NUR 216 Exam 3 | Health Assessment | Practice Questions & Verified Answers
A nurse is assessing a client's cranial nerves. Which of the D. The client can identify a minty scent
following client actions is an indication that cranial nerve 1
is intact? Rationale- Cranial nerve 1, the olfactory nerve, controls the sense of smell. To test
A. The client can stick their tongue out this nerve's function, the nurse should ask the client to identify a nonirritating aroma,
B. The client can smile symmetrically such as mint or coffee
C. The client can hear whispered words
D. The client can identify a minty scent
A nurse is performing a respiratory assessment on a client. A. Crackles
The nurse auscultates a wet, popping sound upon Rationale- crackles, sometimes called rales, are wet, popping sounds created by air
inspiration of the clients breathing. The nurse should moving through liquid or by collapsed alveoli snapping open on inspiration. They are
identify this observation as which of the following findings? most common at the end of inspiration of breathing.
A. Crackles
B. Stridor
C. Wheezes
D. Friction Rub
A nurse is performing a cardiovascular assessment on a C. A brief thump felt near the fourth or fifth intercostal space near the left mid
client which of the following findings should the nurse clavicular line
expect? Rationale- This is where you would inspect and palpate for the point of maximal
A. A continuous sensation of vibration felt over the second impulse. Also called an apical pulse station, it occurs as the Apex of the heart
and third left intercostal spaces bumps against the chest wall with each heartbeat. The apical impulse is not always
B. A high-pitched, scraping sound heard in the third visible but can be felt as a brief thump. This is an expected finding and should be
intercostal space to the left of the sternum performed when you are preparing to auscultate the apical pulse.
C. A brief thump felt near the fourth or fifth intercostal
space near the left mid clavicular line
D. A whooshing or swishing sound over the second
intercostal space along the left arsenal border
The nurse is preparing to perform a comprehensive B. Develop a plan of care
physical assessment on a client. Which of the following Rationale- The first action the nurse should take using the nursing process is to
actions should the nurse plan to take first? assess the client and develop a plan of care. The nursing process follow the steps
A. Document accurate data of assessment, analysis, planning, implementation, and evaluation.
B. Develop a plan of care
C. Validate previous data
D. Evaluate outcomes of care
A nurse is palpating a tender area of a clients abdomen. B. Rebound Tenderness
The nurse slowly applies pressure over the area with their Rationale- The nurse should document that the client is experiencing rebound
fingertips, then quickly releases it. The client reports tenderness, which is an increase in pain when deep palpation over a tender area is
increased pain on the release of pressure. Which of the released. Rebound tenderness is in the right lower quadrant at McBurney's point
findings should the nurse document? (one-third the distance from the anterior iliac crest to the umbilicus) is an indication
A. Borborygmi of acute appendicitis.
B. Rebound Tenderness
C. Tympany
D. Abdominal Guarding
A nurse is performing a physical examination of the spine B. Kyphosis
for an older adult client. The nurse should identify that Rationale- kyphosis, a pronounced "hunchback" curvature of the spine, is an
which of the following findings is common with aging? abnormal angulation of the posterior curve of the thoracic spine, usually a result of
A. Lordosis osteoporosis. It is most common in older adults and tends to increase with aging.
B. Kyphosis This pronounced convexity of the thoracic spine is also common in older clients who
C. Ankylosis have had vertebral fractures.
D. Scoliosis
Disorders in which parts of the ear usually result in B. Inner and external ear
earaches?
A. Inner and middle ear
B. Inner and external ear
C. Middle and external ear
D. Travis and eardrum
Eye discharge is usually associated with: B. Conjunctivitis
A. Hypertension (HTN)
B. Conjunctivitis
C. Otitis externa
D. Meibomianitis
, NUR 216 Exam 3 | Health Assessment | Practice Questions & Verified Answers
Which type of hearing loss results from disorders of the B. Sensorineural hearing loss
inner ear or of the eighth cranial nerve?
