NRS 420 Final Exam V3 | NRS 420 Health
Assessment | Actual Q&A with Rationale (NRS420
Final Exam) | Grand Canyon University
1. A nurse is conducting a general survey on a newly admitted patient. Which components
are included in a standard general survey? Select all that apply.
A. Physical appearance
B. Body structure
C. Mobility
D. Behavior
E. Deep tendon reflexes
F. Vital signs
Correct Answer: A, B, C, D, F
Explanation: The general survey is a study of the whole person, covering the general
health state and any obvious physical characteristics. It includes physical appearance, body
structure, mobility, and behavior. Vital signs are typically considered the final step of the
general survey, while deep tendon reflexes are part of the neurological exam.
2. When assessing a patient’s blood pressure, the nurse knows that which of the following
factors could result in a falsely high reading?
A. Cuff is too wide
,B. Arm is held above the level of the heart
C. Cuff is wrapped too loosely
D. Deflating the cuff too quickly
Correct Answer: C
Explanation: A cuff wrapped too loosely or unevenly provides a falsely high reading
because it requires more pressure to compress the artery. Conversely, a cuff that is too
wide or an arm held above heart level usually results in a falsely low reading. Proper
technique is essential for diagnostic accuracy in hypertensive screening.
3. The nurse is using the PQRSTU mnemonic to assess a patient’s report of chest pain. What
does the ‘S’ stand for in this assessment tool?
A. Severity
B. Site
C. Symptoms
D. Setting
Correct Answer: A
Explanation: In the PQRSTU pain assessment framework, ‘S’ stands for Severity, often
measured on a scale of 0 to 10. This allows the nurse to quantify the patient’s subjective
experience of pain. Understanding severity helps in determining the urgency of
intervention and evaluating the effectiveness of treatments.
, 4. During a skin assessment, the nurse notes a lesion that is flat, circumscribed, and less than
1 cm in diameter. Which term should the nurse use to document this finding?
A. Papule
B. Nodule
C. Wheal
D. Macule
Correct Answer: D
Explanation: A macule is a flat, color-changed area of the skin that is less than 1 cm, such
as a freckle or petechiae. A papule is elevated, while a wheal is transient and erythematous.
Accurate documentation of skin lesions is vital for tracking changes that may indicate
malignancy or infection.
5. Which cranial nerve is the nurse assessing when asking the patient to shrug their shoulders
against resistance?
A. CN XI (Spinal Accessory)
B. CN X (Vagus)
C. CN IX (Glossopharyngeal)
D. CN XII (Hypoglossal)
Correct Answer: A
Assessment | Actual Q&A with Rationale (NRS420
Final Exam) | Grand Canyon University
1. A nurse is conducting a general survey on a newly admitted patient. Which components
are included in a standard general survey? Select all that apply.
A. Physical appearance
B. Body structure
C. Mobility
D. Behavior
E. Deep tendon reflexes
F. Vital signs
Correct Answer: A, B, C, D, F
Explanation: The general survey is a study of the whole person, covering the general
health state and any obvious physical characteristics. It includes physical appearance, body
structure, mobility, and behavior. Vital signs are typically considered the final step of the
general survey, while deep tendon reflexes are part of the neurological exam.
2. When assessing a patient’s blood pressure, the nurse knows that which of the following
factors could result in a falsely high reading?
A. Cuff is too wide
,B. Arm is held above the level of the heart
C. Cuff is wrapped too loosely
D. Deflating the cuff too quickly
Correct Answer: C
Explanation: A cuff wrapped too loosely or unevenly provides a falsely high reading
because it requires more pressure to compress the artery. Conversely, a cuff that is too
wide or an arm held above heart level usually results in a falsely low reading. Proper
technique is essential for diagnostic accuracy in hypertensive screening.
3. The nurse is using the PQRSTU mnemonic to assess a patient’s report of chest pain. What
does the ‘S’ stand for in this assessment tool?
A. Severity
B. Site
C. Symptoms
D. Setting
Correct Answer: A
Explanation: In the PQRSTU pain assessment framework, ‘S’ stands for Severity, often
measured on a scale of 0 to 10. This allows the nurse to quantify the patient’s subjective
experience of pain. Understanding severity helps in determining the urgency of
intervention and evaluating the effectiveness of treatments.
, 4. During a skin assessment, the nurse notes a lesion that is flat, circumscribed, and less than
1 cm in diameter. Which term should the nurse use to document this finding?
A. Papule
B. Nodule
C. Wheal
D. Macule
Correct Answer: D
Explanation: A macule is a flat, color-changed area of the skin that is less than 1 cm, such
as a freckle or petechiae. A papule is elevated, while a wheal is transient and erythematous.
Accurate documentation of skin lesions is vital for tracking changes that may indicate
malignancy or infection.
5. Which cranial nerve is the nurse assessing when asking the patient to shrug their shoulders
against resistance?
A. CN XI (Spinal Accessory)
B. CN X (Vagus)
C. CN IX (Glossopharyngeal)
D. CN XII (Hypoglossal)
Correct Answer: A
