,NSG3160/NSG 3160 Exam 1 | Health Assessment |
Galen College | 26/27 Updated (PDF)
1. Which action best exemplifies the use of evidence-based assessment techniques in clinical practice?
A) Relying on intuition and past clinical experiences to make a diagnosis
B) Following a standardized protocol without considering individual patient variations
C) Integrating the best available research with clinical expertise and patient preferences
D) Using the most current textbook as the sole source of information for care decisions
Correct Answer: Integrating the best available research with clinical expertise and patient preferences
Rationale: Evidence-based practice is the integration of the best research evidence with clinical
expertise and patient values and preferences. Relying solely on intuition, following protocols rigidly,
or depending only on textbooks does not incorporate the full scope of evidence-based decision-
making, which requires a dynamic and patient-centered approach.
2. During a health history interview, the nurse asks the question, "What do you think is causing your
symptoms?" Which type of interview question is the nurse employing?
A) A leading question
B) A closed-ended question
C) An open-ended question
D) A clarifying question
Correct Answer: An open-ended question
Rationale: An open-ended question invites the patient to share their perspective in their own words
without restricting the response. This question format is therapeutic and encourages a comprehensive
narrative. Closed-ended questions elicit a yes/no or short factual answer, leading questions suggest a
desired answer, and clarifying questions seek to verify understanding.
3. A nurse is preparing to conduct a health history on a newly admitted patient. What is the primary
purpose of obtaining a comprehensive health history?
,A) To establish a trusting relationship with the patient
B) To gather subjective data that will guide the physical examination
C) To document information for legal and billing purposes
D) To identify the patient's primary medical diagnosis
Correct Answer: To gather subjective data that will guide the physical examination
Rationale: The comprehensive health history is the foundation of the assessment process. Its primary
purpose is to collect subjective data about the patient's health status, which then directs the focus of
the physical examination and identifies areas of concern. While establishing rapport and
documentation are important, they are secondary to the clinical purpose of data collection. Medical
diagnosis is outside the nursing scope.
4. A patient reports experiencing chest pain. The nurse asks, "Can you describe the pain for me?" This
is an example of which type of communication technique?
A) Facilitation
B) Reflection
C) Clarification
D) Confrontation
Correct Answer: Facilitation
Rationale: Facilitation involves using prompts or open-ended questions to encourage the patient to
elaborate on their story. "Can you describe the pain?" encourages the patient to provide more detail.
Reflection restates the patient's words, clarification seeks to verify understanding, and confrontation
addresses discrepancies.
5. The nurse is performing a physical examination and uses the dorsal surface of the hand to assess
the patient's skin temperature. Which rationale best explains why this part of the hand is used?
A) The dorsal surface has a higher concentration of nerve endings for fine touch
B) The dorsal surface is more sensitive to temperature changes than the palmar surface
C) The dorsal surface is less calloused and more sensitive to vibration
, D) The dorsal surface is the standard technique for assessing skin turgor
Correct Answer: The dorsal surface is more sensitive to temperature changes than the palmar surface
Rationale: The dorsal (back) surface of the hand is more sensitive to temperature because the skin is
thinner and has a higher density of temperature receptors compared to the palmar surface. The
fingertips are used for fine touch, vibration, and texture discrimination due to their high concentration
of nerve endings.
6. A nursing student is learning the four basic physical examination techniques. In which order should
these techniques be performed during a general assessment?
A) Palpation, Percussion, Auscultation, Inspection
B) Inspection, Palpation, Percussion, Auscultation
C) Inspection, Auscultation, Palpation, Percussion
D) Auscultation, Inspection, Palpation, Percussion
Correct Answer: Inspection, Palpation, Percussion, Auscultation
Rationale: The standard order for physical examination techniques is Inspection, Palpation,
Percussion, and Auscultation. However, for the abdomen, auscultation is performed before palpation
and percussion to avoid altering bowel sounds. For most other body systems, the traditional order is
followed.
7. The nurse is assessing a patient's radial pulse and notes a rate of 92 beats per minute with a regular
rhythm. Which term correctly describes this finding?
