NR-304 – Health Assessment Methods Complete
Nursing Assessment Guide, Patient Examination
Techniques, Clinical Documentation, Assessment
Skills, and Practice Questions
Q1. During a comprehensive health assessment, the nurse should perform the four
basic assessment techniques in which order?
A) Palpation, percussion, auscultation, inspection
B) Inspection, palpation, percussion, auscultation
C) Auscultation, inspection, palpation, percussion
D) Percussion, inspection, auscultation, palpation
Answer: B — Inspection, palpation, percussion, auscultation
Rationale: The correct order of assessment techniques
is Inspection, Palpation, Percussion, and Auscultation (IPPA). Inspection should
always be performed first before touching the patient. Auscultation is performed
last because palpation and percussion can alter bowel sounds and other audible
findings. The abdomen is a notable exception where auscultation is performed
before palpation and percussion to avoid altering bowel sounds.
Q2. A nurse is preparing to assess a patient's abdomen. Which assessment
technique should the nurse perform FIRST?
A) Palpation
B) Percussion
C) Inspection
D) Auscultation
Answer: C — Inspection
Rationale: Inspection should always be performed first before any other
assessment technique. For the abdomen, the nurse should inspect for symmetry,
contour, color, scars, visible peristalsis, and pulsations. Auscultation is performed
,before palpation and percussion for the abdomen to avoid altering bowel sounds,
but inspection remains the first step.
Q3. Which of the following best describes the purpose of palpation during a
physical assessment?
A) To listen to internal body sounds
B) To assess texture, temperature, moisture, organ size, and tenderness
C) To assess the density of underlying structures
D) To visualize the patient's body parts
Answer: B — To assess texture, temperature, moisture, organ size, and
tenderness
Rationale: Palpation uses touch to assess texture, temperature, moisture, organ
size, masses, tenderness, and vibrations. Auscultation listens to internal sounds,
percussion assesses density, and inspection is visual assessment. Palpation can be
light (1–2 cm) or deep (4–6 cm) depending on the area being assessed.
Q4. A nurse is using the bell of the stethoscope during a cardiac assessment.
Which sound is the bell best suited to hear?
A) High-pitched breath sounds
B) Low-pitched heart sounds (S3, S4, murmurs)
C) High-pitched bowel sounds
D) Normal breath sounds
Answer: B — Low-pitched heart sounds (S3, S4, murmurs)
Rationale: The bell of the stethoscope is designed to detect low-pitched
sounds such as S3 (ventricular gallop), S4 (atrial gallop), and low-pitched
murmurs. The diaphragm is designed to detect high-pitched sounds such as
breath sounds, normal heart sounds (S1, S2), and high-pitched bowel sounds. The
bell should be held lightly against the skin to function properly.
Q5. A nurse is performing percussion on a patient's chest. A hyperresonant sound
is heard. This finding is most consistent with:
,A) Normal lung tissue
B) Emphysema or pneumothorax
C) Pneumonia or pleural effusion
D) Consolidation
Answer: B — Emphysema or pneumothorax
Rationale: Hyperresonance is an abnormally loud, low-pitched sound heard over
areas with increased air (e.g., emphysema, pneumothorax). Normal lung tissue
produces resonance. Dullness is heard over solid tissue (e.g., pneumonia, pleural
effusion, tumor). Flatness is heard over bone or muscle.
Q6. A nurse is performing a health history on a new patient. Which component of
the health history provides the patient's reason for seeking care?
A) Past medical history
B) Chief complaint
C) Review of systems
D) Family history
Answer: B — Chief complaint
Rationale: The chief complaint is the patient's reason for seeking care stated in
the patient's own words. It is typically recorded as a direct quote (e.g., "I have had
chest pain for 2 days"). The past medical history includes previous illnesses and
surgeries. The review of systems is a systematic inquiry about all body systems.
Family history includes health conditions in the patient's family.
Q7. A nurse is assessing a patient's level of consciousness using the Glasgow
Coma Scale (GCS). Which component is NOT part of the GCS?
A) Eye opening
B) Pupillary response
C) Verbal response
D) Motor response
Answer: B — Pupillary response
, Rationale: The Glasgow Coma Scale (GCS) assesses three components: eye
opening (1–4 points), verbal response (1–5 points), and motor response (1–6
points). Total score ranges from 3 (deep coma) to 15 (fully alert). Pupillary
response is a neurological assessment but is NOT part of the GCS. Pupillary
response assesses cranial nerve III function and is important in neurological
assessment.
Q8. A nurse is performing a functional assessment on a patient. Which of the
following is the nurse assessing?
A) The patient's past medical history
B) The patient's ability to perform activities of daily living (ADLs)
C) The patient's family history
D) The patient's vital signs
Answer: B — The patient's ability to perform activities of daily living (ADLs)
Rationale: A functional assessment evaluates the patient's ability to
perform activities of daily living (ADLs) such as bathing, dressing, eating,
toileting, ambulating, and grooming. It also assesses instrumental activities of
daily living (IADLs) such as managing finances, using transportation, and
preparing meals. This assessment is important for determining the patient's
independence and need for support.
Q9. A nurse is preparing to perform a physical assessment on a patient who is
anxious and tense. Which action by the nurse is most appropriate to promote
relaxation?
A) Begin the assessment immediately to get it over with
B) Explain each step of the assessment and provide reassurance
C) Perform the most invasive assessments first
D) Avoid making eye contact to reduce anxiety
Answer: B — Explain each step of the assessment and provide reassurance
Rationale: To promote relaxation in an anxious patient, the nurse should explain
each step of the assessment before performing it, provide reassurance, and
maintain a calm demeanor. The nurse should start with less invasive assessments
Nursing Assessment Guide, Patient Examination
Techniques, Clinical Documentation, Assessment
Skills, and Practice Questions
Q1. During a comprehensive health assessment, the nurse should perform the four
basic assessment techniques in which order?
