NSG3160 Health Assessment Exam 4 — Galen College of Nursing 100 Questions | 2026–2027 Edition
Exam 4: NSG3160 Health Assessment
100% Correct Questions & Answers — Galen College of Nursing
Aligned with 2026–2027 Galen College of Nursing NSG3160 Curriculum Standards and Nursing Competencies
Total Questions 100 (multiple choice, single best answer)
Passing Score 70% (70/100 correct)
Sections 9 sections: Head-to-Toe, Neurological, Cardiovascular, Respiratory, Abdominal, MSK/Gait, Head/Neck/Lymp
Cognitive Mix 30% Recall • 50% Application • 20% Analysis
Question Style 75% Scenario-based • 15% Direct recall • 10% Clinical analysis
Focus Areas CN assessment, heart sounds/murmurs, breath sounds, abdominal assessment, gait patterns, reflexes, psychoso
How to use this predictor: Attempt each question before reviewing the rationale. Each rationale provides
evidence-based reasoning for the correct answer and explains why each distractor is incorrect, targeting the most
common NSG3160 Exam 4 errors including cranial nerve function confusion, breath sound differentiation, heart sound
identification, abdominal assessment sequencing, abnormal gait identification, reflex grading, and cultural competence
considerations.
Legend: Each question lists four options (A–D). The correct option is marked [CORRECT] in green, followed by the explicit Correct
Answer line and a Rationale with comprehensive health assessment reasoning.
Section 1: Head-to-Toe Comprehensive Assessment (Q1–15)
Q1: A nurse enters a patient's room and observes the following: the patient appears older than the stated age
of 42, has poor personal hygiene, wrinkled clothing, and a flat affect. The patient is slumped in the chair and
does not make eye contact. Which component of the general survey is the nurse performing?
A. Vital signs assessment
B. Complete physical examination
C. General survey [CORRECT]
D. Focused assessment
Correct Answer: C — General survey
Rationale: The general survey is the first component of a head-to-toe assessment that occurs the moment the nurse enters the
room and begins observing the patient. It includes evaluating appearance (age, hygiene, dress, skin color, facial expression),
behavior (level of consciousness, mood/affect, posture), and body structure (height, weight, build). The scenario describes
observation of hygiene, clothing, affect, posture, and eye contact — all elements of the general survey. Vital signs (A)
involve measurable physiological parameters. A complete physical exam (B) is a systematic head-to-toe approach. A
focused assessment (D) targets a specific problem area.
Head-to-Toe • Neuro • Cardio • Respiratory • Abdomen • MSK • Integumentary • Psychosocial • Clinical Judgment Page 1
,NSG3160 Health Assessment Exam 4 — Galen College of Nursing 100 Questions | 2026–2027 Edition
Q2: A nurse assesses a patient's blood pressure as 152/92 mmHg on two separate readings taken 5 minutes
apart. The patient has no history of hypertension. Which is the most appropriate documentation?
A. 'Patient is hypertensive'
B. 'BP elevated at 152/92 mmHg on two readings 5 minutes apart; no prior HTN history' [CORRECT]
C. 'BP high; refer to provider'
D. 'Patient has stage 2 hypertension'
Correct Answer: B — 'BP elevated at 152/92 mmHg on two readings 5 minutes apart; no prior HTN history'
Rationale: Accurate, objective documentation requires recording exact measurements, the conditions under which they were
obtained (two readings 5 minutes apart), and relevant history (no prior hypertension). Labeling the patient as 'hypertensive'
(A) is a medical diagnosis outside nursing scope. Saying 'BP high; refer' (C) lacks specificity and the measurement data.
Staging hypertension as stage 2 (D) is a medical interpretation; the nurse should document objective findings and notify the
provider for clinical classification.
Q3: A nursing student asks the instructor which sequence to follow when performing a comprehensive
head-to-toe assessment. Which response by the instructor is correct?
A. Head → Eyes → Ears → Chest → Abdomen → Extremities
B. General survey → Vital signs → Head to toe systematically [CORRECT]
C. Abdomen → Chest → Neurological → Integumentary
D. Vital signs → Abdomen → Neurological → Musculoskeletal
Correct Answer: B — General survey → Vital signs → Head to toe systematically
Rationale: The correct sequence for a comprehensive head-to-toe assessment begins with the general survey (observing the
patient from the moment you enter), then vital signs, followed by a systematic head-to-toe examination from head to toe.