A) Bradycardia and dysrhythmic
B) Tachycardia and dysrhythmic
C) Tachycardia and arrhythmic
D) Tachycardia and regular
Correct Answer: Tachycardia and regular
Galen College | 26/27 Updated (PDF)
1. Which action best exemplifies the use of evidence-based assessment techniques in clinical practice?
A) Relying on intuition and past clinical experiences to make a diagnosis
B) Following a standardized protocol without considering individual patient variations
C) Integrating the best available research with clinical expertise and patient preferences
D) Using the most current textbook as the sole source of information for care decisions
Correct Answer: Integrating the best available research with clinical expertise and patient preferences
Rationale: Evidence-based practice is the integration of the best research evidence with clinical
expertise and patient values and preferences. Relying solely on intuition, following protocols rigidly,
or depending only on textbooks does not incorporate the full scope of evidence-based decision-
making, which requires a dynamic and patient-centered approach.
2. During a health history interview, the nurse asks the question, "What do you think is causing your
symptoms?" Which type of interview question is the nurse employing?
A) A leading question
B) A closed-ended question
C) An open-ended question
D) A clarifying question
Correct Answer: An open-ended question
Rationale: An open-ended question invites the patient to share their perspective in their own words
without restricting the response. This question format is therapeutic and encourages a comprehensive
narrative. Closed-ended questions elicit a yes/no or short factual answer, leading questions suggest a
desired answer, and clarifying questions seek to verify understanding.
3. A nurse is preparing to conduct a health history on a newly admitted patient. What is the primary
purpose of obtaining a comprehensive health history?
,A) To establish a trusting relationship with the patient
B) To gather subjective data that will guide the physical examination
C) To document information for legal and billing purposes
D) To identify the patient's primary medical diagnosis
Correct Answer: To gather subjective data that will guide the physical examination
Rationale: The comprehensive health history is the foundation of the assessment process. Its primary
purpose is to collect subjective data about the patient's health status, which then directs the focus of
the physical examination and identifies areas of concern. While establishing rapport and
documentation are important, they are secondary to the clinical purpose of data collection. Medical
diagnosis is outside the nursing scope.
4. A patient reports experiencing chest pain. The nurse asks, "Can you describe the pain for me?" This
is an example of which type of communication technique?
A) Facilitation
B) Reflection
C) Clarification
D) Confrontation
Correct Answer: Facilitation
Rationale: Facilitation involves using prompts or open-ended questions to encourage the patient to
elaborate on their story. "Can you describe the pain?" encourages the patient to provide more detail.
Reflection restates the patient's words, clarification seeks to verify understanding, and confrontation
addresses discrepancies.
5. The nurse is performing a physical examination and uses the dorsal surface of the hand to assess
the patient's skin temperature. Which rationale best explains why this part of the hand is used?
A) The dorsal surface has a higher concentration of nerve endings for fine touch
B) The dorsal surface is more sensitive to temperature changes than the palmar surface
C) The dorsal surface is less calloused and more sensitive to vibration
, D) The dorsal surface is the standard technique for assessing skin turgor
Correct Answer: The dorsal surface is more sensitive to temperature changes than the palmar surface
Rationale: The dorsal (back) surface of the hand is more sensitive to temperature because the skin is
thinner and has a higher density of temperature receptors compared to the palmar surface. The
fingertips are used for fine touch, vibration, and texture discrimination due to their high concentration
of nerve endings.
6. A nursing student is learning the four basic physical examination techniques. In which order should
these techniques be performed during a general assessment?
A) Palpation, Percussion, Auscultation, Inspection
B) Inspection, Palpation, Percussion, Auscultation
C) Inspection, Auscultation, Palpation, Percussion
D) Auscultation, Inspection, Palpation, Percussion
Correct Answer: Inspection, Palpation, Percussion, Auscultation
Rationale: The standard order for physical examination techniques is Inspection, Palpation,
Percussion, and Auscultation. However, for the abdomen, auscultation is performed before palpation
and percussion to avoid altering bowel sounds. For most other body systems, the traditional order is
followed.
7. The nurse is assessing a patient's radial pulse and notes a rate of 92 beats per minute with a regular
rhythm. Which term correctly describes this finding?
A) Bradycardia and dysrhythmic
B) Tachycardia and dysrhythmic
C) Tachycardia and arrhythmic
D) Tachycardia and regular
Correct Answer: Tachycardia and regular
