NR414 Final Exam: Health Assessment Across the Lifespan
V4 Updated and Latest Questions and Correct Answers-
Regis University
1. When performing a physical assessment, which technique should the nurse always
perform first for every system except the abdomen?
A. Inspection
B. Percussion
C. Palpation
D. Auscultation
Correct Answer: A
Explanation: Inspection is always the first step in a physical assessment because it provides the initial
visual data. This technique involves careful observation of the patient’s appearance and behavior. By
starting with inspection, the nurse can identify obvious abnormalities before touching the patient.
Palpation is usually the second step in the sequence for most body systems. Percussion follows palpation
to determine the density of underlying tissues and organs. Auscultation is typically performed last to
listen to internal body sounds. However, in abdominal assessments, auscultation must precede palpation
and percussion to avoid altering bowel sounds. Accurate assessment depends on following this logical
and standardized sequence of techniques. It ensures that the nurse does not miss subtle physical findings
during the exam. Systematic inspection sets the stage for a comprehensive and focused physical
evaluation.
2. The nurse is collecting subjective data during a health history. Which of the following is an
example of subjective data?
A. The patient’s blood pressure is 120/80 mmHg.
B. The nurse observes a rash on the patient’s arm.
C. The patient states they feel nauseated.
D. The patient’s weight is 150 pounds.
Correct Answer: C
Explanation: Subjective data refers to information that the patient reports about their own sensations or
feelings. Nausea is a symptom that only the patient can experience and describe to the nurse. Objective
data, on the other hand, is observable and measurable by the healthcare provider. Blood pressure
readings are objective because they are measured using a medical device. Observing a rash is an objective
finding because the nurse can see it. Weight is a quantifiable measurement and is therefore considered
objective data in a clinical setting. Subjective data is often referred to as symptoms while objective data is
called signs. Collecting both types of data is essential for a complete health assessment. The nurse should
document the patient’s exact words for subjective data whenever possible. This distinction helps in
formulating accurate nursing diagnoses and treatment plans.
,3. Which assessment finding would be most indicative of dehydration in an elderly patient?
A. Skin tenting on the back of the hand
B. Dry mucous membranes
C. Decreased appetite
D. Occasional dizziness
Correct Answer: B
Explanation: Dry mucous membranes are a highly reliable indicator of dehydration across all age groups
including the elderly. In older adults, skin turgor is often a less reliable indicator due to natural loss of
elasticity. Skin tenting on the back of the hand is common in the elderly even when hydrated. Checking
skin turgor over the sternum or forehead is more accurate for this demographic. Decreased appetite can
be caused by many factors other than dehydration in older adults. Dizziness is a non-specific symptom
that could relate to cardiac or neurological issues. Dehydration is a serious concern in the elderly because
they have a decreased thirst sensation. The nurse should look for multiple signs such as dark urine and
low output. Assessing the tongue for longitudinal furrows is another way to check hydration status.
Maintaining adequate fluid intake is crucial for preventing complications like urinary tract infections.
4. When assessing the thorax and lungs, what sound is considered normal when percussing
over healthy lung tissue?
A. Dullness
B. Tympany
C. Hyperresonance
D. Resonance
Correct Answer: D
Explanation: Resonance is the low-pitched, clear, hollow sound heard over healthy adult lung tissue. It
indicates that the lungs are filled with air rather than fluid or solid mass. Dullness is heard over dense
organs like the liver or when fluid replaces air. If resonance changes to dullness in the lungs, it might
indicate pneumonia or a tumor. Hyperresonance is a lower-pitched, booming sound found when too
much air is present. Emphysema or pneumothorax can cause hyperresonance during a percussion
assessment of the chest. Tympany is a drum-like sound normally heard over air-filled structures like the
stomach. Percussion is a skill that requires practice to distinguish between these subtle sound variations.
The nurse should compare sounds from one side of the chest to the other. Consistent findings of
resonance suggest that the underlying lung parenchyma is healthy.
