NR 304 Exam 1 Health Assessment — Full Questions and Well-Explained Answers | 2026
Updated | 100% Correct.
1. How would you assess for rebound tenderness and what does it indicate?
To assess for rebound tenderness, press the abdominal area slowly and gently, then quickly
release your hand. Ask the client whether pain is worse when you press down or when you let
go.
A positive rebound tenderness finding is pain on release, not on pressure. This usually indicates
peritoneal irritation, which may occur with conditions such as appendicitis or peritonitis.
Because this maneuver can increase discomfort, it should be done carefully and only when
clinically necessary.
2. What do absent pulses suggest?
Absent peripheral pulses suggest severely impaired blood flow distal to the pulse site. This can
indicate arterial occlusion, severe peripheral artery disease, embolism, trauma, or shock.
This is a serious finding because tissues beyond the blocked area may not be receiving enough
oxygen. A limb with absent pulses may also be cool, pale, painful, numb, or weak.
3. How might limited personal resources negatively impact a client’s gastrointestinal
health?
Limited personal resources can affect gastrointestinal health by reducing access to healthy food,
clean water, medications, transportation, preventive care, and timely treatment.
A client may eat a poor-quality diet, skip meals, delay seeing a provider, or be unable to afford
treatment for chronic GI issues. This can increase the risk of malnutrition, constipation, ulcers,
poorly controlled chronic illness, and worsening GI symptoms.
4. How can you differentiate ascites from other causes of abdominal distension?
Ascites is a buildup of fluid in the abdomen. It can be differentiated from other causes of
abdominal distension by assessment techniques such as shifting dullness and fluid wave
testing.
The abdomen may appear protuberant with bulging flanks, especially when the client is
supine. Unlike distension from gas, ascites produces fluid-related findings on percussion. Causes
often include liver disease, portal hypertension, cancer, or heart failure.
5. What is the purpose of the whisper test and how is it performed?
The whisper test is a quick screening method used to assess hearing ability.
To perform it, the nurse stands behind the client so lip reading is prevented, occludes one ear at a
time, and whispers a simple word or sequence of numbers into the unoccluded ear. The client
repeats what was heard.
Inability to correctly repeat the whispered words may suggest hearing impairment in that ear.
6. What are the implications of absent or very quiet bowel sounds during abdominal
auscultation?
Absent or very quiet bowel sounds may indicate decreased intestinal activity. This can occur
with ileus, peritonitis, bowel obstruction in later stages, or after abdominal surgery.
Hypoactive or absent sounds are concerning when accompanied by pain, distension, vomiting, or
, inability to pass stool or gas. Since bowel sounds can vary, the nurse should listen long enough
before deciding they are absent and then report significant abnormalities promptly.
7. What signs and symptoms would increase your suspicion for appendicitis?
Appendicitis is suspected when a client has pain that begins near the umbilicus and later
localizes to the right lower quadrant, often at McBurney’s point. Other common findings
include rebound tenderness, nausea, vomiting, anorexia, fever, guarding, and elevated
white blood cell count.
Pain that worsens with movement, coughing, or release of pressure also raises concern.
8. What pupil responses require immediate intervention in a neurologic assessment?
Pupil findings requiring immediate attention include unequal pupils, fixed pupils, nonreactive
pupils, sudden dilation, or pinpoint pupils with altered mental status, especially if these
changes are new.
These findings can suggest increased intracranial pressure, brain herniation, stroke, head
trauma, drug overdose, or neurologic deterioration. Sudden changes in pupil response are
urgent and should be reported immediately.
9. What would you suspect in a client who reports leg pain during walking that resolves
with rest?
This pattern is classic for intermittent claudication, which strongly suggests peripheral artery
disease (PAD).
With PAD, narrowed arteries cannot deliver enough oxygen-rich blood to the leg muscles during
activity. When the client rests, the oxygen demand decreases and the pain improves. The nurse
should also assess pulses, skin temperature, color, and capillary refill.
10. How does expressive aphasia present in a stroke client, and how should you modify
communication?
Expressive aphasia means the client understands language but has difficulty speaking or
forming words. Speech may be slow, labored, incomplete, or absent.
Communication should be modified by using simple questions, allowing extra time to
respond, speaking calmly, using yes/no questions when appropriate, and using nonverbal
aids such as writing or picture boards. Do not assume the client is confused simply because
speech is impaired.
11. What are common assessment findings that may indicate a client is experiencing
dysphagia?
Findings suggesting dysphagia include coughing during eating, choking, drooling, pocketing
food, wet or gurgly voice after swallowing, repeated throat clearing, difficulty initiating
swallowing, and food sticking in the throat.
A client may also have unexplained weight loss, recurrent aspiration pneumonia, or
avoidance of certain textures. Dysphagia increases the risk of aspiration and requires prompt
evaluation.
