NSG 3160 HEALTH ASSESSMENT EXAM 2/ 300
ACTUAL QUESTIONS AND CORRECT ANSWERS
WITH RATIONALE LATEST UPDATE ALREADY
GRADED A+ ASSURED PASS
This comprehensive NSG 3160 Health Assessment Exam 2 covers advanced
physical assessment across all body systems. It tests your ability to perform and
interpret a systematic head-to-toe examination, integrating subjective data
collection with objective findings. Expect detailed questions on techniques for
inspecting, palpating, percussing, and auscultating the integumentary, head and
neck, thorax and lungs, cardiovascular, abdominal, and neurological systems. You
must master normal versus abnormal findings, recognize signs of common
pathologies, and apply clinical reasoning to prioritize care. The exam emphasizes
cultural considerations, age-related variations, and accurate documentation,
ensuring you are prepared for safe, evidence-based nursing practice.
Section 1: Mental Status and Cognitive Assessment
Question 1: A nurse is assessing a patient's mental status. Which of the following
components is included in the A, B, C, and T of the mental health assessment?
A) Attitude, behavior, cleanliness, talk/speech
B) Appearance, behavior, cognition, and thought
C) Airway, breathing, circulation
D) Ability, beliefs, culture, traditions
Answer: B
Rationale: The A, B, C, and T of the mental health assessment stands for
Appearance, Behavior, Cognition, and Thought. This framework helps
systematically evaluate a patient's mental status and includes observation of
posture, body movements, dress, grooming, and hygiene for appearance; level of
consciousness, facial expression, speech, mood and affect for behavior; orientation,
attention span, memory for cognition; and thought content, perceptions, and
suicidal thoughts for thought process.
,Question 2: A nurse is assessing a patient's level of consciousness. The patient
drifts off to sleep when not stimulated. Which term best describes this finding?
A) Lethargic
B) Obtunded
C) Stuporous
D) Comatose
Answer: B
Rationale: An obtunded patient drifts off to sleep when not stimulated but can be
aroused with stimulation. Lethargic patients are drowsy but can be easily
awakened. Stuporous patients respond only to persistent shaking or pain, and
comatose patients show no response to any external stimuli .
Question 3: A nurse is assessing a patient's mental status. The nurse must first
evaluate which aspect to accurately assess their mental status?
A) Appearance
B) Behavior
C) Level of consciousness
D) Thought process
Answer: C
Rationale: The nurse must first evaluate the patient's level of consciousness to
accurately assess their mental status. This is the most fundamental aspect of mental
status assessment, as a patient must be awake and alert before other cognitive
functions can be reliably assessed .
Question 4: A nurse is assessing a patient's recent memory. Which method should
the nurse use?
A) "What was your first job?"
B) "What is today's date?"
C) Ask for a 24-hour diet recall
D) Assess the patient's ability to complete a thought without wandering
Answer: C
Rationale: Asking a patient for a 24-hour diet recall is a common method to assess
recent memory. Remote memory is assessed by asking about past events like a first
job, orientation is assessed by asking about the date, and thought process is
assessed by evaluating how thoughts are organized .
Question 5: A nurse is testing a patient's new learning ability using the four
unrelated words test. After 5 minutes, the nurse asks the patient to recall the words.
This tests which type of memory?
,A) Remote memory
B) Immediate memory
C) Recent memory
D) New learning
Answer: D
Rationale: The four unrelated words test assesses new learning at 5 minutes. To
test the duration of memory, the nurse would ask for recall at 10 and 30 minutes,
which assesses recent memory .
Question 6: A patient has difficulty speaking but appears to understand what is
being said to them. Which type of aphasia should the nurse suspect?
A) Wernicke aphasia
B) Expressive aphasia (Broca aphasia)
C) Global aphasia
D) Conduction aphasia
Answer: B
Rationale: Expressive aphasia, also known as Broca aphasia, is characterized by
difficulty producing speech while comprehension remains intact. Wernicke aphasia
involves fluent but nonsensical speech with poor comprehension. Global aphasia
affects both expression and comprehension .
Question 7: A nurse is assessing a patient's judgment. Which question would best
assess this cognitive function?
