[NSG 3160 Exam 1Health Assessment] EXAM with
Questions and Answers/Plus a Rationale Updated 2026
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Table of Contents
1. Foundations of Health Assessment and Communication
2. Skin, Hair, and Nails Assessment
3. Head, Neck, Eyes, Ears, Nose, and Throat (HEENT)
4. Thorax, Lungs, and Cardiovascular System
5. Abdominal, Musculoskeletal, and Neurological Assessment
1. A patient presents with a persistent, non-healing ulcer on the lower lip that is indurated with
rolled borders. Which assessment finding should the nurse prioritize to differentiate between
squamous cell carcinoma and a benign lesion?
A. Palpation of the submental and submandibular lymph nodes for fixed, nontender masses.
B. Measurement of the lesion diameter to determine if it exceeds 6 mm.
C. Observation of the patient’s sun exposure history and tobacco usage patterns.
D. Inspection of the oral mucosa for the presence of leukoplakia or erythroplakia.
Answer: A
CORRECT ANSWER : A
Rationale: Indurated, non-healing ulcers with rolled borders are highly suspicious for squamous
cell carcinoma, which commonly metastasizes to local lymph nodes; fixed, nontender nodes
indicate malignancy. While sun exposure (C) and physical dimensions (B) are relevant, they do
, not confirm the malignant status as effectively as palpating for regional lymph node involvement.
Inspection (D) is important but is secondary to evaluating metastatic spread.
2. During an ophthalmic examination, the nurse notes a red reflex is present in the right eye but
absent in the left eye. What is the most likely clinical implication, and what is the nurse's
immediate action?
A. Cataracts; refer the patient for an urgent ophthalmology evaluation.
B. Retinal detachment; perform an immediate cover-uncover test.
C. Glaucoma; check intraocular pressure using tonometry.
D. Corneal abrasion; assess visual acuity using the Snellen chart.
Answer: A
CORRECT ANSWER : A
Rationale: An absent red reflex is a hallmark sign of a cataract (opacity of the lens) or
potentially a retinoblastoma, requiring immediate specialist referral. Retinal detachment (B)
would not typically cause a complete absence of the red reflex. Glaucoma (C) involves pressure
and optic nerve changes not identified by the red reflex, and a corneal abrasion (D) would cause
pain and fluorescein uptake, not a loss of red reflex.
3. While assessing a patient with chronic obstructive pulmonary disease (COPD), the nurse
identifies a "barrel chest" deformity. Which physiological mechanism explains the development
of this physical finding?
A. Chronic hyperinflation of the alveoli leading to increased residual volume.
B. Kyphosis resulting from vertebral compression fractures.
C. Compensatory hypertrophy of the accessory respiratory muscles.
D. Pectus excavatum causing secondary thoracic cavity remodeling.
Answer: A
CORRECT ANSWER : A
Rationale: In COPD, air trapping due to expiratory airway obstruction leads to chronic
hyperinflation and an increase in the anteroposterior diameter of the chest, creating a barrel
chest. Kyphosis (B) is a spinal deformity, not a direct result of lung hyperinflation. Muscle
hypertrophy (C) is a consequence of increased work of breathing, not the cause of the chest
shape. Pectus excavatum (D) is a congenital depression, not a result of COPD.
,4. A patient reports a sudden, "thunderclap" headache followed by nuchal rigidity. Which
assessment technique is most critical to perform next?
A. Test for Kernig’s and Brudzinski’s signs.
B. Perform a full neurological assessment including cranial nerves.
C. Assess the patient’s blood pressure in both arms.
D. Evaluate the patient’s level of consciousness using the GCS.
Answer: A
CORRECT ANSWER : A
Rationale: A thunderclap headache accompanied by nuchal rigidity is a classic presentation of a
subarachnoid hemorrhage, which causes meningeal irritation. Kernig’s and Brudzinski’s signs
are specific indicators of meningeal irritation. While GCS (D) and neuro assessments (B) are
vital for monitoring, identifying meningeal signs is the priority for the specific symptoms
described. Blood pressure (C) is diagnostic for hypertension but secondary to neurologic
emergency screening.
5. During an abdominal exam, the nurse notes a pulsating mass in the epigastric region. What is the
most appropriate action?