A) Palpation, percussion, auscultation, inspection
B) Inspection, palpation, percussion, auscultation
C) Auscultation, inspection, palpation, percussion
D) Percussion, inspection, auscultation, palpation
Answer: B — Inspection, palpation, percussion, auscultation
Rationale: The correct order of assessment techniques
is Inspection, Palpation, Percussion, and Auscultation (IPPA). Inspection should
always be performed first before touching the patient. Auscultation is performed
last because palpation and percussion can alter bowel sounds and other audible
findings. The abdomen is a notable exception where auscultation is performed
before palpation and percussion to avoid altering bowel sounds.
Q2. A nurse is preparing to assess a patient's abdomen. Which assessment
technique should the nurse perform FIRST?
A) Palpation
B) Percussion
C) Inspection
D) Auscultation
Answer: C — Inspection
Rationale: Inspection should always be performed first before any other
assessment technique. For the abdomen, the nurse should inspect for symmetry,
contour, color, scars, visible peristalsis, and pulsations. Auscultation is performed
,before palpation and percussion for the abdomen to avoid altering bowel sounds,
but inspection remains the first step.
Q3. Which of the following best describes the purpose of palpation during a
physical assessment?
A) To listen to internal body sounds
B) To assess texture, temperature, moisture, organ size, and tenderness
C) To assess the density of underlying structures
D) To visualize the patient's body parts
Answer: B — To assess texture, temperature, moisture, organ size, and
tenderness
Rationale: Palpation uses touch to assess texture, temperature, moisture, organ
size, masses, tenderness, and vibrations. Auscultation listens to internal sounds,
percussion assesses density, and inspection is visual assessment. Palpation can be
light (1–2 cm) or deep (4–6 cm) depending on the area being assessed.
Q4. A nurse is using the bell of the stethoscope during a cardiac assessment.
Which sound is the bell best suited to hear?
A) High-pitched breath sounds
B) Low-pitched heart sounds (S3, S4, murmurs)
C) High-pitched bowel sounds
D) Normal breath sounds
Answer: B — Low-pitched heart sounds (S3, S4, murmurs)
Rationale: The bell of the stethoscope is designed to detect low-pitched
sounds such as S3 (ventricular gallop), S4 (atrial gallop), and low-pitched
murmurs. The diaphragm is designed to detect high-pitched sounds such as
breath sounds, normal heart sounds (S1, S2), and high-pitched bowel sounds. The
bell should be held lightly against the skin to function properly.
Q5. A nurse is performing percussion on a patient's chest. A hyperresonant sound
is heard. This finding is most consistent with:
,A) Normal lung tissue
B) Emphysema or pneumothorax
C) Pneumonia or pleural effusion
D) Consolidation
Answer: B — Emphysema or pneumothorax
Rationale: Hyperresonance is an abnormally loud, low-pitched sound heard over
areas with increased air (e.g., emphysema, pneumothorax). Normal lung tissue
produces resonance. Dullness is heard over solid tissue (e.g., pneumonia, pleural
effusion, tumor). Flatness is heard over bone or muscle.
Q6. A nurse is performing a health history on a new patient. Which component of
the health history provides the patient's reason for seeking care?
A) Past medical history
B) Chief complaint
C) Review of systems
D) Family history
Answer: B — Chief complaint
Rationale: The chief complaint is the patient's reason for seeking care stated in
the patient's own words. It is typically recorded as a direct quote (e.g., "I have had
chest pain for 2 days"). The past medical history includes previous illnesses and
surgeries. The review of systems is a systematic inquiry about all body systems.
Family history includes health conditions in the patient's family.
Q7. A nurse is assessing a patient's level of consciousness using the Glasgow
Coma Scale (GCS). Which component is NOT part of the GCS?
A) Eye opening
B) Pupillary response
C) Verbal response
D) Motor response
Answer: B — Pupillary response
, Rationale: The Glasgow Coma Scale (GCS) assesses three components: eye
opening (1–4 points), verbal response (1–5 points), and motor response (1–6
points). Total score ranges from 3 (deep coma) to 15 (fully alert). Pupillary
response is a neurological assessment but is NOT part of the GCS. Pupillary
response assesses cranial nerve III function and is important in neurological
assessment.
Q8. A nurse is performing a functional assessment on a patient. Which of the
following is the nurse assessing?
A) The patient's past medical history
B) The patient's ability to perform activities of daily living (ADLs)
C) The patient's family history
D) The patient's vital signs
Answer: B — The patient's ability to perform activities of daily living (ADLs)
Rationale: A functional assessment evaluates the patient's ability to
perform activities of daily living (ADLs) such as bathing, dressing, eating,
toileting, ambulating, and grooming. It also assesses instrumental activities of
daily living (IADLs) such as managing finances, using transportation, and
preparing meals. This assessment is important for determining the patient's
independence and need for support.
Q9. A nurse is preparing to perform a physical assessment on a patient who is
anxious and tense. Which action by the nurse is most appropriate to promote
relaxation?
A) Begin the assessment immediately to get it over with
B) Explain each step of the assessment and provide reassurance
C) Perform the most invasive assessments first
D) Avoid making eye contact to reduce anxiety
Answer: B — Explain each step of the assessment and provide reassurance
Rationale: To promote relaxation in an anxious patient, the nurse should explain
each step of the assessment before performing it, provide reassurance, and
maintain a calm demeanor. The nurse should start with less invasive assessments
