NSG3160 Exam 3 Health Assessment Latest
Update Graded A+
Question 1
During a respiratory assessment, the nurse notes crackles in the lower lobes. What is
the most likely cause?
• A. Bronchospasm
• B. Fluid in the alveoli
• C. Upper airway obstruction
• D. Pleural friction rub
Rationale: Crackles (rales) are caused by air moving through fluid in the alveoli, often
seen in conditions like pneumonia or heart failure. Bronchospasm produces wheezes,
not crackles.
Question 2
A patient presents with jugular vein distention (JVD) while sitting upright. This finding
is most consistent with:
• A. Dehydration
• B. Right-sided heart failure
• C. Pulmonary embolism
• D. Hypovolemia
Rationale: JVD indicates increased venous pressure, most commonly due to right-
sided heart failure. Dehydration and hypovolemia would reduce venous filling, not
increase it.
Question 3
When assessing the abdomen, the nurse should perform the exam in which order?
• A. Palpation → Percussion → Auscultation → Inspection
• B. Inspection → Palpation → Percussion → Auscultation
• C. Inspection → Auscultation → Percussion → Palpation
• D. Auscultation → Inspection → Percussion → Palpation
Rationale: Auscultation must occur before percussion and palpation to avoid altering
bowel sounds. The correct sequence is inspection, auscultation, percussion, palpation.
Question 4
,A patient reports sudden unilateral weakness and slurred speech. What is the
nurse’s priority action?
• A. Perform a full neurological exam
• B. Activate emergency stroke protocol
• C. Check blood glucose
• D. Document findings
Rationale: Sudden neurological deficits suggest stroke. Immediate activation of stroke
protocol ensures rapid intervention (e.g., CT scan, thrombolytics). Assessment and
documentation follow after stabilization.
Question 5
During a skin assessment, the nurse notes a lesion with irregular borders, variegated
color, and diameter >6mm. What is the most concerning diagnosis?
• A. Basal cell carcinoma
• B. Actinic keratosis
• C. Malignant melanoma
• D. Squamous cell carcinoma
Rationale: The ABCDE rule (Asymmetry, Border irregularity, Color variation, Diameter
>6mm, Evolving) points to malignant melanoma. Other skin cancers usually present
with more uniform lesions.
Question 6
When performing a neurological assessment, the nurse asks the patient to smile. The
nurse notes that one side of the mouth does not move. This finding suggests:
• A. Hypoglossal nerve impairment
• B. Facial nerve (CN VII) impairment
• C. Trigeminal nerve (CN V) impairment
• D. Glossopharyngeal nerve (CN IX) impairment
Rationale: The facial nerve controls facial expressions. Asymmetry when smiling
indicates CN VII dysfunction. CN XII affects tongue movement, CN V affects chewing,
and CN IX affects swallowing.
Question 7
A patient reports shortness of breath when lying flat. The nurse documents this as:
• A. Dyspnea
• B. Tachypnea
, • C. Orthopnea
• D. Apnea
Rationale: Orthopnea is difficulty breathing when lying flat, often associated with heart
failure. Dyspnea is general difficulty breathing, tachypnea is rapid breathing, and apnea
is absence of breathing.
Question 8
During cardiac auscultation, the nurse hears an extra heart sound immediately after
S2. This is most likely:
• A. Systolic murmur
• B. S3 gallop
• C. S4 gallop
• D. Pericardial rub
Rationale: An S3 occurs right after S2 and is associated with heart failure or fluid
overload. S4 occurs before S1. Murmurs are prolonged sounds, and pericardial rubs are
scratchy, high-pitched sounds.
Question 9
The nurse palpates the dorsalis pedis pulse and finds it weak and thready. This is
documented as:
• A. 0 (absent)
• B. 1+ (bounding)
• C. 1+ (weak)
• D. 3+ (normal)
Rationale: Pulse grading: 0 = absent, 1+ = weak/thready, 2+ = normal, 3+ = bounding.
A weak dorsalis pedis pulse may indicate peripheral arterial disease.
Question 10
A patient presents with clubbing of the fingers. This finding is most often associated
with:
• A. Acute asthma attack
• B. Hypertension
• C. Chronic hypoxia (e.g., COPD)
• D. Dehydration
Update Graded A+
Question 1
During a respiratory assessment, the nurse notes crackles in the lower lobes. What is
the most likely cause?