A. Conductive hearing loss
B. Sensorineural hearing loss
C. Mixed hearing loss
D. Functional hearing loss
Which term is used to test for corneal sensitivity? D. Wisp of cotton
A. Cotton-tipped applicator
B. Gauze pad
C. Tissue
D. Wisp of cotton
What should you palpate before inserting the otoscope into A. Tragus
the patient's ear?
A. Tragus
B. Lymph nodes
C. Helix
D. Earlobe
Which symptom commonly accompanies throat pain? B. Ear pain
A. Eye pain
B. Ear pain
C. Headache
D. Nasal congestion
If your patient presents with severe epistaxis, what is D. Their vital signs
important for you to check quickly?
A. Their history
B. Their height
C. Their weight
D. Their vital signs
What is scoliosis? A deformity caused by a lateral curvature of the thoracic spine. It is typically
detected in adolescence. Mild scoliosis usually has little consequence, but more
severe curvature can restrict lung function.
What is ankylosis? Immobility and consolidation of a joint due to disease, injury, or surgical procedures.
The stiff joint is often a result of a congenital condition or scarring.
What is kyphosis? a pronounced "hunchback" curvature of the spine, is an abnormal angulation of the
posterior curve of the thoracic spine, usually a result of osteoporosis. It is most
common in older adults and tends to increase with aging. This pronounced
convexity of the thoracic spine is also common in older clients who have had
vertebral fractures.
A nurse is performing an abdominal assessment on a C. Right lower quadrant
client. Over which of the following areas of the client's Rationale-Evidence-based practice indicates that the first area the nurse should
abdomen should the nurse attempt to auscultate active auscultate for active bowel sounds is over the right lower quadrant of the client's
bowel sounds first? abdomen. The right lower quadrant is located to the right of the umbilicus and
A. Right upper quadrant contains the ileocecal valve. This is where the small intestine connects to the large
B. Left upper quadrant intestine, and it is normally very active with bowel sounds. For an average adult, the
C. Right lower quadrant nurse should expect to hear 5 to 30 bowel sounds per minute.
D. Left lower quadrant
What is lordosis? Lordosis, or swayback, is an abnormal exaggerated lumbar curve (anterior
convexity) of the lumbar spine. It is common in clients who are obese or pregnant.
A nurse is assessing a client's cranial nerves. Which of the D. The client can identify a minty scent
following client actions is an indication that cranial nerve 1
is intact? Rationale- Cranial nerve 1, the olfactory nerve, controls the sense of smell. To test
A. The client can stick their tongue out this nerve's function, the nurse should ask the client to identify a nonirritating aroma,
B. The client can smile symmetrically such as mint or coffee
C. The client can hear whispered words
D. The client can identify a minty scent
A nurse is performing a respiratory assessment on a client. A. Crackles
The nurse auscultates a wet, popping sound upon Rationale- crackles, sometimes called rales, are wet, popping sounds created by air
inspiration of the clients breathing. The nurse should moving through liquid or by collapsed alveoli snapping open on inspiration. They are
identify this observation as which of the following findings? most common at the end of inspiration of breathing.
A. Crackles
B. Stridor
C. Wheezes
D. Friction Rub
A nurse is performing a cardiovascular assessment on a C. A brief thump felt near the fourth or fifth intercostal space near the left mid
client which of the following findings should the nurse clavicular line
expect? Rationale- This is where you would inspect and palpate for the point of maximal
A. A continuous sensation of vibration felt over the second impulse. Also called an apical pulse station, it occurs as the Apex of the heart
and third left intercostal spaces bumps against the chest wall with each heartbeat. The apical impulse is not always
B. A high-pitched, scraping sound heard in the third visible but can be felt as a brief thump. This is an expected finding and should be
intercostal space to the left of the sternum performed when you are preparing to auscultate the apical pulse.
