NUR 3270/NUR3270 Exam 4 V1 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing a patient’s abdomen, what is the correct sequence of examination
techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Palpation, Auscultation, Inspection
Answer: A
Rationale: The correct sequence for abdominal assessment is inspection, auscultation,
percussion, and then palpation. Auscultation is performed before percussion and palpation
because these maneuvers can stimulate peristalsis and alter bowel sounds. This specific
order ensures that the most accurate assessment of the patient’s natural bowel activity is
recorded.
2. Which cranial nerve is being tested when the nurse asks the patient to shrug their
shoulders against resistance?
A. Cranial Nerve XI (Spinal Accessory)
B. Cranial Nerve X (Vagus)
,C. Cranial Nerve VII (Facial)
D. Cranial Nerve XII (Hypoglossal)
Answer: A
Rationale: Cranial Nerve XI, the Spinal Accessory nerve, controls the trapezius and
sternocleidomastoid muscles. Asking the patient to shrug their shoulders or turn their head
against resistance evaluates the strength and integrity of this nerve. A lack of symmetry or
weakness during this task could indicate neurological damage or muscle pathology.
3. What does a score of 7 on the Glasgow Coma Scale (GCS) indicate?
A. The patient is in a coma.
B. The patient is fully alert and oriented.
C. The patient has mild cognitive impairment.
D. The patient is awake but confused.
Answer: A
Rationale: The Glasgow Coma Scale measures eye-opening, verbal response, and motor
response with scores ranging from 3 to 15. A score of 8 or less is generally accepted as the
clinical definition of a coma. A score of 7 specifically indicates a severe neurological
impairment requiring immediate intervention and monitoring.
, 4. Which heart sound is caused by the closure of the atrioventricular valves (mitral and
tricuspid)?
A. S4
B. S2
C. S3
D. S1
Answer: D
Rationale: The S1 sound, often described as ‘lub’, marks the beginning of systole and is
caused by the closure of the mitral and tricuspid valves. This sound is usually loudest at the
apex of the heart. It signifies that the ventricles are contracting and pushing blood toward
the lungs and body.
5. When assessing for clubbing of the fingernails, what angle would the nurse expect to see at
the nail base in a patient with chronic hypoxia?
A. 180 degrees or greater
B. 160 degrees
C. 45 degrees
D. 90 degrees
Answer: A
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing a patient’s abdomen, what is the correct sequence of examination
techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Palpation, Auscultation, Inspection
Answer: A
Rationale: The correct sequence for abdominal assessment is inspection, auscultation,
percussion, and then palpation. Auscultation is performed before percussion and palpation
because these maneuvers can stimulate peristalsis and alter bowel sounds. This specific
order ensures that the most accurate assessment of the patient’s natural bowel activity is
recorded.
2. Which cranial nerve is being tested when the nurse asks the patient to shrug their
shoulders against resistance?
A. Cranial Nerve XI (Spinal Accessory)
B. Cranial Nerve X (Vagus)
,C. Cranial Nerve VII (Facial)
D. Cranial Nerve XII (Hypoglossal)
Answer: A
Rationale: Cranial Nerve XI, the Spinal Accessory nerve, controls the trapezius and
sternocleidomastoid muscles. Asking the patient to shrug their shoulders or turn their head
against resistance evaluates the strength and integrity of this nerve. A lack of symmetry or
weakness during this task could indicate neurological damage or muscle pathology.
3. What does a score of 7 on the Glasgow Coma Scale (GCS) indicate?
A. The patient is in a coma.
B. The patient is fully alert and oriented.
C. The patient has mild cognitive impairment.
D. The patient is awake but confused.
Answer: A
Rationale: The Glasgow Coma Scale measures eye-opening, verbal response, and motor
response with scores ranging from 3 to 15. A score of 8 or less is generally accepted as the
clinical definition of a coma. A score of 7 specifically indicates a severe neurological
impairment requiring immediate intervention and monitoring.
, 4. Which heart sound is caused by the closure of the atrioventricular valves (mitral and
tricuspid)?
A. S4
B. S2
C. S3
D. S1
Answer: D
Rationale: The S1 sound, often described as ‘lub’, marks the beginning of systole and is
caused by the closure of the mitral and tricuspid valves. This sound is usually loudest at the
apex of the heart. It signifies that the ventricles are contracting and pushing blood toward
the lungs and body.
5. When assessing for clubbing of the fingernails, what angle would the nurse expect to see at
the nail base in a patient with chronic hypoxia?
A. 180 degrees or greater
B. 160 degrees
C. 45 degrees
D. 90 degrees
Answer: A