Option (A) omits the general survey and vital signs. Option (C) begins with the abdomen before the chest and does not
follow a head-to-toe flow. Option (D) places the abdomen before the head, which disrupts the systematic head-to-toe
approach.
Q4: A nurse needs to assess a patient's abdomen. Which position is most appropriate for the abdominal
examination?
A. Supine with knees slightly flexed [CORRECT]
B. Sims position (left lateral with right knee flexed)
C. Lithotomy position
D. Sitting upright at 90 degrees
Correct Answer: A — Supine with knees slightly flexed
Rationale: The dorsal recumbent position (supine with knees slightly flexed) relaxes the abdominal muscles, allowing for
better palpation, percussion, and auscultation of abdominal organs. Sims position (B) is a left lateral position used primarily
for rectal examinations and enemas. Lithotomy (C) is used for pelvic exams. Sitting upright (D) is appropriate for chest/lung
auscultation but does not adequately expose or relax the abdomen.
Head-to-Toe • Neuro • Cardio • Respiratory • Abdomen • MSK • Integumentary • Psychosocial • Clinical Judgment Page 2
,NSG3160 Health Assessment Exam 4 — Galen College of Nursing 100 Questions | 2026–2027 Edition
Q5: A nurse is teaching a new graduate about obtaining the most accurate core body temperature. Which
site should the nurse recommend as the gold standard for core temperature?
A. Oral
B. Tympanic
C. Rectal [CORRECT]
D. Axillary
Correct Answer: C — Rectal
Rationale: Rectal temperature is considered the most accurate estimate of core body temperature because it reflects deep
tissue temperature and is minimally affected by environmental factors. Oral (A) is convenient and commonly used but can be
affected by oral intake, mouth breathing, and gum chewing. Tympanic (B) measures infrared radiation from the tympanic
membrane but may be affected by cerumen or ambient temperature. Axillary (D) is the least accurate because it measures
skin surface temperature, not core temperature.
Q6: A nurse assesses a patient's pulse and notes the following: rate 88/min, rhythm is irregularly irregular,
and strength varies beat to beat. Which pattern does this describe?
A. Sinus bradycardia
B. Atrial fibrillation [CORRECT]
C. Sinus arrhythmia
D. Normal sinus rhythm
Correct Answer: B — Atrial fibrillation
Rationale: An irregularly irregular rhythm with varying pulse strength is the hallmark of atrial fibrillation (AFib). In AFib,
the atria quiver instead of contracting effectively, causing erratic ventricular response and variable stroke volume, which
produces pulse deficits. Sinus bradycardia (A) is a regular rhythm with rate <60/min. Sinus arrhythmia (C) is a regular
variation with respiration (faster on inspiration, slower on expiration). Normal sinus rhythm (D) is regular with rate
60-100/min.
Q7: A nurse observes a patient's respiratory pattern and notes cycles of progressively deeper breathing that
peak and then become shallower, followed by a period of apnea. Which breathing pattern does the nurse
document?
A. Cheyne-Stokes respirations [CORRECT]
B. Kussmaul respirations
C. Biot's respirations
D. Hypoventilation
Correct Answer: A — Cheyne-Stokes respirations
Rationale: Cheyne-Stokes respirations are characterized by a crescendo-decrescendo pattern of breathing with periods of
apnea. The pattern progresses from shallow to deep breathing, peaks, then reverses to shallow, followed by apnea. This is
associated with heart failure, brain injury, and increased intracranial pressure. Kussmaul respirations (B) are deep, rapid
breathing associated with metabolic acidosis (DKA, renal failure) without the cyclic pattern. Biot's respirations (C) are
irregular, unpredictable breathing with apneic periods. Hypoventilation (D) is slow, shallow breathing without the
crescendo-decrescendo cycle.
Head-to-Toe • Neuro • Cardio • Respiratory • Abdomen • MSK • Integumentary • Psychosocial • Clinical Judgment Page 3
, NSG3160 Health Assessment Exam 4 — Galen College of Nursing 100 Questions | 2026–2027 Edition
Q8: A nurse is using the 0-10 numeric rating scale to assess a patient's pain. The patient rates their pain as a
7 and states, 'It hurts all over, and nothing helps.' Which principle of pain assessment is the nurse
demonstrating?
