NSG 3160 HEALTH ASSESSMENT EXAM
2 V1 QUESTIONS AND ANSWERS
1. During a respiratory assessment, the nurse notes a palpable vibration increased over the
right lower lobe when the patient says ‘ninety-nine’. This finding is consistent with:
A. Pneumothorax
B. Consolidation of lung tissue
C. Pleural effusion
D. Obstructed bronchus
Answer: B
Conceptual Explanation: Increased tactile fremitus occurs with compression or
consolidation of lung tissue, such as in lobar pneumonia, as sound travels better through
solid/liquid media than air.
2. When auscultating the heart of a 70-year-old patient, the nurse hears a soft, low-pitched
sound early in diastole at the apex. What is the most likely interpretation of this finding?
A. A normal physiological S3
B. A pathological S4 indicating hypertension
C. A normal closure of the semilunar valves
,D. A pathological S3 indicating heart failure
Answer: D
Conceptual Explanation: In older adults, an S3 (ventricular gallop) is often pathological
and represents decreased ventricular compliance or heart failure. S4 occurs late in diastole.
3. The nurse is assessing a patient for peripheral vascular disease. Which finding is most
characteristic of chronic arterial insufficiency?
A. Brownish skin discoloration around the ankles
B. Pitting edema of the lower extremities
C. Ulcers located on the medial malleolus
D. Pale, cool skin with diminished pulses
Answer: D
Conceptual Explanation: Arterial insufficiency results in decreased oxygenated blood
flow, causing pallor, coolness, and weak pulses. Brownish pigment and medial ulcers are
signs of venous insufficiency.
4. In what order should the nurse perform an abdominal assessment?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Inspection, Percussion, Palpation, Auscultation
, Answer: A
Conceptual Explanation: Auscultation is performed before percussion and palpation to
avoid stimulating bowel sounds or causing discomfort that might alter the physical
findings.
5. Which cranial nerve is being tested when the nurse asks the patient to stick out their
tongue and move it from side to side?
A. CN IX (Glossopharyngeal)
B. CN X (Vagus)
C. CN XII (Hypoglossal)
D. CN XI (Spinal Accessory)
Answer: C
Conceptual Explanation: Cranial nerve XII (Hypoglossal) controls the motor function of
the tongue. Deviation or weakness indicates dysfunction.
6. A patient presents with sudden onset of ‘the worst headache of my life’. The nurse
suspects which condition?
A. Migraine with aura
B. Cluster headache
C. Tension headache
D. Subarachnoid hemorrhage
2 V1 QUESTIONS AND ANSWERS
1. During a respiratory assessment, the nurse notes a palpable vibration increased over the
right lower lobe when the patient says ‘ninety-nine’. This finding is consistent with:
A. Pneumothorax
B. Consolidation of lung tissue
C. Pleural effusion
D. Obstructed bronchus
Answer: B
Conceptual Explanation: Increased tactile fremitus occurs with compression or
consolidation of lung tissue, such as in lobar pneumonia, as sound travels better through
solid/liquid media than air.
2. When auscultating the heart of a 70-year-old patient, the nurse hears a soft, low-pitched
sound early in diastole at the apex. What is the most likely interpretation of this finding?
A. A normal physiological S3
B. A pathological S4 indicating hypertension
C. A normal closure of the semilunar valves
,D. A pathological S3 indicating heart failure
Answer: D
Conceptual Explanation: In older adults, an S3 (ventricular gallop) is often pathological
and represents decreased ventricular compliance or heart failure. S4 occurs late in diastole.
3. The nurse is assessing a patient for peripheral vascular disease. Which finding is most
characteristic of chronic arterial insufficiency?
A. Brownish skin discoloration around the ankles
B. Pitting edema of the lower extremities
C. Ulcers located on the medial malleolus
D. Pale, cool skin with diminished pulses
Answer: D
Conceptual Explanation: Arterial insufficiency results in decreased oxygenated blood
flow, causing pallor, coolness, and weak pulses. Brownish pigment and medial ulcers are
signs of venous insufficiency.
4. In what order should the nurse perform an abdominal assessment?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Inspection, Percussion, Palpation, Auscultation
, Answer: A
Conceptual Explanation: Auscultation is performed before percussion and palpation to
avoid stimulating bowel sounds or causing discomfort that might alter the physical
findings.
5. Which cranial nerve is being tested when the nurse asks the patient to stick out their
tongue and move it from side to side?
A. CN IX (Glossopharyngeal)
B. CN X (Vagus)
C. CN XII (Hypoglossal)
D. CN XI (Spinal Accessory)
Answer: C
Conceptual Explanation: Cranial nerve XII (Hypoglossal) controls the motor function of
the tongue. Deviation or weakness indicates dysfunction.
6. A patient presents with sudden onset of ‘the worst headache of my life’. The nurse
suspects which condition?
A. Migraine with aura
B. Cluster headache
C. Tension headache
D. Subarachnoid hemorrhage
