NRS 420 Final Exam V2 | NRS 420 Health
Assessment | Actual Q&A with Rationale (NRS420
Final Exam) | Grand Canyon University
1. When performing a comprehensive skin assessment on an elderly patient, which of the
following findings should the nurse document as normal age-related changes? (Select All That
Apply)
A. Decreased skin elasticity and sagging.
B. Increased subcutaneous fat in the extremities.
C. Presence of senile lentigines (liver spots).
D. Decreased moisture leading to dry skin (xerosis).
E. Thinned, translucent appearance of the skin.
F. Increased melanin production resulting in a uniform tan.
Correct Answer: A, C, D, E
Explanation: Normal aging results in a loss of collagen and elastin, leading to sagging and
decreased elasticity. Senile lentigines are common benign pigmented spots that occur due
to sun exposure over time. As sebaceous gland activity decreases, the skin becomes drier,
and the loss of subcutaneous tissue makes the skin appear thinner and more fragile.
,2. During a cardiac assessment, the nurse notes a low-pitched, extra heart sound heard early
in diastole at the apex. How should the nurse document this finding?
A. S3 heart sound
B. S4 heart sound
C. Systolic murmur
D. Pericardial friction rub
Correct Answer: A
Explanation: The S3 heart sound occurs early in diastole during the rapid ventricular
filling phase and is often called a ventricular gallop. It is best heard with the bell of the
stethoscope at the apex while the patient is in the left lateral decubitus position. In older
adults, S3 can indicate heart failure or volume overload, whereas in children and young
adults, it may be a normal finding.
3. The nurse is preparing to assess a patient’s abdomen. In which sequence should the nurse
perform the physical assessment techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Palpation, Inspection, Auscultation
Correct Answer: A
, Explanation: For an abdominal assessment, the sequence must be inspection followed by
auscultation to ensure bowel sounds are not altered by manipulation. Percussion and
palpation are performed last because they can stimulate peristalsis or cause pain that may
lead to muscle guarding. Adhering to this specific order ensures the most accurate clinical
findings regarding the patient’s gastrointestinal status.
4. A patient presents with a ‘curtain-like’ shadow over their field of vision and sudden flashes
of light. Which condition should the nurse suspect?
A. Glaucoma
B. Cataracts
C. Retinal detachment
D. Macular degeneration
Correct Answer: C
Explanation: Retinal detachment is a medical emergency characterized by the sudden
appearance of floaters, flashes of light (photopsia), and a shadow or curtain in the
peripheral or central vision. Unlike cataracts, which cause gradual blurring, or glaucoma,
which involves increased intraocular pressure, retinal detachment requires immediate
surgical intervention to prevent permanent vision loss. The nurse must recognize these
symptoms quickly to facilitate urgent ophthalmological consultation.
Assessment | Actual Q&A with Rationale (NRS420
Final Exam) | Grand Canyon University
1. When performing a comprehensive skin assessment on an elderly patient, which of the
following findings should the nurse document as normal age-related changes? (Select All That
Apply)
A. Decreased skin elasticity and sagging.
B. Increased subcutaneous fat in the extremities.
C. Presence of senile lentigines (liver spots).
D. Decreased moisture leading to dry skin (xerosis).
E. Thinned, translucent appearance of the skin.
F. Increased melanin production resulting in a uniform tan.
Correct Answer: A, C, D, E
Explanation: Normal aging results in a loss of collagen and elastin, leading to sagging and
decreased elasticity. Senile lentigines are common benign pigmented spots that occur due
to sun exposure over time. As sebaceous gland activity decreases, the skin becomes drier,
and the loss of subcutaneous tissue makes the skin appear thinner and more fragile.
,2. During a cardiac assessment, the nurse notes a low-pitched, extra heart sound heard early
in diastole at the apex. How should the nurse document this finding?
A. S3 heart sound
B. S4 heart sound
C. Systolic murmur
D. Pericardial friction rub
Correct Answer: A
Explanation: The S3 heart sound occurs early in diastole during the rapid ventricular
filling phase and is often called a ventricular gallop. It is best heard with the bell of the
stethoscope at the apex while the patient is in the left lateral decubitus position. In older
adults, S3 can indicate heart failure or volume overload, whereas in children and young
adults, it may be a normal finding.
3. The nurse is preparing to assess a patient’s abdomen. In which sequence should the nurse
perform the physical assessment techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Palpation, Inspection, Auscultation
Correct Answer: A
, Explanation: For an abdominal assessment, the sequence must be inspection followed by
auscultation to ensure bowel sounds are not altered by manipulation. Percussion and
palpation are performed last because they can stimulate peristalsis or cause pain that may
lead to muscle guarding. Adhering to this specific order ensures the most accurate clinical
findings regarding the patient’s gastrointestinal status.
4. A patient presents with a ‘curtain-like’ shadow over their field of vision and sudden flashes
of light. Which condition should the nurse suspect?
A. Glaucoma
B. Cataracts
C. Retinal detachment
D. Macular degeneration
Correct Answer: C
Explanation: Retinal detachment is a medical emergency characterized by the sudden
appearance of floaters, flashes of light (photopsia), and a shadow or curtain in the
peripheral or central vision. Unlike cataracts, which cause gradual blurring, or glaucoma,
which involves increased intraocular pressure, retinal detachment requires immediate
surgical intervention to prevent permanent vision loss. The nurse must recognize these
symptoms quickly to facilitate urgent ophthalmological consultation.