A. Pain is what the patient says it is [CORRECT]
B. Objective data should override subjective reports
C. Pain assessment is only necessary for acute conditions
D. Vital signs are the primary indicator of pain severity
Correct Answer: A — Pain is what the patient says it is
Rationale: The fundamental principle of pain assessment is that pain is a subjective experience — 'pain is whatever the
patient says it is, existing whenever the patient says it does.' The nurse accepts the patient's self-report of 7/10 as the valid
assessment. Option (B) contradicts this core principle. Pain assessment is necessary for both acute and chronic conditions
(C). While vital signs may change with pain, they are not reliable indicators of pain intensity and should not be the primary
measure (D).
Q9: A nurse documents a patient encounter using the SOAP format. Which entry belongs in the 'O'
(Objective) section?
A. Patient reports chest pain for 2 hours
B. Skin is warm, dry, and intact; VS 128/82, HR 88, RR 18 [CORRECT]
C. Patient appears anxious about upcoming surgery
D. Patient states 'I have been feeling dizzy'
Correct Answer: B — Skin is warm, dry, and intact; VS 128/82, HR 88, RR 18
Rationale: The SOAP format includes: S (Subjective) — what the patient reports; O (Objective) — measurable, observable
data obtained through assessment; A (Assessment) — clinical judgment or nursing diagnosis; P (Plan) — interventions.
Warm, dry, intact skin and vital signs are measurable, observable findings that belong in the Objective section. Chest pain
reports (A), anxiety observation (C), and dizziness report (D) are subjective data or interpretations and belong in the
Subjective section or require further documentation.
Q10: A nurse calculates a patient's BMI as 31.2. The patient's height is 5'5" and weight is 186 lb. Which
classification applies?
A. Normal weight (BMI 18.5-24.9)
B. Overweight (BMI 25-29.9)
C. Obese Class I (BMI 30-34.9) [CORRECT]
D. Morbidly obese (BMI >40)
Correct Answer: C — Obese Class I (BMI 30-34.9)
Rationale: BMI = weight (kg) / height (m²). The patient's BMI of 31.2 falls within the Obese Class I category (BMI
30.0-34.9). BMI classifications per the CDC/WHO: Normal = 18.5-24.9, Overweight = 25.0-29.9, Obese Class I =
30.0-34.9, Obese Class II = 35.0-39.9, Obese Class III (morbid) = 40.0+. This classification guides health education
regarding risks such as cardiovascular disease, diabetes, and joint problems.
Head-to-Toe • Neuro • Cardio • Respiratory • Abdomen • MSK • Integumentary • Psychosocial • Clinical Judgment Page 4
Exam 4: NSG3160 Health Assessment
100% Correct Questions & Answers — Galen College of Nursing
Aligned with 2026–2027 Galen College of Nursing NSG3160 Curriculum Standards and Nursing Competencies
Total Questions 100 (multiple choice, single best answer)
Passing Score 70% (70/100 correct)
Sections 9 sections: Head-to-Toe, Neurological, Cardiovascular, Respiratory, Abdominal, MSK/Gait, Head/Neck/Lymp
Cognitive Mix 30% Recall • 50% Application • 20% Analysis
Question Style 75% Scenario-based • 15% Direct recall • 10% Clinical analysis
Focus Areas CN assessment, heart sounds/murmurs, breath sounds, abdominal assessment, gait patterns, reflexes, psychoso
How to use this predictor: Attempt each question before reviewing the rationale. Each rationale provides
evidence-based reasoning for the correct answer and explains why each distractor is incorrect, targeting the most
common NSG3160 Exam 4 errors including cranial nerve function confusion, breath sound differentiation, heart sound
identification, abdominal assessment sequencing, abnormal gait identification, reflex grading, and cultural competence
considerations.
Legend: Each question lists four options (A–D). The correct option is marked [CORRECT] in green, followed by the explicit Correct
Answer line and a Rationale with comprehensive health assessment reasoning.
Section 1: Head-to-Toe Comprehensive Assessment (Q1–15)
Q1: A nurse enters a patient's room and observes the following: the patient appears older than the stated age
of 42, has poor personal hygiene, wrinkled clothing, and a flat affect. The patient is slumped in the chair and
does not make eye contact. Which component of the general survey is the nurse performing?
A. Vital signs assessment
B. Complete physical examination
C. General survey [CORRECT]
D. Focused assessment
Correct Answer: C — General survey
Rationale: The general survey is the first component of a head-to-toe assessment that occurs the moment the nurse enters the
room and begins observing the patient. It includes evaluating appearance (age, hygiene, dress, skin color, facial expression),
behavior (level of consciousness, mood/affect, posture), and body structure (height, weight, build). The scenario describes
observation of hygiene, clothing, affect, posture, and eye contact — all elements of the general survey. Vital signs (A)
involve measurable physiological parameters. A complete physical exam (B) is a systematic head-to-toe approach. A
focused assessment (D) targets a specific problem area.