• A. Bronchospasm
• B. Fluid in the alveoli
• C. Upper airway obstruction
• D. Pleural friction rub
Rationale: Crackles (rales) are caused by air moving through fluid in the alveoli, often
seen in conditions like pneumonia or heart failure. Bronchospasm produces wheezes,
not crackles.
Question 2
A patient presents with jugular vein distention (JVD) while sitting upright. This finding
is most consistent with:
• A. Dehydration
• B. Right-sided heart failure
• C. Pulmonary embolism
• D. Hypovolemia
Rationale: JVD indicates increased venous pressure, most commonly due to right-
sided heart failure. Dehydration and hypovolemia would reduce venous filling, not
increase it.
Question 3
When assessing the abdomen, the nurse should perform the exam in which order?
• A. Palpation → Percussion → Auscultation → Inspection
• B. Inspection → Palpation → Percussion → Auscultation
• C. Inspection → Auscultation → Percussion → Palpation
• D. Auscultation → Inspection → Percussion → Palpation
Rationale: Auscultation must occur before percussion and palpation to avoid altering
bowel sounds. The correct sequence is inspection, auscultation, percussion, palpation.
Question 4
,A patient reports sudden unilateral weakness and slurred speech. What is the
nurse’s priority action?
• A. Perform a full neurological exam
• B. Activate emergency stroke protocol
• C. Check blood glucose
• D. Document findings
Rationale: Sudden neurological deficits suggest stroke. Immediate activation of stroke
protocol ensures rapid intervention (e.g., CT scan, thrombolytics). Assessment and
documentation follow after stabilization.
Question 5
During a skin assessment, the nurse notes a lesion with irregular borders, variegated
color, and diameter >6mm. What is the most concerning diagnosis?
• A. Basal cell carcinoma
• B. Actinic keratosis
• C. Malignant melanoma
• D. Squamous cell carcinoma
Rationale: The ABCDE rule (Asymmetry, Border irregularity, Color variation, Diameter
>6mm, Evolving) points to malignant melanoma. Other skin cancers usually present
with more uniform lesions.
Question 6
When performing a neurological assessment, the nurse asks the patient to smile. The
nurse notes that one side of the mouth does not move. This finding suggests:
• A. Hypoglossal nerve impairment
• B. Facial nerve (CN VII) impairment
• C. Trigeminal nerve (CN V) impairment
• D. Glossopharyngeal nerve (CN IX) impairment
Rationale: The facial nerve controls facial expressions. Asymmetry when smiling
indicates CN VII dysfunction. CN XII affects tongue movement, CN V affects chewing,
and CN IX affects swallowing.
Question 7
A patient reports shortness of breath when lying flat. The nurse documents this as:
• A. Dyspnea
• B. Tachypnea
, • C. Orthopnea
• D. Apnea
Rationale: Orthopnea is difficulty breathing when lying flat, often associated with heart
failure. Dyspnea is general difficulty breathing, tachypnea is rapid breathing, and apnea
is absence of breathing.
Question 8
During cardiac auscultation, the nurse hears an extra heart sound immediately after
S2. This is most likely:
• A. Systolic murmur
• B. S3 gallop
• C. S4 gallop
• D. Pericardial rub
Rationale: An S3 occurs right after S2 and is associated with heart failure or fluid
overload. S4 occurs before S1. Murmurs are prolonged sounds, and pericardial rubs are
scratchy, high-pitched sounds.
Question 9
The nurse palpates the dorsalis pedis pulse and finds it weak and thready. This is
documented as:
• A. 0 (absent)
• B. 1+ (bounding)
• C. 1+ (weak)
• D. 3+ (normal)
Rationale: Pulse grading: 0 = absent, 1+ = weak/thready, 2+ = normal, 3+ = bounding.
A weak dorsalis pedis pulse may indicate peripheral arterial disease.
Question 10
A patient presents with clubbing of the fingers. This finding is most often associated
with:
• A. Acute asthma attack
• B. Hypertension
• C. Chronic hypoxia (e.g., COPD)
• D. Dehydration
