Advanced NSG 3160 Health Assessment EXAM with
Questions and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
Table of Contents
1. Neurological Assessment
2. Musculoskeletal and Integumentary Systems
3. Comprehensive Health History and Interviewing Techniques
4. Cardiovascular and Peripheral Vascular Assessment
5. Respiratory and Thoracic Assessment
1. A patient presents with a history of progressive muscle weakness and localized atrophy in the
lower extremities. Upon physical examination, you note fasciculations and diminished deep
tendon reflexes in the affected areas. Based on these findings, which lower motor neuron (LMN)
disorder is most strongly suggested?
A. Amyotrophic Lateral Sclerosis (ALS)
B. Multiple Sclerosis (MS)
C. Guillain-Barré Syndrome
D. Parkinson’s Disease
Answer: C
CORRECT ANSWER : C
Rationale: Guillain-Barré Syndrome is characterized by acute, ascending LMN weakness,
hyporeflexia, and atrophy, consistent with the patient's presentation. ALS involves both upper
and lower motor neuron signs; MS is a central demyelinating disease presenting with upper
, motor neuron signs; and Parkinson’s primarily involves extrapyramidal motor dysfunction
rather than LMN atrophy.
2. During a cardiovascular assessment, a nurse identifies a localized, systolic thrill at the second
intercostal space, right sternal border. Which of the following heart sounds or conditions is most
likely associated with this finding?
A. Mitral regurgitation
B. Aortic stenosis
C. Pulmonic valve insufficiency
D. Tricuspid regurgitation
Answer: B
CORRECT ANSWER : B
Rationale: A thrill at the right second intercostal space (the aortic area) is a hallmark clinical
sign of severe aortic stenosis. Mitral regurgitation is best heard at the apex, pulmonic issues are
heard at the left second intercostal space, and tricuspid regurgitation is heard at the left lower
sternal border.
3. A patient with suspected peripheral arterial disease (PAD) exhibits significant pallor of the lower
extremities upon elevation, followed by reactive hyperemia when the legs are placed in a
dependent position. Which diagnostic index should the nurse calculate to quantify the severity of
this vascular compromise?
A. Capillary refill time
B. Ankle-Brachial Index (ABI)
C. Venous filling time
D. Homans' sign
Answer: B
CORRECT ANSWER : B
Rationale: The Ankle-Brachial Index is the standard, objective, non-invasive test for assessing
the severity of PAD by comparing systolic pressures between the ankle and the arm. Capillary
refill is subjective; venous filling time assesses venous, not arterial, sufficiency; and Homans'
sign is unreliable for diagnosing DVT.
, 4. A nurse is performing a respiratory assessment on an elderly patient with chronic obstructive
pulmonary disease (COPD). The nurse notes a barrel-chested appearance and percussion reveals
hyperresonance throughout all lung fields. What is the physiological basis for these findings?
A. Air trapping and hyperinflation of the alveoli
B. Increased surfactant production
C. Pleural effusion within the lower lobes
D. Atelectasis of the upper lung fields
Answer: A
CORRECT ANSWER : A
Rationale: COPD causes air trapping, which increases residual volume and leads to the "barrel
chest" deformity and hyperresonance on percussion due to excessive air. Surfactant production
does not increase in COPD; pleural effusion produces dullness, not hyperresonance; and
atelectasis results in collapsed alveoli, which would also produce dullness.
5. When assessing a patient with suspected rheumatoid arthritis (RA), which clinical manifestation
would lead the nurse to suspect that the condition is in an active, inflammatory stage?
A. Heberden’s nodes on the distal interphalangeal joints
B. Morning stiffness lasting longer than 60 minutes
C. Asymmetrical joint involvement of the large weight-bearing joints
D. Pain that improves significantly with continued physical activity
Answer: B
CORRECT ANSWER : B
Rationale: Morning stiffness lasting over an hour is a classic diagnostic criterion for active,
inflammatory rheumatoid arthritis. Heberden’s nodes are indicative of osteoarthritis; RA
typically presents with symmetrical small joint involvement; and while RA pain may improve
with movement, the primary indicator of active inflammation is the prolonged morning stiffness.
6. A nurse is assessing a patient’s cranial nerve function. The patient demonstrates inability to
deviate the tongue toward the affected side when asked to stick it out, and shows atrophy and
fasciculations on one side of the tongue. Which nerve is involved?
