NR414 Exam 2: Health Assessment Across the Lifespan V4
Updated and Latest Questions and Correct Answers- Regis
University
1. When assessing a patient’s skin turgor, which finding is considered normal for a well-
hydrated healthy adult?
A. Skin returns to original position within 3 seconds
B. Skin remains tented for 1 to 2 seconds
C. Skin returns to original position immediately
D. Skin exhibits pitting after being pinched
Correct Answer: C
Explanation: The correct answer is C because immediate return indicates elastic skin and adequate
hydration. Skin turgor is a vital indicator of a patient’s fluid status. To perform this, the nurse gently
pinches the skin on the chest or forearm. Tenting is an abnormal finding where the skin stays pinched up.
A delay of 3 seconds would suggest mild dehydration. Pitting is a sign of edema, not turgor issues. In
older adults, elasticity decreases, making this test less reliable on the hand. Therefore, the clavicle area is
often the preferred site for geriatric patients. Consistent assessment techniques ensure comparable
results over time. Prompt documentation of skin findings is necessary for tracking patient progress.
2. Which cranial nerve is being tested when a nurse asks a patient to follow a finger in the
six cardinal positions of gaze?
A. Cranial Nerve II
B. Cranial Nerve VII
C. Cranial Nerve V
D. Cranial Nerves III, IV, and VI
Correct Answer: D
Explanation: The correct answer is B because these three nerves control the extraocular muscles of the
eye. Cranial Nerve III is the oculomotor nerve. Cranial Nerve IV is the trochlear nerve. Cranial Nerve VI is
the abducens nerve. Cranial Nerve II is responsible for vision acuity, not movement. Cranial Nerve V
handles facial sensation and mastication. Cranial Nerve VII manages facial expressions. Testing the six
cardinal positions helps identify muscle weakness or nerve palsy. The nurse should observe for smooth
pursuit and any signs of nystagmus. Coordination of these nerves is essential for binocular vision. This
assessment is a standard part of a neurological and ophthalmic exam.
,3. A nurse is performing a respiratory assessment and notes a low-pitched, snoring sound
over the large airways. This is documented as:
A. Rhonchi
B. Wheezes
C. Fine crackles
D. Pleural friction rub
Correct Answer: A
Explanation: The correct answer is C as rhonchi are low-pitched, sonorous sounds often caused by
secretions. Fine crackles are high-pitched, popping sounds heard during inspiration. Wheezes are high-
pitched, musical sounds suggesting narrowed airways. A pleural friction rub sounds like leather rubbing
together. Rhonchi often clear or change after the patient coughs. These sounds are typically heard in the
larger bronchi and trachea. Auscultation should be performed on a bare chest for accuracy. The nurse
must compare findings bilaterally across all lung lobes. Accurate identification of lung sounds informs the
choice of respiratory interventions. Documenting the timing and location of these sounds is essential for
the medical record.
4. The first heart sound (S1) is produced by the closure of which valves?
A. Mitral and Tricuspid
B. Aortic and Pulmonic
C. Aortic and Mitral
D. Tricuspid and Pulmonic
Correct Answer: A
Explanation: The correct answer is B because S1 signifies the beginning of systole. S1 is the ‘lub’ sound
in the ‘lub-dub’ heart cycle. The mitral and tricuspid valves are known as the atrioventricular valves.
Closure of the semilunar valves creates the S2 sound. S1 is usually heard loudest at the apex of the heart.
The nurse should use the diaphragm of the stethoscope to hear S1. Palpating the carotid pulse can help
identify S1 as they occur simultaneously. Abnormalities in S1 can indicate various valvular or conduction
issues. Assessment across the lifespan involves noting changes in heart rate and rhythm. Understanding
cardiac anatomy is fundamental to performing a correct physical assessment.
, 5. During an abdominal assessment, in what order should the nurse perform the physical
examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Inspection, Percussion, Palpation, Auscultation
D. Auscultation, Inspection, Palpation, Percussion
Correct Answer: B
Explanation: The correct answer is C because palpation and percussion can alter bowel sounds.
Auscultation must come second to ensure bowel motility is accurately recorded. Inspection is always the
first step in any physical assessment. The nurse looks for symmetry, contour, and any visible pulsations.
Percussion helps determine the size of organs and presence of fluid. Palpation identifies tenderness,
masses, or organomegaly. This specific order is unique to the abdominal examination protocol. Always
ask the patient if they have any painful areas before beginning. The patient should be in a supine position
with knees slightly flexed. Effective assessment prevents false findings of bowel activity or pain.
6. A 5/5 muscle strength rating indicates:
A. Slight contraction, no movement
B. Normal strength against full resistance
C. Full range of motion against gravity only
D. Full range of motion against some resistance
Correct Answer: B
Explanation: The correct answer is A, representing normal muscle power. Strength is graded on a scale
from 0 to 5. A grade of 0 means no muscle contraction is detected. A grade of 1 indicates a flicker of
movement or contraction. Grade 2 means movement is possible only if gravity is eliminated. Grade 3
allows for movement against gravity but not resistance. Grade 4 indicates movement against moderate
resistance. The nurse must test muscle groups bilaterally to compare strength. Consistency in grading is
vital for monitoring neurological or musculoskeletal recovery. Documenting specific findings helps track
patient improvement or decline over time. This objective measurement is a staple of the physical therapy
and nursing evaluation.
