NSG 3160 Exam 2 V3 | NSG 3160 Health
Assessment | Actual Q&A with Rationale (NSG3160
Exam 2) | Galen
1. A nurse is preparing to assess the respiratory system of an adult client. Which landmark
should the nurse use to locate the second rib and begin counting the intercostal spaces?
A. Suprasternal notch
B. Costal margin
C. Xiphoid process
D. Sternal angle (Angle of Louis)
Correct Answer: D
Explanation: The sternal angle, also known as the Angle of Louis, is continuous with the
second rib. This landmark is essential for identifying intercostal spaces during thoracic
assessment. Identifying this point allows the clinician to accurately locate and document
findings in specific lung fields.
2. Which of the following are considered non-modifiable risk factors for breast cancer? Select
all that apply.
A. Family history of breast cancer
B. Personal history of early menarche (before age 12)
C. Postmenopausal obesity
,D. Genetic mutations (BRCA1 or BRCA2)
E. Late menopause (after age 55)
F. Alcohol consumption of more than one drink per day
Correct Answer: A, B, D, E
Explanation: Non-modifiable risk factors include genetics, family history, and
reproductive history such as early menarche or late menopause. Obesity and alcohol
consumption are considered modifiable risk factors because they involve lifestyle choices.
A thorough health history must differentiate between these categories to provide
appropriate patient education and screening recommendations.
3. While auscultating the heart, the nurse identifies the S1 heart sound. The nurse correctly
understands that S1 is caused by the closure of which valves?
A. Aortic and Pulmonic
B. Tricuspid and Pulmonic
C. Mitral and Aortic
D. Mitral and Tricuspid
Correct Answer: D
Explanation: S1 represents the closure of the atrioventricular (AV) valves, which are the
mitral and tricuspid valves. This sound marks the beginning of systole and is usually
, loudest at the apex of the heart. The closure occurs when ventricular pressure exceeds
atrial pressure at the start of contraction.
4. A client presents with pitting edema in the lower extremities. The nurse notes a deep
pitting indentation that remains for a short time (approx. 10-15 seconds) and a leg that looks
swollen. How should the nurse document this finding?
A. 1+ Edema
B. 2+ Edema
C. 3+ Edema
D. 4+ Edema
Correct Answer: C
Explanation: 3+ edema is characterized by a deep pit that lasts for a short time and
noticeably swollen legs. This scale helps standardize the assessment of fluid volume excess
in clinical practice. The nurse must assess the depth and duration of the indentation to
assign the correct grade.
5. During an abdominal assessment, in which order should the nurse perform the following
physical examination techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Percussion, Palpation
Assessment | Actual Q&A with Rationale (NSG3160
Exam 2) | Galen
1. A nurse is preparing to assess the respiratory system of an adult client. Which landmark
should the nurse use to locate the second rib and begin counting the intercostal spaces?
A. Suprasternal notch
B. Costal margin
C. Xiphoid process
D. Sternal angle (Angle of Louis)
Correct Answer: D
Explanation: The sternal angle, also known as the Angle of Louis, is continuous with the
second rib. This landmark is essential for identifying intercostal spaces during thoracic
assessment. Identifying this point allows the clinician to accurately locate and document
findings in specific lung fields.
2. Which of the following are considered non-modifiable risk factors for breast cancer? Select
all that apply.
A. Family history of breast cancer
B. Personal history of early menarche (before age 12)
C. Postmenopausal obesity
,D. Genetic mutations (BRCA1 or BRCA2)
E. Late menopause (after age 55)
F. Alcohol consumption of more than one drink per day
Correct Answer: A, B, D, E
Explanation: Non-modifiable risk factors include genetics, family history, and
reproductive history such as early menarche or late menopause. Obesity and alcohol
consumption are considered modifiable risk factors because they involve lifestyle choices.
A thorough health history must differentiate between these categories to provide
appropriate patient education and screening recommendations.
3. While auscultating the heart, the nurse identifies the S1 heart sound. The nurse correctly
understands that S1 is caused by the closure of which valves?
A. Aortic and Pulmonic
B. Tricuspid and Pulmonic
C. Mitral and Aortic
D. Mitral and Tricuspid
Correct Answer: D
Explanation: S1 represents the closure of the atrioventricular (AV) valves, which are the
mitral and tricuspid valves. This sound marks the beginning of systole and is usually
, loudest at the apex of the heart. The closure occurs when ventricular pressure exceeds
atrial pressure at the start of contraction.
4. A client presents with pitting edema in the lower extremities. The nurse notes a deep
pitting indentation that remains for a short time (approx. 10-15 seconds) and a leg that looks
swollen. How should the nurse document this finding?
A. 1+ Edema
B. 2+ Edema
C. 3+ Edema
D. 4+ Edema
Correct Answer: C
Explanation: 3+ edema is characterized by a deep pit that lasts for a short time and
noticeably swollen legs. This scale helps standardize the assessment of fluid volume excess
in clinical practice. The nurse must assess the depth and duration of the indentation to
assign the correct grade.
5. During an abdominal assessment, in which order should the nurse perform the following
physical examination techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Percussion, Palpation