Head-to-Toe • Neuro • Cardio • Respiratory • Abdomen • MSK • Integumentary • Psychosocial • Clinical Judgment Page 1
,NSG3160 Health Assessment Exam 4 — Galen College of Nursing 100 Questions | 2026–2027 Edition
Q2: A nurse assesses a patient's blood pressure as 152/92 mmHg on two separate readings taken 5 minutes
apart. The patient has no history of hypertension. Which is the most appropriate documentation?
A. 'Patient is hypertensive'
B. 'BP elevated at 152/92 mmHg on two readings 5 minutes apart; no prior HTN history' [CORRECT]
C. 'BP high; refer to provider'
D. 'Patient has stage 2 hypertension'
Correct Answer: B — 'BP elevated at 152/92 mmHg on two readings 5 minutes apart; no prior HTN history'
Rationale: Accurate, objective documentation requires recording exact measurements, the conditions under which they were
obtained (two readings 5 minutes apart), and relevant history (no prior hypertension). Labeling the patient as 'hypertensive'
(A) is a medical diagnosis outside nursing scope. Saying 'BP high; refer' (C) lacks specificity and the measurement data.
Staging hypertension as stage 2 (D) is a medical interpretation; the nurse should document objective findings and notify the
provider for clinical classification.
Q3: A nursing student asks the instructor which sequence to follow when performing a comprehensive
head-to-toe assessment. Which response by the instructor is correct?
A. Head → Eyes → Ears → Chest → Abdomen → Extremities
B. General survey → Vital signs → Head to toe systematically [CORRECT]
C. Abdomen → Chest → Neurological → Integumentary
D. Vital signs → Abdomen → Neurological → Musculoskeletal
Correct Answer: B — General survey → Vital signs → Head to toe systematically
Rationale: The correct sequence for a comprehensive head-to-toe assessment begins with the general survey (observing the
patient from the moment you enter), then vital signs, followed by a systematic head-to-toe examination from head to toe.
Option (A) omits the general survey and vital signs. Option (C) begins with the abdomen before the chest and does not
follow a head-to-toe flow. Option (D) places the abdomen before the head, which disrupts the systematic head-to-toe
approach.
Q4: A nurse needs to assess a patient's abdomen. Which position is most appropriate for the abdominal
examination?
A. Supine with knees slightly flexed [CORRECT]
B. Sims position (left lateral with right knee flexed)
C. Lithotomy position
D. Sitting upright at 90 degrees
Correct Answer: A — Supine with knees slightly flexed
Rationale: The dorsal recumbent position (supine with knees slightly flexed) relaxes the abdominal muscles, allowing for
better palpation, percussion, and auscultation of abdominal organs. Sims position (B) is a left lateral position used primarily
for rectal examinations and enemas. Lithotomy (C) is used for pelvic exams. Sitting upright (D) is appropriate for chest/lung
auscultation but does not adequately expose or relax the abdomen.
Head-to-Toe • Neuro • Cardio • Respiratory • Abdomen • MSK • Integumentary • Psychosocial • Clinical Judgment Page 2
,NSG3160 Health Assessment Exam 4 — Galen College of Nursing 100 Questions | 2026–2027 Edition
Q5: A nurse is teaching a new graduate about obtaining the most accurate core body temperature. Which
site should the nurse recommend as the gold standard for core temperature?
A. Oral
B. Tympanic
C. Rectal [CORRECT]
D. Axillary
Correct Answer: C — Rectal
Rationale: Rectal temperature is considered the most accurate estimate of core body temperature because it reflects deep
tissue temperature and is minimally affected by environmental factors. Oral (A) is convenient and commonly used but can be
affected by oral intake, mouth breathing, and gum chewing. Tympanic (B) measures infrared radiation from the tympanic
membrane but may be affected by cerumen or ambient temperature. Axillary (D) is the least accurate because it measures
skin surface temperature, not core temperature.
Q6: A nurse assesses a patient's pulse and notes the following: rate 88/min, rhythm is irregularly irregular,
and strength varies beat to beat. Which pattern does this describe?
