NSG 3160 Exam 3 V2 | NSG 3160 Health
Assessment | Actual Q&A with Rationale (NSG3160
Exam 3) | Galen
1. A nurse is preparing to assess a client’s abdomen. In which order should the nurse perform
the physical assessment techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: C
Explanation: Auscultation must be performed before percussion and palpation to avoid
stimulating bowel sounds. This ensures that the sounds heard are a true reflection of the
patient’s bowel activity. Palpation is performed last to minimize discomfort and avoid
altering the physical state of the abdominal organs.
2. During a neurological examination, which of the following assessments would the nurse
use to evaluate cerebellar function? (Select All That Apply)
A. Finger-to-nose test
B. Heel-to-shin test
C. Romberg test
,D. Rapid alternating movements
E. Pupillary light reflex
F. Deep tendon reflexes
Correct Answer: ABCD
Explanation: Cerebellar function is primarily responsible for coordination and balance,
which are tested through maneuvers like finger-to-nose and rapid alternating movements.
The Romberg test specifically evaluates the client’s ability to maintain an upright position,
which relies on cerebellar and vestibular input. Tests for pupillary reflexes and deep
tendon reflexes evaluate cranial nerves and spinal arcs rather than cerebellar coordination.
3. The nurse notes that a client has ‘borborygmi’ during abdominal auscultation. How should
the nurse describe this finding in the documentation?
A. Hypoactive bowel sounds following abdominal surgery
B. Hyperactive bowel sounds, common with early bowel obstruction
C. A harsh, blowing sound heard over the aorta
D. Absent bowel sounds after five minutes of listening
Correct Answer: B
Explanation: Borborygmi refers to hyperactive, loud, gurgling bowel sounds often heard in
cases of hunger or hypermotility. These sounds can occur in the early stages of a bowel
obstruction as the intestine works to push contents past the blockage. The nurse should
, correctly identify this as hyperactive activity rather than a vascular bruit or hypoactive
sound.
4. When assessing muscle strength, the nurse observes that the client can move the limb
through a full range of motion against gravity but not against resistance. Which grade should
the nurse assign?
A. Grade 1
B. Grade 2
C. Grade 5
D. Grade 4
E. Grade 3
Correct Answer: E
Explanation: Muscle strength is graded on a scale of 0 to 5, where Grade 3 represents the
ability to complete full range of motion against gravity only. Grade 4 would indicate
movement against some resistance, while Grade 5 is normal strength. Identifying the
correct grade is essential for monitoring neurological or musculoskeletal progression.
5. To assess for Cholecystitis, the nurse should perform which of the following physical
assessment maneuvers?
A. McBurney’s point palpation
B. Blumberg sign
Assessment | Actual Q&A with Rationale (NSG3160
Exam 3) | Galen
1. A nurse is preparing to assess a client’s abdomen. In which order should the nurse perform
the physical assessment techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: C
Explanation: Auscultation must be performed before percussion and palpation to avoid
stimulating bowel sounds. This ensures that the sounds heard are a true reflection of the
patient’s bowel activity. Palpation is performed last to minimize discomfort and avoid
altering the physical state of the abdominal organs.
2. During a neurological examination, which of the following assessments would the nurse
use to evaluate cerebellar function? (Select All That Apply)
A. Finger-to-nose test
B. Heel-to-shin test
C. Romberg test
,D. Rapid alternating movements
E. Pupillary light reflex
F. Deep tendon reflexes
Correct Answer: ABCD
Explanation: Cerebellar function is primarily responsible for coordination and balance,
which are tested through maneuvers like finger-to-nose and rapid alternating movements.
The Romberg test specifically evaluates the client’s ability to maintain an upright position,
which relies on cerebellar and vestibular input. Tests for pupillary reflexes and deep
tendon reflexes evaluate cranial nerves and spinal arcs rather than cerebellar coordination.
3. The nurse notes that a client has ‘borborygmi’ during abdominal auscultation. How should
the nurse describe this finding in the documentation?
A. Hypoactive bowel sounds following abdominal surgery
B. Hyperactive bowel sounds, common with early bowel obstruction
C. A harsh, blowing sound heard over the aorta
D. Absent bowel sounds after five minutes of listening
Correct Answer: B
Explanation: Borborygmi refers to hyperactive, loud, gurgling bowel sounds often heard in
cases of hunger or hypermotility. These sounds can occur in the early stages of a bowel
obstruction as the intestine works to push contents past the blockage. The nurse should
, correctly identify this as hyperactive activity rather than a vascular bruit or hypoactive
sound.
4. When assessing muscle strength, the nurse observes that the client can move the limb
through a full range of motion against gravity but not against resistance. Which grade should
the nurse assign?
A. Grade 1
B. Grade 2
C. Grade 5
D. Grade 4
E. Grade 3
Correct Answer: E
Explanation: Muscle strength is graded on a scale of 0 to 5, where Grade 3 represents the
ability to complete full range of motion against gravity only. Grade 4 would indicate
movement against some resistance, while Grade 5 is normal strength. Identifying the
correct grade is essential for monitoring neurological or musculoskeletal progression.
5. To assess for Cholecystitis, the nurse should perform which of the following physical
assessment maneuvers?
A. McBurney’s point palpation
B. Blumberg sign
