bowel activity before any
physical stimulation occurs.
2. A nurse is auscultating the heart at the 5th intercostal space, left midclavicular line. Which
heart sound is primarily heard at this location?
A. S1 sound (closure of mitral and tricuspid valves)
B. S2 sound (closure of aortic and pulmonic valves)
,C. S3 sound (ventricular gallop)
D. S4 sound (atrial gallop)
Correct Answer: A
Rationale: The 5th intercostal space at the left midclavicular line is the mitral area, where
S1 is heard loudest. S1 marks the beginning of systole and corresponds with the closure of
the atrioventricular valves. Correct identification of this sound is essential for determining
the heart rate and identifying the systolic phase of the cardiac cycle.
3. During a respiratory assessment, the nurse hears high-pitched, musical sounds primarily
during expiration. How should the nurse document this finding?
A. Wheezes
B. Course crackles
C. Fine crackles
D. Pleural friction rub
Correct Answer: A
Rationale: Wheezes are continuous, musical sounds caused by air squeezing through
narrowed or obstructed airways. They are commonly associated with conditions such as
asthma or chronic obstructive pulmonary disease. Documentation must include the timing
within the respiratory cycle and the pitch of the sound.
, 4. A nurse is testing a patient’s cranial nerve V (Trigeminal). Which action should the nurse
ask the patient to perform?
A. Clench the teeth while the nurse palpates the temporal and masseter muscles
B. Smile and show teeth
C. Shrug the shoulders against resistance
D. Stick out the tongue and move it from side to side
Correct Answer: A
Rationale: The trigeminal nerve (CN V) has both motor and sensory components, and
clenching teeth tests the motor function of the muscles of mastication. The nurse should
also assess sensory function by touching the face with a cotton wisp in three areas.
Evaluating this nerve is critical for patients with suspected neurological deficits or facial
trauma.
5. When grading peripheral pulses, the nurse notes that the pulse is ‘normal’ or ‘expected.’
Which numerical grade should be assigned?
A. 1+
B. 2+
C. 3+
D. 4+
Correct Answer: B