Updated and Latest Questions and Correct Answers- Regis
University
1. When assessing a patient’s skin turgor, which finding is considered normal for a well-
hydrated healthy adult?
A. Skin returns to original position within 3 seconds
B. Skin remains tented for 1 to 2 seconds
C. Skin returns to original position immediately
D. Skin exhibits pitting after being pinched
Correct Answer: C
Explanation: The correct answer is C because immediate return indicates elastic skin and adequate
hydration. Skin turgor is a vital indicator of a patient’s fluid status. To perform this, the nurse gently
pinches the skin on the chest or forearm. Tenting is an abnormal finding where the skin stays pinched up.
A delay of 3 seconds would suggest mild dehydration. Pitting is a sign of edema, not turgor issues. In
older adults, elasticity decreases, making this test less reliable on the hand. Therefore, the clavicle area is
often the preferred site for geriatric patients. Consistent assessment techniques ensure comparable
results over time. Prompt documentation of skin findings is necessary for tracking patient progress.
2. Which cranial nerve is being tested when a nurse asks a patient to follow a finger in the
six cardinal positions of gaze?
A. Cranial Nerve II
B. Cranial Nerve VII
C. Cranial Nerve V
D. Cranial Nerves III, IV, and VI
Correct Answer: D
Explanation: The correct answer is B because these three nerves control the extraocular muscles of the
eye. Cranial Nerve III is the oculomotor nerve. Cranial Nerve IV is the trochlear nerve. Cranial Nerve VI is
the abducens nerve. Cranial Nerve II is responsible for vision acuity, not movement. Cranial Nerve V
handles facial sensation and mastication. Cranial Nerve VII manages facial expressions. Testing the six
cardinal positions helps identify muscle weakness or nerve palsy. The nurse should observe for smooth
pursuit and any signs of nystagmus. Coordination of these nerves is essential for binocular vision. This
assessment is a standard part of a neurological and ophthalmic exam.
,3. A nurse is performing a respiratory assessment and notes a low-pitched, snoring sound
over the large airways. This is documented as:
A. Rhonchi
B. Wheezes
C. Fine crackles
D. Pleural friction rub
Correct Answer: A
Explanation: The correct answer is C as rhonchi are low-pitched, sonorous sounds often caused by
secretions. Fine crackles are high-pitched, popping sounds heard during inspiration. Wheezes are high-
pitched, musical sounds suggesting narrowed airways. A pleural friction rub sounds like leather rubbing
together. Rhonchi often clear or change after the patient coughs. These sounds are typically heard in the
larger bronchi and trachea. Auscultation should be performed on a bare chest for accuracy. The nurse
must compare findings bilaterally across all lung lobes. Accurate identification of lung sounds informs the
choice of respiratory interventions. Documenting the timing and location of these sounds is essential for
the medical record.
4. The first heart sound (S1) is produced by the closure of which valves?
A. Mitral and Tricuspid
B. Aortic and Pulmonic
C. Aortic and Mitral
D. Tricuspid and Pulmonic
Correct Answer: A
Explanation: The correct answer is B because S1 signifies the beginning of systole. S1 is the ‘lub’ sound
in the ‘lub-dub’ heart cycle. The mitral and tricuspid valves are known as the atrioventricular valves.
Closure of the semilunar valves creates the S2 sound. S1 is usually heard loudest at the apex of the heart.
The nurse should use the diaphragm of the stethoscope to hear S1. Palpating the carotid pulse can help
identify S1 as they occur simultaneously. Abnormalities in S1 can indicate various valvular or conduction
issues. Assessment across the lifespan involves noting changes in heart rate and rhythm. Understanding
cardiac anatomy is fundamental to performing a correct physical assessment.
, 5. During an abdominal assessment, in what order should the nurse perform the physical
examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Inspection, Percussion, Palpation, Auscultation
D. Auscultation, Inspection, Palpation, Percussion
Correct Answer: B
Explanation: The correct answer is C because palpation and percussion can alter bowel sounds.
Auscultation must come second to ensure bowel motility is accurately recorded. Inspection is always the
first step in any physical assessment. The nurse looks for symmetry, contour, and any visible pulsations.
Percussion helps determine the size of organs and presence of fluid. Palpation identifies tenderness,
masses, or organomegaly. This specific order is unique to the abdominal examination protocol. Always
ask the patient if they have any painful areas before beginning. The patient should be in a supine position
with knees slightly flexed. Effective assessment prevents false findings of bowel activity or pain.
6. A 5/5 muscle strength rating indicates:
A. Slight contraction, no movement
B. Normal strength against full resistance
C. Full range of motion against gravity only
D. Full range of motion against some resistance
Correct Answer: B
Explanation: The correct answer is A, representing normal muscle power. Strength is graded on a scale
from 0 to 5. A grade of 0 means no muscle contraction is detected. A grade of 1 indicates a flicker of
movement or contraction. Grade 2 means movement is possible only if gravity is eliminated. Grade 3
allows for movement against gravity but not resistance. Grade 4 indicates movement against moderate
resistance. The nurse must test muscle groups bilaterally to compare strength. Consistency in grading is
vital for monitoring neurological or musculoskeletal recovery. Documenting specific findings helps track
patient improvement or decline over time. This objective measurement is a staple of the physical therapy
and nursing evaluation.