A. Palpate deeply to determine the dimensions of the mass.
B. Auscultate the area for a bruit, then stop further palpation.
C. Percuss the area to determine if the mass is fluid-filled.
D. Instruct the patient to perform a Valsalva maneuver to see if the mass protrudes.
Answer: B
CORRECT ANSWER : B
Rationale: A pulsating epigastric mass is highly suggestive of an abdominal aortic aneurysm
(AAA). Deep palpation (A) is contraindicated as it carries a risk of rupture. Auscultation (B)
provides diagnostic information regarding turbulence (bruit) without risking rupture. Percussion
(C) and the Valsalva maneuver (D) provide no diagnostic benefit and may be dangerous in the
presence of a suspected aneurysm.
6. A patient exhibits a positive Murphy’s sign during abdominal assessment. This finding is most
consistent with which clinical condition?
, A. Acute appendicitis.
B. Acute cholecystitis.
C. Acute pancreatitis.
D. Splenic rupture.
Answer: B
CORRECT ANSWER : B
Rationale: Murphy’s sign is elicited by deep palpation of the right upper quadrant during
inspiration; it is positive if the patient experiences sudden arrest of inspiration due to pain,
which is specific to acute cholecystitis. Appendicitis (A) is associated with McBurney’s point
tenderness. Pancreatitis (C) presents with epigastric pain radiating to the back. Splenic rupture
(D) would involve Kehr's sign (left shoulder pain).
7. During a cardiovascular assessment, the nurse hears a soft, blowing murmur at the apex that is
best heard with the patient in the left lateral decubitus position. Which valve and condition are
most likely involved?
A. Aortic valve; aortic stenosis.
B. Pulmonic valve; pulmonic regurgitation.
C. Mitral valve; mitral regurgitation.
D. Tricuspid valve; tricuspid stenosis.
Answer: C
CORRECT ANSWER : C
Rationale: The mitral valve is best auscultated at the apex, and the left lateral decubitus position
enhances the sound of mitral valve murmurs. Mitral regurgitation is characterized by a blowing
holosystolic murmur. Aortic stenosis (A) is heard at the right second intercostal space. Pulmonic
(B) and Tricuspid (D) conditions are localized to different areas of the chest.
8. When assessing a patient’s peripheral vascular system, the nurse notes dependent rubor and thin,
shiny skin on the lower extremities. What additional finding should the nurse expect?
A. Diminished or absent pedal pulses.
B. Pitting edema on the medial malleolus.
Questions and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
Table of Contents
1. Foundations of Health Assessment and Communication
2. Skin, Hair, and Nails Assessment
3. Head, Neck, Eyes, Ears, Nose, and Throat (HEENT)
4. Thorax, Lungs, and Cardiovascular System
5. Abdominal, Musculoskeletal, and Neurological Assessment
1. A patient presents with a persistent, non-healing ulcer on the lower lip that is indurated with
rolled borders. Which assessment finding should the nurse prioritize to differentiate between
squamous cell carcinoma and a benign lesion?
A. Palpation of the submental and submandibular lymph nodes for fixed, nontender masses.
B. Measurement of the lesion diameter to determine if it exceeds 6 mm.
C. Observation of the patient’s sun exposure history and tobacco usage patterns.
D. Inspection of the oral mucosa for the presence of leukoplakia or erythroplakia.
Answer: A
CORRECT ANSWER : A
Rationale: Indurated, non-healing ulcers with rolled borders are highly suspicious for squamous
cell carcinoma, which commonly metastasizes to local lymph nodes; fixed, nontender nodes
indicate malignancy. While sun exposure (C) and physical dimensions (B) are relevant, they do
, not confirm the malignant status as effectively as palpating for regional lymph node involvement.
Inspection (D) is important but is secondary to evaluating metastatic spread.
2. During an ophthalmic examination, the nurse notes a red reflex is present in the right eye but
absent in the left eye. What is the most likely clinical implication, and what is the nurse's
immediate action?
A. Cataracts; refer the patient for an urgent ophthalmology evaluation.
B. Retinal detachment; perform an immediate cover-uncover test.
C. Glaucoma; check intraocular pressure using tonometry.
D. Corneal abrasion; assess visual acuity using the Snellen chart.
Answer: A
CORRECT ANSWER : A
Rationale: An absent red reflex is a hallmark sign of a cataract (opacity of the lens) or
potentially a retinoblastoma, requiring immediate specialist referral. Retinal detachment (B)
would not typically cause a complete absence of the red reflex. Glaucoma (C) involves pressure
and optic nerve changes not identified by the red reflex, and a corneal abrasion (D) would cause
pain and fluorescein uptake, not a loss of red reflex.