C. A brief thump felt near the fourth or fifth intercostal
space near the left mid clavicular line
D. A whooshing or swishing sound over the second
intercostal space along the left arsenal border
The nurse is preparing to perform a comprehensive B. Develop a plan of care
physical assessment on a client. Which of the following Rationale- The first action the nurse should take using the nursing process is to
actions should the nurse plan to take first? assess the client and develop a plan of care. The nursing process follow the steps
A. Document accurate data of assessment, analysis, planning, implementation, and evaluation.
B. Develop a plan of care
C. Validate previous data
D. Evaluate outcomes of care
A nurse is palpating a tender area of a clients abdomen. B. Rebound Tenderness
The nurse slowly applies pressure over the area with their Rationale- The nurse should document that the client is experiencing rebound
fingertips, then quickly releases it. The client reports tenderness, which is an increase in pain when deep palpation over a tender area is
increased pain on the release of pressure. Which of the released. Rebound tenderness is in the right lower quadrant at McBurney's point
findings should the nurse document? (one-third the distance from the anterior iliac crest to the umbilicus) is an indication
A. Borborygmi of acute appendicitis.
B. Rebound Tenderness
C. Tympany
D. Abdominal Guarding
A nurse is performing a physical examination of the spine B. Kyphosis
for an older adult client. The nurse should identify that Rationale- kyphosis, a pronounced "hunchback" curvature of the spine, is an
which of the following findings is common with aging? abnormal angulation of the posterior curve of the thoracic spine, usually a result of
A. Lordosis osteoporosis. It is most common in older adults and tends to increase with aging.
B. Kyphosis This pronounced convexity of the thoracic spine is also common in older clients who
C. Ankylosis have had vertebral fractures.
D. Scoliosis
Disorders in which parts of the ear usually result in B. Inner and external ear
earaches?
A. Inner and middle ear
B. Inner and external ear
C. Middle and external ear
D. Travis and eardrum
Eye discharge is usually associated with: B. Conjunctivitis
A. Hypertension (HTN)
B. Conjunctivitis
C. Otitis externa
D. Meibomianitis
, NUR 216 Exam 3 | Health Assessment | Practice Questions & Verified Answers
Which type of hearing loss results from disorders of the B. Sensorineural hearing loss
inner ear or of the eighth cranial nerve?
A. Conductive hearing loss
B. Sensorineural hearing loss
C. Mixed hearing loss
D. Functional hearing loss
Which term is used to test for corneal sensitivity? D. Wisp of cotton
A. Cotton-tipped applicator
B. Gauze pad
C. Tissue
D. Wisp of cotton
What should you palpate before inserting the otoscope into A. Tragus
the patient's ear?
A. Tragus
B. Lymph nodes
C. Helix
D. Earlobe
Which symptom commonly accompanies throat pain? B. Ear pain
A. Eye pain
B. Ear pain
C. Headache
D. Nasal congestion
If your patient presents with severe epistaxis, what is D. Their vital signs
important for you to check quickly?
A. Their history
B. Their height
C. Their weight
D. Their vital signs
What is scoliosis? A deformity caused by a lateral curvature of the thoracic spine. It is typically
detected in adolescence. Mild scoliosis usually has little consequence, but more
severe curvature can restrict lung function.
What is ankylosis? Immobility and consolidation of a joint due to disease, injury, or surgical procedures.
The stiff joint is often a result of a congenital condition or scarring.
What is kyphosis? a pronounced "hunchback" curvature of the spine, is an abnormal angulation of the
posterior curve of the thoracic spine, usually a result of osteoporosis. It is most
common in older adults and tends to increase with aging. This pronounced
convexity of the thoracic spine is also common in older clients who have had
vertebral fractures.
A nurse is performing an abdominal assessment on a C. Right lower quadrant
client. Over which of the following areas of the client's Rationale-Evidence-based practice indicates that the first area the nurse should
abdomen should the nurse attempt to auscultate active auscultate for active bowel sounds is over the right lower quadrant of the client's
bowel sounds first? abdomen. The right lower quadrant is located to the right of the umbilicus and
A. Right upper quadrant contains the ileocecal valve. This is where the small intestine connects to the large
B. Left upper quadrant intestine, and it is normally very active with bowel sounds. For an average adult, the
C. Right lower quadrant nurse should expect to hear 5 to 30 bowel sounds per minute.
D. Left lower quadrant
What is lordosis? Lordosis, or swayback, is an abnormal exaggerated lumbar curve (anterior
convexity) of the lumbar spine. It is common in clients who are obese or pregnant.