A) "Do you feel that you are being watched, followed, or controlled?"
B) "What would you do if you found a stamped, addressed envelope lying on the
sidewalk?"
C) "What does the statement, 'People in glass houses shouldn't throw stones,' mean
to you?"
D) "What is today's date?"
Answer: B
Rationale: Asking a hypothetical question about what to do with a stamped,
addressed envelope tests judgment. Questions about being watched test for
paranoia or delusions. Asking about a proverb tests abstract reasoning. Asking
about the date tests orientation .
Question 8: A nurse is assessing a patient's attention span. Which approach is
appropriate?
A) Ask, "What is today's date?"
B) Ask for a 24-hour diet recall
C) Give a series of directions to follow and note the correct sequence performed
, D) Ask about the patient's first job
Answer: C
Rationale: Giving a series of directions to follow and noting the correct sequence
performed is a method to assess a patient's attention span. Orientation is assessed
by asking about the date. Recent memory is assessed by diet recall or other recent
event questions. Remote memory is assessed by asking about past events like a
first job .
Question 9: A patient is unable to recognize familiar objects despite having normal
sensory function. This finding is consistent with which condition?
A) Agnosia
B) Apraxia
C) Aphasia
D) Amnesia
Answer: A
Rationale: Agnosia is the inability to recognize familiar objects despite intact
sensory function. Apraxia is the inability to perform learned movements. Aphasia
is a language disorder. Amnesia is memory loss .
Question 10: Which of the following is not one of the four most common anxiety
disorders?
A) Panic disorder
B) Posttraumatic stress disorder
C) Social anxiety disorder
D) Depression
Answer: D
Rationale: The four most common anxiety disorders are panic disorder,
posttraumatic stress disorder, social anxiety disorder, and generalized anxiety
disorder. Depression is a mood disorder, not an anxiety disorder .
Section 2: Pain Assessment
Question 11: A nurse is assessing a patient's pain. What is the most reliable
indicator of pain?
A) Patient's vital signs
B) Subjective report
C) Results of diagnostic imaging
D) Physical examination findings
Answer: B
ACTUAL QUESTIONS AND CORRECT ANSWERS
WITH RATIONALE LATEST UPDATE ALREADY
GRADED A+ ASSURED PASS
This comprehensive NSG 3160 Health Assessment Exam 2 covers advanced
physical assessment across all body systems. It tests your ability to perform and
interpret a systematic head-to-toe examination, integrating subjective data
collection with objective findings. Expect detailed questions on techniques for
inspecting, palpating, percussing, and auscultating the integumentary, head and
neck, thorax and lungs, cardiovascular, abdominal, and neurological systems. You
must master normal versus abnormal findings, recognize signs of common
pathologies, and apply clinical reasoning to prioritize care. The exam emphasizes
cultural considerations, age-related variations, and accurate documentation,
ensuring you are prepared for safe, evidence-based nursing practice.
Section 1: Mental Status and Cognitive Assessment
Question 1: A nurse is assessing a patient's mental status. Which of the following
components is included in the A, B, C, and T of the mental health assessment?
A) Attitude, behavior, cleanliness, talk/speech
B) Appearance, behavior, cognition, and thought
C) Airway, breathing, circulation
D) Ability, beliefs, culture, traditions
Answer: B
Rationale: The A, B, C, and T of the mental health assessment stands for
Appearance, Behavior, Cognition, and Thought. This framework helps
systematically evaluate a patient's mental status and includes observation of
posture, body movements, dress, grooming, and hygiene for appearance; level of
consciousness, facial expression, speech, mood and affect for behavior; orientation,
attention span, memory for cognition; and thought content, perceptions, and
suicidal thoughts for thought process.
,Question 2: A nurse is assessing a patient's level of consciousness. The patient
drifts off to sleep when not stimulated. Which term best describes this finding?
A) Lethargic
B) Obtunded
C) Stuporous
D) Comatose
Answer: B
Rationale: An obtunded patient drifts off to sleep when not stimulated but can be
aroused with stimulation. Lethargic patients are drowsy but can be easily
awakened. Stuporous patients respond only to persistent shaking or pain, and
comatose patients show no response to any external stimuli .
