NUR 3270/NUR3270 Final Exam V1 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing the abdomen, which of the following is the correct order of techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Inspection, Percussion, Palpation, Auscultation
D. Auscultation, Inspection, Palpation, Percussion
Answer: B
Rationale: In abdominal assessment, auscultation is performed before percussion and
palpation to avoid stimulating bowel sounds. Manually manipulating the abdomen can
increase peristalsis and lead to inaccurate findings. This specific sequence ensures that the
nurse hears the patient’s baseline bowel activity.
2. Which cranial nerve is being tested when the nurse asks the patient to identify a common
scent like coffee?
A. Cranial Nerve I
B. Cranial Nerve II
C. Cranial Nerve III
D. Cranial Nerve V
,Answer: A
Rationale: Cranial Nerve I is the olfactory nerve responsible for the sense of smell. To test
this nerve, the nurse ensures the nasal passages are patent and asks the patient to close
their eyes while identifying a familiar odor. This assessment is particularly important for
patients reporting a loss of taste, as smell contributes significantly to flavor perception.
3. Where is the apical pulse located in a healthy adult?
A. Second intercostal space at the left sternal border
B. Second intercostal space at the right sternal border
C. Fourth intercostal space at the left sternal border
D. Fifth intercostal space at the left midclavicular line
Answer: D
Rationale: The apical pulse, or the point of maximal impulse (PMI), is normally found at
the 5th intercostal space at the midclavicular line. It represents the pulsation of the left
ventricle against the chest wall during contraction. Assessing this site provides the most
accurate measurement of the heart rate and rhythm.
4. A patient presents with a blood pressure of 140/90 mmHg while lying down and 110/70
mmHg when standing. What is this condition called?
A. Hypertension
B. Hypervolemia
, C. Postural Tachycardia
D. Orthostatic Hypotension
Answer: D
Rationale: Orthostatic hypotension is defined as a drop in systolic blood pressure of at
least 20 mmHg or diastolic pressure of at least 10 mmHg within three minutes of standing.
This condition often results from peripheral vasodilation or fluid volume deficit. It
increases the risk of falls and dizziness in elderly or medicated patients.
5. What is the best way to assess skin turgor in an elderly patient?
A. Pinch the skin over the sternum or under the clavicle
B. Pinch the skin on the back of the hand
C. Check for pitting edema on the ankles
D. Palpate the skin for moisture and temperature
Answer: A
Rationale: In older adults, the skin on the back of the hand loses elasticity due to aging,
which can provide a false positive for dehydration. Testing turgor over the sternum or
under the clavicle provides a more accurate reflection of hydration status. Good turgor is
indicated by the skin immediately returning to its original position after being released.
6. On a pulse scale of 0 to 3+, how would a nurse document a ‘normal’ pulse?
A. 1+
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing the abdomen, which of the following is the correct order of techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Inspection, Percussion, Palpation, Auscultation
D. Auscultation, Inspection, Palpation, Percussion
Answer: B
Rationale: In abdominal assessment, auscultation is performed before percussion and
palpation to avoid stimulating bowel sounds. Manually manipulating the abdomen can
increase peristalsis and lead to inaccurate findings. This specific sequence ensures that the
nurse hears the patient’s baseline bowel activity.
2. Which cranial nerve is being tested when the nurse asks the patient to identify a common
scent like coffee?
A. Cranial Nerve I
B. Cranial Nerve II
C. Cranial Nerve III
D. Cranial Nerve V
,Answer: A
Rationale: Cranial Nerve I is the olfactory nerve responsible for the sense of smell. To test
this nerve, the nurse ensures the nasal passages are patent and asks the patient to close
their eyes while identifying a familiar odor. This assessment is particularly important for
patients reporting a loss of taste, as smell contributes significantly to flavor perception.
3. Where is the apical pulse located in a healthy adult?
A. Second intercostal space at the left sternal border
B. Second intercostal space at the right sternal border
C. Fourth intercostal space at the left sternal border
D. Fifth intercostal space at the left midclavicular line
Answer: D
Rationale: The apical pulse, or the point of maximal impulse (PMI), is normally found at
the 5th intercostal space at the midclavicular line. It represents the pulsation of the left
ventricle against the chest wall during contraction. Assessing this site provides the most
accurate measurement of the heart rate and rhythm.
4. A patient presents with a blood pressure of 140/90 mmHg while lying down and 110/70
mmHg when standing. What is this condition called?
A. Hypertension
B. Hypervolemia
, C. Postural Tachycardia
D. Orthostatic Hypotension
Answer: D
Rationale: Orthostatic hypotension is defined as a drop in systolic blood pressure of at
least 20 mmHg or diastolic pressure of at least 10 mmHg within three minutes of standing.
This condition often results from peripheral vasodilation or fluid volume deficit. It
increases the risk of falls and dizziness in elderly or medicated patients.
5. What is the best way to assess skin turgor in an elderly patient?
A. Pinch the skin over the sternum or under the clavicle
B. Pinch the skin on the back of the hand
C. Check for pitting edema on the ankles
D. Palpate the skin for moisture and temperature
Answer: A
Rationale: In older adults, the skin on the back of the hand loses elasticity due to aging,
which can provide a false positive for dehydration. Testing turgor over the sternum or
under the clavicle provides a more accurate reflection of hydration status. Good turgor is
indicated by the skin immediately returning to its original position after being released.
6. On a pulse scale of 0 to 3+, how would a nurse document a ‘normal’ pulse?
A. 1+
