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NSG 3160 HEALTH ASSESSMENT EXAM
3 QUESTIONS WITH VERIFIED
SOLUTIONS
Question 1
A nurse is preparing to assess a patient's abdomen. Which sequence represents
the correct order of assessment techniques?
A. Inspection, palpation, percussion, auscultation
B. Auscultation, inspection, percussion, palpation
C. Inspection, auscultation, percussion, palpation
D. Palpation, percussion, auscultation, inspection
Correct Answer: C
Rationale: The correct abdominal assessment sequence is Inspection,
Auscultation, Percussion, Palpation. Auscultation is performed before percussion
and palpation because physical manipulation can artificially stimulate bowel
sounds and alter their frequency.
Question 2
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A nurse is auscultating bowel sounds in a patient with a suspected bowel
obstruction. How long should the nurse listen in each quadrant before
documenting absent bowel sounds?
A. 30 seconds
B. 1 minute
C. 2 minutes
D. 5 minutes
Correct Answer: D
Rationale: The nurse should listen in all four quadrants for at least 5 minutes
before documenting absent bowel sounds. Bowel sounds are high-pitched and
irregular, ranging from 5 to 34 per minute.
Question 3
A patient presents with tenderness at McBurney's point. The nurse practitioner
suspects:
A. Cholecystitis
B. Appendicitis
C. Diverticulitis
D. Pancreatitis
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Correct Answer: B
Rationale: McBurney's point is located in the right lower quadrant, one-third of
the distance from the anterior superior iliac spine to the umbilicus. Tenderness at
this point is the classic sign of appendicitis.
Question 4
A nurse is assessing a patient with a suspected enlarged spleen. Which action
should the nurse take?
A. Deeply palpate the left upper quadrant
B. Avoid palpating the spleen due to rupture risk
C. Percuss the spleen to confirm enlargement
D. Auscultate the spleen for bruits
Correct Answer: B
Rationale: An enlarged spleen should NOT be palpated because it can easily
rupture. The nurse should percuss for splenic enlargement using Castell sign or
Traube space percussion.
Question 5
NSG 3160 HEALTH ASSESSMENT EXAM
3 QUESTIONS WITH VERIFIED
SOLUTIONS
Question 1
A nurse is preparing to assess a patient's abdomen. Which sequence represents
the correct order of assessment techniques?
A. Inspection, palpation, percussion, auscultation
B. Auscultation, inspection, percussion, palpation
C. Inspection, auscultation, percussion, palpation
D. Palpation, percussion, auscultation, inspection
Correct Answer: C
Rationale: The correct abdominal assessment sequence is Inspection,
Auscultation, Percussion, Palpation. Auscultation is performed before percussion
and palpation because physical manipulation can artificially stimulate bowel
sounds and alter their frequency.
Question 2
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A nurse is auscultating bowel sounds in a patient with a suspected bowel
obstruction. How long should the nurse listen in each quadrant before
documenting absent bowel sounds?
A. 30 seconds
B. 1 minute
C. 2 minutes
D. 5 minutes
Correct Answer: D
Rationale: The nurse should listen in all four quadrants for at least 5 minutes
before documenting absent bowel sounds. Bowel sounds are high-pitched and
irregular, ranging from 5 to 34 per minute.
Question 3
A patient presents with tenderness at McBurney's point. The nurse practitioner
suspects:
A. Cholecystitis
B. Appendicitis
C. Diverticulitis
D. Pancreatitis
, 3|Page
Correct Answer: B
Rationale: McBurney's point is located in the right lower quadrant, one-third of
the distance from the anterior superior iliac spine to the umbilicus. Tenderness at
this point is the classic sign of appendicitis.
Question 4
A nurse is assessing a patient with a suspected enlarged spleen. Which action
should the nurse take?
A. Deeply palpate the left upper quadrant
B. Avoid palpating the spleen due to rupture risk
C. Percuss the spleen to confirm enlargement
D. Auscultate the spleen for bruits
Correct Answer: B
Rationale: An enlarged spleen should NOT be palpated because it can easily
rupture. The nurse should percuss for splenic enlargement using Castell sign or
Traube space percussion.
Question 5