A. CN IX (Glossopharyngeal)
Questions and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
Table of Contents
1. Neurological Assessment
2. Musculoskeletal and Integumentary Systems
3. Comprehensive Health History and Interviewing Techniques
4. Cardiovascular and Peripheral Vascular Assessment
5. Respiratory and Thoracic Assessment
1. A patient presents with a history of progressive muscle weakness and localized atrophy in the
lower extremities. Upon physical examination, you note fasciculations and diminished deep
tendon reflexes in the affected areas. Based on these findings, which lower motor neuron (LMN)
disorder is most strongly suggested?
A. Amyotrophic Lateral Sclerosis (ALS)
B. Multiple Sclerosis (MS)
C. Guillain-Barré Syndrome
D. Parkinson’s Disease
Answer: C
CORRECT ANSWER : C
Rationale: Guillain-Barré Syndrome is characterized by acute, ascending LMN weakness,
hyporeflexia, and atrophy, consistent with the patient's presentation. ALS involves both upper
and lower motor neuron signs; MS is a central demyelinating disease presenting with upper
, motor neuron signs; and Parkinson’s primarily involves extrapyramidal motor dysfunction
rather than LMN atrophy.
2. During a cardiovascular assessment, a nurse identifies a localized, systolic thrill at the second
intercostal space, right sternal border. Which of the following heart sounds or conditions is most
likely associated with this finding?
A. Mitral regurgitation
B. Aortic stenosis
C. Pulmonic valve insufficiency
D. Tricuspid regurgitation
Answer: B
CORRECT ANSWER : B
Rationale: A thrill at the right second intercostal space (the aortic area) is a hallmark clinical
sign of severe aortic stenosis. Mitral regurgitation is best heard at the apex, pulmonic issues are
heard at the left second intercostal space, and tricuspid regurgitation is heard at the left lower
sternal border.
3. A patient with suspected peripheral arterial disease (PAD) exhibits significant pallor of the lower
extremities upon elevation, followed by reactive hyperemia when the legs are placed in a
dependent position. Which diagnostic index should the nurse calculate to quantify the severity of
this vascular compromise?
A. Capillary refill time
B. Ankle-Brachial Index (ABI)
C. Venous filling time
D. Homans' sign
Answer: B
CORRECT ANSWER : B
Rationale: The Ankle-Brachial Index is the standard, objective, non-invasive test for assessing
the severity of PAD by comparing systolic pressures between the ankle and the arm. Capillary
refill is subjective; venous filling time assesses venous, not arterial, sufficiency; and Homans'
sign is unreliable for diagnosing DVT.
, 4. A nurse is performing a respiratory assessment on an elderly patient with chronic obstructive
pulmonary disease (COPD). The nurse notes a barrel-chested appearance and percussion reveals
hyperresonance throughout all lung fields. What is the physiological basis for these findings?
A. Air trapping and hyperinflation of the alveoli
B. Increased surfactant production
C. Pleural effusion within the lower lobes
D. Atelectasis of the upper lung fields
Answer: A
CORRECT ANSWER : A
Rationale: COPD causes air trapping, which increases residual volume and leads to the "barrel
chest" deformity and hyperresonance on percussion due to excessive air. Surfactant production
does not increase in COPD; pleural effusion produces dullness, not hyperresonance; and
atelectasis results in collapsed alveoli, which would also produce dullness.
5. When assessing a patient with suspected rheumatoid arthritis (RA), which clinical manifestation
would lead the nurse to suspect that the condition is in an active, inflammatory stage?
A. Heberden’s nodes on the distal interphalangeal joints
B. Morning stiffness lasting longer than 60 minutes
C. Asymmetrical joint involvement of the large weight-bearing joints
D. Pain that improves significantly with continued physical activity
Answer: B
CORRECT ANSWER : B
Rationale: Morning stiffness lasting over an hour is a classic diagnostic criterion for active,
inflammatory rheumatoid arthritis. Heberden’s nodes are indicative of osteoarthritis; RA
typically presents with symmetrical small joint involvement; and while RA pain may improve
with movement, the primary indicator of active inflammation is the prolonged morning stiffness.
6. A nurse is assessing a patient’s cranial nerve function. The patient demonstrates inability to
deviate the tongue toward the affected side when asked to stick it out, and shows atrophy and
fasciculations on one side of the tongue. Which nerve is involved?
A. CN IX (Glossopharyngeal)
