NSG 351 Exam 1 V2 | NSG 351 Health
Assessment | Actual Q&A with Rationale
(NSG351 Exam 1) | James Madison
University
1. When performing a physical examination, in what order does the nurse typically perform
the assessment techniques for most body systems?
A. Auscultation, Inspection, Palpation, Percussion
B. Inspection, Palpation, Percussion, Auscultation
C. Palpation, Percussion, Auscultation, Inspection
D. Percussion, Auscultation, Inspection, Palpation
Answer: B
Rationale: The standard sequence for physical assessment is inspection, followed by
palpation, percussion, and finally auscultation. This order allows the nurse to gather data
visually before touching or disturbing the area. However, it is important to note that the
order changes to inspection, auscultation, percussion, and palpation when assessing the
abdomen to avoid altering bowel sounds.
2. Which of the following would be considered ‘objective data’ during a health assessment?
A. The nurse observing a 2 cm laceration on the left forearm.
B. The patient stating they have a headache.
,C. The patient reporting feelings of anxiety.
D. The patient describing their pain as ‘sharp’.
Answer: A
Rationale: Objective data is information that is observed, felt, heard, or measured by the
healthcare professional during the physical examination. Subjective data, on the other
hand, consists of information provided by the patient that cannot be directly verified by the
examiner. A laceration is a visible physical finding that qualifies as objective clinical
evidence.
3. When using the PQRST mnemonic to assess a patient’s pain, what does the ‘Q’ represent?
A. Quantity
B. Quality or Character
C. Quelling factors
D. Quickness of onset
Answer: B
Rationale: The ‘Q’ in the PQRST assessment tool stands for Quality or Character of the
pain. The nurse asks the patient to describe how the pain feels, such as burning, sharp, dull,
or stabbing. This helps the clinician understand the nature of the underlying condition and
tailor the treatment plan accordingly.
, 4. The nurse is assessing a patient’s blood pressure. Which of the following errors would
result in a falsely high blood pressure reading?
A. The patient’s arm is positioned above the level of the heart.
B. The nurse pushes too hard with the stethoscope diaphragm.
C. The nurse deflates the cuff too quickly.
D. The blood pressure cuff is too narrow for the patient’s arm.
Answer: D
Rationale: Using a blood pressure cuff that is too small or narrow for the patient’s arm will
result in a falsely high reading. The cuff must be the appropriate size, where the width of
the rubber bladder should equal 40% of the circumference of the person’s arm. Conversely,
a cuff that is too large or an arm positioned above heart level can result in a falsely low
reading.
5. During a mental status examination, the nurse assesses the ‘ABCT’ components. What does
the ‘C’ stand for?
A. Cognitive functions
B. Character
C. Culture
D. Communication style
Answer: A
Assessment | Actual Q&A with Rationale
(NSG351 Exam 1) | James Madison
University
1. When performing a physical examination, in what order does the nurse typically perform
the assessment techniques for most body systems?
A. Auscultation, Inspection, Palpation, Percussion
B. Inspection, Palpation, Percussion, Auscultation
C. Palpation, Percussion, Auscultation, Inspection
D. Percussion, Auscultation, Inspection, Palpation
Answer: B
Rationale: The standard sequence for physical assessment is inspection, followed by
palpation, percussion, and finally auscultation. This order allows the nurse to gather data
visually before touching or disturbing the area. However, it is important to note that the
order changes to inspection, auscultation, percussion, and palpation when assessing the
abdomen to avoid altering bowel sounds.
2. Which of the following would be considered ‘objective data’ during a health assessment?
A. The nurse observing a 2 cm laceration on the left forearm.
B. The patient stating they have a headache.
,C. The patient reporting feelings of anxiety.
D. The patient describing their pain as ‘sharp’.
Answer: A
Rationale: Objective data is information that is observed, felt, heard, or measured by the
healthcare professional during the physical examination. Subjective data, on the other
hand, consists of information provided by the patient that cannot be directly verified by the
examiner. A laceration is a visible physical finding that qualifies as objective clinical
evidence.
3. When using the PQRST mnemonic to assess a patient’s pain, what does the ‘Q’ represent?
A. Quantity
B. Quality or Character
C. Quelling factors
D. Quickness of onset
Answer: B
Rationale: The ‘Q’ in the PQRST assessment tool stands for Quality or Character of the
pain. The nurse asks the patient to describe how the pain feels, such as burning, sharp, dull,
or stabbing. This helps the clinician understand the nature of the underlying condition and
tailor the treatment plan accordingly.
, 4. The nurse is assessing a patient’s blood pressure. Which of the following errors would
result in a falsely high blood pressure reading?
A. The patient’s arm is positioned above the level of the heart.
B. The nurse pushes too hard with the stethoscope diaphragm.
C. The nurse deflates the cuff too quickly.
D. The blood pressure cuff is too narrow for the patient’s arm.
Answer: D
Rationale: Using a blood pressure cuff that is too small or narrow for the patient’s arm will
result in a falsely high reading. The cuff must be the appropriate size, where the width of
the rubber bladder should equal 40% of the circumference of the person’s arm. Conversely,
a cuff that is too large or an arm positioned above heart level can result in a falsely low
reading.
5. During a mental status examination, the nurse assesses the ‘ABCT’ components. What does
the ‘C’ stand for?
A. Cognitive functions
B. Character
C. Culture
D. Communication style
Answer: A