Question 3: A nurse is assessing a patient's mental status. The nurse must first
evaluate which aspect to accurately assess their mental status?
A) Appearance
B) Behavior
C) Level of consciousness
D) Thought process
Answer: C
Rationale: The nurse must first evaluate the patient's level of consciousness to
accurately assess their mental status. This is the most fundamental aspect of mental
status assessment, as a patient must be awake and alert before other cognitive
functions can be reliably assessed .
Question 4: A nurse is assessing a patient's recent memory. Which method should
the nurse use?
A) "What was your first job?"
B) "What is today's date?"
C) Ask for a 24-hour diet recall
D) Assess the patient's ability to complete a thought without wandering
Answer: C
Rationale: Asking a patient for a 24-hour diet recall is a common method to assess
recent memory. Remote memory is assessed by asking about past events like a first
job, orientation is assessed by asking about the date, and thought process is
assessed by evaluating how thoughts are organized .
Question 5: A nurse is testing a patient's new learning ability using the four
unrelated words test. After 5 minutes, the nurse asks the patient to recall the words.
This tests which type of memory?
,A) Remote memory
B) Immediate memory
C) Recent memory
D) New learning
Answer: D
Rationale: The four unrelated words test assesses new learning at 5 minutes. To
test the duration of memory, the nurse would ask for recall at 10 and 30 minutes,
which assesses recent memory .
Question 6: A patient has difficulty speaking but appears to understand what is
being said to them. Which type of aphasia should the nurse suspect?
A) Wernicke aphasia
B) Expressive aphasia (Broca aphasia)
C) Global aphasia
D) Conduction aphasia
Answer: B
Rationale: Expressive aphasia, also known as Broca aphasia, is characterized by
difficulty producing speech while comprehension remains intact. Wernicke aphasia
involves fluent but nonsensical speech with poor comprehension. Global aphasia
affects both expression and comprehension .
Question 7: A nurse is assessing a patient's judgment. Which question would best
assess this cognitive function?
A) "Do you feel that you are being watched, followed, or controlled?"
B) "What would you do if you found a stamped, addressed envelope lying on the
sidewalk?"
C) "What does the statement, 'People in glass houses shouldn't throw stones,' mean
to you?"
D) "What is today's date?"
Answer: B
Rationale: Asking a hypothetical question about what to do with a stamped,
addressed envelope tests judgment. Questions about being watched test for
paranoia or delusions. Asking about a proverb tests abstract reasoning. Asking
about the date tests orientation .
Question 8: A nurse is assessing a patient's attention span. Which approach is
appropriate?
A) Ask, "What is today's date?"
B) Ask for a 24-hour diet recall
C) Give a series of directions to follow and note the correct sequence performed
, D) Ask about the patient's first job
Answer: C
Rationale: Giving a series of directions to follow and noting the correct sequence
performed is a method to assess a patient's attention span. Orientation is assessed
by asking about the date. Recent memory is assessed by diet recall or other recent
event questions. Remote memory is assessed by asking about past events like a
first job .
Question 9: A patient is unable to recognize familiar objects despite having normal
sensory function. This finding is consistent with which condition?
A) Agnosia
B) Apraxia
C) Aphasia
D) Amnesia
Answer: A
Rationale: Agnosia is the inability to recognize familiar objects despite intact
sensory function. Apraxia is the inability to perform learned movements. Aphasia
is a language disorder. Amnesia is memory loss .
Question 10: Which of the following is not one of the four most common anxiety
disorders?
A) Panic disorder
B) Posttraumatic stress disorder
C) Social anxiety disorder
D) Depression
Answer: D
Rationale: The four most common anxiety disorders are panic disorder,
posttraumatic stress disorder, social anxiety disorder, and generalized anxiety
disorder. Depression is a mood disorder, not an anxiety disorder .
Section 2: Pain Assessment
Question 11: A nurse is assessing a patient's pain. What is the most reliable
indicator of pain?
A) Patient's vital signs
B) Subjective report
C) Results of diagnostic imaging
D) Physical examination findings
Answer: B
