NUR 3270/NUR3270 Exam 3 V3 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing the abdomen, which sequence of techniques should the nurse use?
A. Inspection, Palpation, Percussion, Auscultation
B. Palpation, Percussion, Auscultation, Inspection
C. Auscultation, Inspection, Percussion, Palpation
D. Inspection, Auscultation, Percussion, Palpation
Answer: D
Rationale: Auscultation is performed before percussion and palpation because manual
manipulation of the abdomen can stimulate peristalsis. This stimulation might result in
false bowel sounds that do not represent the patient’s baseline. Following this specific
order ensures the most accurate clinical assessment of the gastrointestinal system.
2. A nurse is testing a patient’s deep tendon reflexes and notes they are very brisk with
clonus. How should the nurse document this finding?
A. 1+
B. 4+
C. 3+
D. 2+
,Answer: B
Rationale: A 4+ reflex grade indicates a very brisk, hyperactive response often associated
with disease processes. Clonus, which is a set of rapid, rhythmic contractions of the muscle,
is a hallmark of a 4+ rating. Normal reflexes are typically documented as 2+, while 3+ is
considered brisker than average but not necessarily pathological.
3. During a musculoskeletal exam, the nurse asks the patient to move their arm away from
the midline of the body. This movement is called:
A. Abduction
B. Adduction
C. Flexion
D. Extension
Answer: A
Rationale: Abduction is the movement of a limb or other part away from the midline of the
body or from another part. In contrast, adduction refers to moving the limb toward the
midline of the body. Understanding these directional terms is essential for accurately
documenting range of motion during physical assessments.
4. A 50-year-old male patient reports difficulty starting his urine stream and feeling that his
bladder is not empty. The nurse suspects:
A. Urethritis
B. Testicular Torsion
, C. Benign Prostatic Hyperplasia (BPH)
D. Hypospadias
Answer: C
Rationale: Benign Prostatic Hyperplasia (BPH) is a common condition in aging men where
the prostate gland enlarges and compresses the urethra. Symptoms typically include
hesitancy, weak stream, and a sensation of incomplete voiding. This condition is non-
cancerous but requires clinical management to alleviate urinary obstruction symptoms.
5. While percussing the abdomen, the nurse expects to hear which sound over most of the
area?
A. Resonance
B. Dullness
C. Hyperresonance
D. Tympany
Answer: D
Rationale: Tympany is the predominant sound heard during percussion of the abdomen
because of the presence of air in the stomach and intestines. Dullness is usually heard over
solid organs like the liver or spleen, or over a full bladder. Identifying the correct
percussion notes helps the nurse detect abnormalities like organomegaly or masses.
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing the abdomen, which sequence of techniques should the nurse use?
A. Inspection, Palpation, Percussion, Auscultation
B. Palpation, Percussion, Auscultation, Inspection
C. Auscultation, Inspection, Percussion, Palpation
D. Inspection, Auscultation, Percussion, Palpation
Answer: D
Rationale: Auscultation is performed before percussion and palpation because manual
manipulation of the abdomen can stimulate peristalsis. This stimulation might result in
false bowel sounds that do not represent the patient’s baseline. Following this specific
order ensures the most accurate clinical assessment of the gastrointestinal system.
2. A nurse is testing a patient’s deep tendon reflexes and notes they are very brisk with
clonus. How should the nurse document this finding?
A. 1+
B. 4+
C. 3+
D. 2+
,Answer: B
Rationale: A 4+ reflex grade indicates a very brisk, hyperactive response often associated
with disease processes. Clonus, which is a set of rapid, rhythmic contractions of the muscle,
is a hallmark of a 4+ rating. Normal reflexes are typically documented as 2+, while 3+ is
considered brisker than average but not necessarily pathological.
3. During a musculoskeletal exam, the nurse asks the patient to move their arm away from
the midline of the body. This movement is called:
A. Abduction
B. Adduction
C. Flexion
D. Extension
Answer: A
Rationale: Abduction is the movement of a limb or other part away from the midline of the
body or from another part. In contrast, adduction refers to moving the limb toward the
midline of the body. Understanding these directional terms is essential for accurately
documenting range of motion during physical assessments.
4. A 50-year-old male patient reports difficulty starting his urine stream and feeling that his
bladder is not empty. The nurse suspects:
A. Urethritis
B. Testicular Torsion
, C. Benign Prostatic Hyperplasia (BPH)
D. Hypospadias
Answer: C
Rationale: Benign Prostatic Hyperplasia (BPH) is a common condition in aging men where
the prostate gland enlarges and compresses the urethra. Symptoms typically include
hesitancy, weak stream, and a sensation of incomplete voiding. This condition is non-
cancerous but requires clinical management to alleviate urinary obstruction symptoms.
5. While percussing the abdomen, the nurse expects to hear which sound over most of the
area?
A. Resonance
B. Dullness
C. Hyperresonance
D. Tympany
Answer: D
Rationale: Tympany is the predominant sound heard during percussion of the abdomen
because of the presence of air in the stomach and intestines. Dullness is usually heard over
solid organs like the liver or spleen, or over a full bladder. Identifying the correct
percussion notes helps the nurse detect abnormalities like organomegaly or masses.