, 5. What is the correct location to auscultate the apical pulse in an adult patient?
A. Fifth intercostal space, left midclavicular line
B. Second intercostal space, left sternal border
C. Second intercostal space, right sternal border
D. Fourth intercostal space, left sternal border
Correct Answer: A
Explanation: The apical pulse is best heard at the fifth intercostal space at the left midclavicular line.
This location corresponds to the mitral valve area and the apex of the heart. The second intercostal space
at the right sternal border is the aortic area. The second intercostal space at the left sternal border is the
pulmonic area. The fourth intercostal space at the left sternal border is generally the tricuspid area.
Auscultating the apical pulse is the most accurate way to measure the heart rate. It is particularly
important when the peripheral pulse is irregular or hard to find. The nurse should count the apical pulse
for one full minute for complete accuracy. This site is also where the point of maximal impulse is usually
located. Knowing these landmarks is essential for a proper cardiovascular physical assessment.
6. During an eye assessment, the nurse tests the pupillary response to light. What does a
normal response include?
A. Dilation of both pupils
B. Constriction of the pupil receiving the light only
C. Constriction of both pupils simultaneously
D. No change in the size of either pupil
Correct Answer: C
Explanation: A normal pupillary light reflex involves both a direct and a consensual response. When
light is shown into one eye, that pupil should constrict, which is the direct response. Simultaneously, the
other pupil should also constrict, which is known as the consensual response. This occurs because the
optic nerve pathways are interconnected in the brainstem. Dilation of the pupils is an abnormal response
to bright light and suggests other issues. If only one pupil constricts, it may indicate damage to the cranial
nerves or brainstem. The nurse uses a penlight to assess this reflex in a darkened room. PERRLA is the
acronym used to document normal pupillary findings during a neurological exam. It stands for Pupils
Equal, Round, Reactive to Light, and Accommodation. Assessing these reflexes helps evaluate the function
of Cranial Nerve II and III. Consistent monitoring is vital for patients with potential neurological
impairment or head trauma.
V4 Updated and Latest Questions and Correct Answers-
Regis University
1. When performing a physical assessment, which technique should the nurse always
perform first for every system except the abdomen?
A. Inspection
B. Percussion
C. Palpation
D. Auscultation
Correct Answer: A
Explanation: Inspection is always the first step in a physical assessment because it provides the initial
visual data. This technique involves careful observation of the patient’s appearance and behavior. By
starting with inspection, the nurse can identify obvious abnormalities before touching the patient.
Palpation is usually the second step in the sequence for most body systems. Percussion follows palpation
to determine the density of underlying tissues and organs. Auscultation is typically performed last to
listen to internal body sounds. However, in abdominal assessments, auscultation must precede palpation
and percussion to avoid altering bowel sounds. Accurate assessment depends on following this logical
and standardized sequence of techniques. It ensures that the nurse does not miss subtle physical findings
during the exam. Systematic inspection sets the stage for a comprehensive and focused physical
evaluation.
2. The nurse is collecting subjective data during a health history. Which of the following is an
example of subjective data?
A. The patient’s blood pressure is 120/80 mmHg.
B. The nurse observes a rash on the patient’s arm.
C. The patient states they feel nauseated.
D. The patient’s weight is 150 pounds.
Correct Answer: C
Explanation: Subjective data refers to information that the patient reports about their own sensations or
feelings. Nausea is a symptom that only the patient can experience and describe to the nurse. Objective
data, on the other hand, is observable and measurable by the healthcare provider. Blood pressure
readings are objective because they are measured using a medical device. Observing a rash is an objective
finding because the nurse can see it. Weight is a quantifiable measurement and is therefore considered
objective data in a clinical setting. Subjective data is often referred to as symptoms while objective data is
called signs. Collecting both types of data is essential for a complete health assessment. The nurse should
document the patient’s exact words for subjective data whenever possible. This distinction helps in
formulating accurate nursing diagnoses and treatment plans.