12. What clinical concerns are raised when a client presents with dilated or constricted
pupils?
Updated | 100% Correct.
1. How would you assess for rebound tenderness and what does it indicate?
To assess for rebound tenderness, press the abdominal area slowly and gently, then quickly
release your hand. Ask the client whether pain is worse when you press down or when you let
go.
A positive rebound tenderness finding is pain on release, not on pressure. This usually indicates
peritoneal irritation, which may occur with conditions such as appendicitis or peritonitis.
Because this maneuver can increase discomfort, it should be done carefully and only when
clinically necessary.
2. What do absent pulses suggest?
Absent peripheral pulses suggest severely impaired blood flow distal to the pulse site. This can
indicate arterial occlusion, severe peripheral artery disease, embolism, trauma, or shock.
This is a serious finding because tissues beyond the blocked area may not be receiving enough
oxygen. A limb with absent pulses may also be cool, pale, painful, numb, or weak.
3. How might limited personal resources negatively impact a client’s gastrointestinal
health?
Limited personal resources can affect gastrointestinal health by reducing access to healthy food,
clean water, medications, transportation, preventive care, and timely treatment.
A client may eat a poor-quality diet, skip meals, delay seeing a provider, or be unable to afford
treatment for chronic GI issues. This can increase the risk of malnutrition, constipation, ulcers,
poorly controlled chronic illness, and worsening GI symptoms.
4. How can you differentiate ascites from other causes of abdominal distension?
Ascites is a buildup of fluid in the abdomen. It can be differentiated from other causes of
abdominal distension by assessment techniques such as shifting dullness and fluid wave
testing.
The abdomen may appear protuberant with bulging flanks, especially when the client is
supine. Unlike distension from gas, ascites produces fluid-related findings on percussion. Causes
often include liver disease, portal hypertension, cancer, or heart failure.
5. What is the purpose of the whisper test and how is it performed?
The whisper test is a quick screening method used to assess hearing ability.
To perform it, the nurse stands behind the client so lip reading is prevented, occludes one ear at a
time, and whispers a simple word or sequence of numbers into the unoccluded ear. The client
repeats what was heard.
Inability to correctly repeat the whispered words may suggest hearing impairment in that ear.
6. What are the implications of absent or very quiet bowel sounds during abdominal
auscultation?
Absent or very quiet bowel sounds may indicate decreased intestinal activity. This can occur
with ileus, peritonitis, bowel obstruction in later stages, or after abdominal surgery.
Hypoactive or absent sounds are concerning when accompanied by pain, distension, vomiting, or
, inability to pass stool or gas. Since bowel sounds can vary, the nurse should listen long enough
before deciding they are absent and then report significant abnormalities promptly.
7. What signs and symptoms would increase your suspicion for appendicitis?
Appendicitis is suspected when a client has pain that begins near the umbilicus and later
localizes to the right lower quadrant, often at McBurney’s point. Other common findings
include rebound tenderness, nausea, vomiting, anorexia, fever, guarding, and elevated
white blood cell count.
Pain that worsens with movement, coughing, or release of pressure also raises concern.
8. What pupil responses require immediate intervention in a neurologic assessment?
Pupil findings requiring immediate attention include unequal pupils, fixed pupils, nonreactive
pupils, sudden dilation, or pinpoint pupils with altered mental status, especially if these
changes are new.
These findings can suggest increased intracranial pressure, brain herniation, stroke, head
trauma, drug overdose, or neurologic deterioration. Sudden changes in pupil response are
urgent and should be reported immediately.
9. What would you suspect in a client who reports leg pain during walking that resolves
with rest?
This pattern is classic for intermittent claudication, which strongly suggests peripheral artery
disease (PAD).
With PAD, narrowed arteries cannot deliver enough oxygen-rich blood to the leg muscles during
activity. When the client rests, the oxygen demand decreases and the pain improves. The nurse
should also assess pulses, skin temperature, color, and capillary refill.
10. How does expressive aphasia present in a stroke client, and how should you modify
communication?
Expressive aphasia means the client understands language but has difficulty speaking or
forming words. Speech may be slow, labored, incomplete, or absent.
Communication should be modified by using simple questions, allowing extra time to
respond, speaking calmly, using yes/no questions when appropriate, and using nonverbal
aids such as writing or picture boards. Do not assume the client is confused simply because
speech is impaired.
11. What are common assessment findings that may indicate a client is experiencing
dysphagia?
Findings suggesting dysphagia include coughing during eating, choking, drooling, pocketing
food, wet or gurgly voice after swallowing, repeated throat clearing, difficulty initiating
swallowing, and food sticking in the throat.
A client may also have unexplained weight loss, recurrent aspiration pneumonia, or
avoidance of certain textures. Dysphagia increases the risk of aspiration and requires prompt
evaluation.
12. What clinical concerns are raised when a client presents with dilated or constricted
pupils?