3. While assessing a patient with chronic obstructive pulmonary disease (COPD), the nurse
identifies a "barrel chest" deformity. Which physiological mechanism explains the development
of this physical finding?
A. Chronic hyperinflation of the alveoli leading to increased residual volume.
B. Kyphosis resulting from vertebral compression fractures.
C. Compensatory hypertrophy of the accessory respiratory muscles.
D. Pectus excavatum causing secondary thoracic cavity remodeling.
Answer: A
CORRECT ANSWER : A
Rationale: In COPD, air trapping due to expiratory airway obstruction leads to chronic
hyperinflation and an increase in the anteroposterior diameter of the chest, creating a barrel
chest. Kyphosis (B) is a spinal deformity, not a direct result of lung hyperinflation. Muscle
hypertrophy (C) is a consequence of increased work of breathing, not the cause of the chest
shape. Pectus excavatum (D) is a congenital depression, not a result of COPD.
,4. A patient reports a sudden, "thunderclap" headache followed by nuchal rigidity. Which
assessment technique is most critical to perform next?
A. Test for Kernig’s and Brudzinski’s signs.
B. Perform a full neurological assessment including cranial nerves.
C. Assess the patient’s blood pressure in both arms.
D. Evaluate the patient’s level of consciousness using the GCS.
Answer: A
CORRECT ANSWER : A
Rationale: A thunderclap headache accompanied by nuchal rigidity is a classic presentation of a
subarachnoid hemorrhage, which causes meningeal irritation. Kernig’s and Brudzinski’s signs
are specific indicators of meningeal irritation. While GCS (D) and neuro assessments (B) are
vital for monitoring, identifying meningeal signs is the priority for the specific symptoms
described. Blood pressure (C) is diagnostic for hypertension but secondary to neurologic
emergency screening.
5. During an abdominal exam, the nurse notes a pulsating mass in the epigastric region. What is the
most appropriate action?
A. Palpate deeply to determine the dimensions of the mass.
B. Auscultate the area for a bruit, then stop further palpation.
C. Percuss the area to determine if the mass is fluid-filled.
D. Instruct the patient to perform a Valsalva maneuver to see if the mass protrudes.
Answer: B
CORRECT ANSWER : B
Rationale: A pulsating epigastric mass is highly suggestive of an abdominal aortic aneurysm
(AAA). Deep palpation (A) is contraindicated as it carries a risk of rupture. Auscultation (B)
provides diagnostic information regarding turbulence (bruit) without risking rupture. Percussion
(C) and the Valsalva maneuver (D) provide no diagnostic benefit and may be dangerous in the
presence of a suspected aneurysm.
6. A patient exhibits a positive Murphy’s sign during abdominal assessment. This finding is most
consistent with which clinical condition?
, A. Acute appendicitis.
B. Acute cholecystitis.
C. Acute pancreatitis.
D. Splenic rupture.
Answer: B
CORRECT ANSWER : B
Rationale: Murphy’s sign is elicited by deep palpation of the right upper quadrant during
inspiration; it is positive if the patient experiences sudden arrest of inspiration due to pain,
which is specific to acute cholecystitis. Appendicitis (A) is associated with McBurney’s point
tenderness. Pancreatitis (C) presents with epigastric pain radiating to the back. Splenic rupture
(D) would involve Kehr's sign (left shoulder pain).
7. During a cardiovascular assessment, the nurse hears a soft, blowing murmur at the apex that is
best heard with the patient in the left lateral decubitus position. Which valve and condition are
most likely involved?
A. Aortic valve; aortic stenosis.
B. Pulmonic valve; pulmonic regurgitation.
C. Mitral valve; mitral regurgitation.
D. Tricuspid valve; tricuspid stenosis.
Answer: C
CORRECT ANSWER : C
Rationale: The mitral valve is best auscultated at the apex, and the left lateral decubitus position
enhances the sound of mitral valve murmurs. Mitral regurgitation is characterized by a blowing
holosystolic murmur. Aortic stenosis (A) is heard at the right second intercostal space. Pulmonic
(B) and Tricuspid (D) conditions are localized to different areas of the chest.
8. When assessing a patient’s peripheral vascular system, the nurse notes dependent rubor and thin,
shiny skin on the lower extremities. What additional finding should the nurse expect?
A. Diminished or absent pedal pulses.
B. Pitting edema on the medial malleolus.