,3. Which assessment finding would be most indicative of dehydration in an elderly patient?
A. Skin tenting on the back of the hand
B. Dry mucous membranes
C. Decreased appetite
D. Occasional dizziness
Correct Answer: B
Explanation: Dry mucous membranes are a highly reliable indicator of dehydration across all age groups
including the elderly. In older adults, skin turgor is often a less reliable indicator due to natural loss of
elasticity. Skin tenting on the back of the hand is common in the elderly even when hydrated. Checking
skin turgor over the sternum or forehead is more accurate for this demographic. Decreased appetite can
be caused by many factors other than dehydration in older adults. Dizziness is a non-specific symptom
that could relate to cardiac or neurological issues. Dehydration is a serious concern in the elderly because
they have a decreased thirst sensation. The nurse should look for multiple signs such as dark urine and
low output. Assessing the tongue for longitudinal furrows is another way to check hydration status.
Maintaining adequate fluid intake is crucial for preventing complications like urinary tract infections.
4. When assessing the thorax and lungs, what sound is considered normal when percussing
over healthy lung tissue?
A. Dullness
B. Tympany
C. Hyperresonance
D. Resonance
Correct Answer: D
Explanation: Resonance is the low-pitched, clear, hollow sound heard over healthy adult lung tissue. It
indicates that the lungs are filled with air rather than fluid or solid mass. Dullness is heard over dense
organs like the liver or when fluid replaces air. If resonance changes to dullness in the lungs, it might
indicate pneumonia or a tumor. Hyperresonance is a lower-pitched, booming sound found when too
much air is present. Emphysema or pneumothorax can cause hyperresonance during a percussion
assessment of the chest. Tympany is a drum-like sound normally heard over air-filled structures like the
stomach. Percussion is a skill that requires practice to distinguish between these subtle sound variations.
The nurse should compare sounds from one side of the chest to the other. Consistent findings of
resonance suggest that the underlying lung parenchyma is healthy.
, 5. What is the correct location to auscultate the apical pulse in an adult patient?
A. Fifth intercostal space, left midclavicular line
B. Second intercostal space, left sternal border
C. Second intercostal space, right sternal border
D. Fourth intercostal space, left sternal border
Correct Answer: A
Explanation: The apical pulse is best heard at the fifth intercostal space at the left midclavicular line.
This location corresponds to the mitral valve area and the apex of the heart. The second intercostal space
at the right sternal border is the aortic area. The second intercostal space at the left sternal border is the
pulmonic area. The fourth intercostal space at the left sternal border is generally the tricuspid area.
Auscultating the apical pulse is the most accurate way to measure the heart rate. It is particularly
important when the peripheral pulse is irregular or hard to find. The nurse should count the apical pulse
for one full minute for complete accuracy. This site is also where the point of maximal impulse is usually
located. Knowing these landmarks is essential for a proper cardiovascular physical assessment.
6. During an eye assessment, the nurse tests the pupillary response to light. What does a
normal response include?
A. Dilation of both pupils
B. Constriction of the pupil receiving the light only
C. Constriction of both pupils simultaneously
D. No change in the size of either pupil
Correct Answer: C
Explanation: A normal pupillary light reflex involves both a direct and a consensual response. When
light is shown into one eye, that pupil should constrict, which is the direct response. Simultaneously, the
other pupil should also constrict, which is known as the consensual response. This occurs because the
optic nerve pathways are interconnected in the brainstem. Dilation of the pupils is an abnormal response
to bright light and suggests other issues. If only one pupil constricts, it may indicate damage to the cranial
nerves or brainstem. The nurse uses a penlight to assess this reflex in a darkened room. PERRLA is the
acronym used to document normal pupillary findings during a neurological exam. It stands for Pupils
Equal, Round, Reactive to Light, and Accommodation. Assessing these reflexes helps evaluate the function
of Cranial Nerve II and III. Consistent monitoring is vital for patients with potential neurological
impairment or head trauma.