A. Sinus bradycardia
B. Atrial fibrillation [CORRECT]
C. Sinus arrhythmia
D. Normal sinus rhythm
Correct Answer: B — Atrial fibrillation
Rationale: An irregularly irregular rhythm with varying pulse strength is the hallmark of atrial fibrillation (AFib). In AFib,
the atria quiver instead of contracting effectively, causing erratic ventricular response and variable stroke volume, which
produces pulse deficits. Sinus bradycardia (A) is a regular rhythm with rate <60/min. Sinus arrhythmia (C) is a regular
variation with respiration (faster on inspiration, slower on expiration). Normal sinus rhythm (D) is regular with rate
60-100/min.
Q7: A nurse observes a patient's respiratory pattern and notes cycles of progressively deeper breathing that
peak and then become shallower, followed by a period of apnea. Which breathing pattern does the nurse
document?
A. Cheyne-Stokes respirations [CORRECT]
B. Kussmaul respirations
C. Biot's respirations
D. Hypoventilation
Correct Answer: A — Cheyne-Stokes respirations
Rationale: Cheyne-Stokes respirations are characterized by a crescendo-decrescendo pattern of breathing with periods of
apnea. The pattern progresses from shallow to deep breathing, peaks, then reverses to shallow, followed by apnea. This is
associated with heart failure, brain injury, and increased intracranial pressure. Kussmaul respirations (B) are deep, rapid
breathing associated with metabolic acidosis (DKA, renal failure) without the cyclic pattern. Biot's respirations (C) are
irregular, unpredictable breathing with apneic periods. Hypoventilation (D) is slow, shallow breathing without the
crescendo-decrescendo cycle.
Head-to-Toe • Neuro • Cardio • Respiratory • Abdomen • MSK • Integumentary • Psychosocial • Clinical Judgment Page 3
, NSG3160 Health Assessment Exam 4 — Galen College of Nursing 100 Questions | 2026–2027 Edition
Q8: A nurse is using the 0-10 numeric rating scale to assess a patient's pain. The patient rates their pain as a
7 and states, 'It hurts all over, and nothing helps.' Which principle of pain assessment is the nurse
demonstrating?
A. Pain is what the patient says it is [CORRECT]
B. Objective data should override subjective reports
C. Pain assessment is only necessary for acute conditions
D. Vital signs are the primary indicator of pain severity
Correct Answer: A — Pain is what the patient says it is
Rationale: The fundamental principle of pain assessment is that pain is a subjective experience — 'pain is whatever the
patient says it is, existing whenever the patient says it does.' The nurse accepts the patient's self-report of 7/10 as the valid
assessment. Option (B) contradicts this core principle. Pain assessment is necessary for both acute and chronic conditions
(C). While vital signs may change with pain, they are not reliable indicators of pain intensity and should not be the primary
measure (D).
Q9: A nurse documents a patient encounter using the SOAP format. Which entry belongs in the 'O'
(Objective) section?
A. Patient reports chest pain for 2 hours
B. Skin is warm, dry, and intact; VS 128/82, HR 88, RR 18 [CORRECT]
C. Patient appears anxious about upcoming surgery
D. Patient states 'I have been feeling dizzy'
Correct Answer: B — Skin is warm, dry, and intact; VS 128/82, HR 88, RR 18
Rationale: The SOAP format includes: S (Subjective) — what the patient reports; O (Objective) — measurable, observable
data obtained through assessment; A (Assessment) — clinical judgment or nursing diagnosis; P (Plan) — interventions.
Warm, dry, intact skin and vital signs are measurable, observable findings that belong in the Objective section. Chest pain
reports (A), anxiety observation (C), and dizziness report (D) are subjective data or interpretations and belong in the
Subjective section or require further documentation.
Q10: A nurse calculates a patient's BMI as 31.2. The patient's height is 5'5" and weight is 186 lb. Which
classification applies?
A. Normal weight (BMI 18.5-24.9)
B. Overweight (BMI 25-29.9)
C. Obese Class I (BMI 30-34.9) [CORRECT]
D. Morbidly obese (BMI >40)
Correct Answer: C — Obese Class I (BMI 30-34.9)
Rationale: BMI = weight (kg) / height (m²). The patient's BMI of 31.2 falls within the Obese Class I category (BMI
30.0-34.9). BMI classifications per the CDC/WHO: Normal = 18.5-24.9, Overweight = 25.0-29.9, Obese Class I =
30.0-34.9, Obese Class II = 35.0-39.9, Obese Class III (morbid) = 40.0+. This classification guides health education
regarding risks such as cardiovascular disease, diabetes, and joint problems.
Head-to-Toe • Neuro • Cardio • Respiratory • Abdomen • MSK • Integumentary • Psychosocial • Clinical Judgment Page 4
