NSG 3160 Final Exam V2 | NSG 3160 Health
Assessment | Actual Q&A with Rationale (NSG3160
Final Exam) | Galen
1. A nurse is preparing to perform a physical assessment of a patient’s abdomen. In which
order should the nurse perform the assessment techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Percussion, Palpation, Auscultation, Inspection
C. Auscultation, Inspection, Palpation, Percussion
D. Inspection, Auscultation, Percussion, Palpation
Correct Answer: D
Explanation: The correct sequence for an abdominal assessment is inspection followed by
auscultation, percussion, and finally palpation. This specific order is used because
palpation and percussion can stimulate bowel activity and alter the frequency of bowel
sounds. Auscultating first ensures that the sounds heard reflect the patient’s baseline
physiological state without external interference.
2. The nurse is educating a client on how to monitor skin lesions for potential malignancy
using the ABCDE rule. Which characteristics should the nurse instruct the client to look for?
(Select All That Apply)
A. Asymmetry of the lesion
B. Border irregularity
,C. Color variation or multicolored appearance
D. Diameter greater than 6 mm
E. Evolution or change in size, shape, or symptoms
F. Feeling of coldness when touched
Correct Answer: A, B, C, D, E
Explanation: The ABCDE mnemonic is a critical clinical tool used to identify warning signs
of melanoma. Asymmetry, irregular borders, and color variations are primary indicators
that a mole may be malignant. A diameter exceeding 6 mm and any evolution in the lesion’s
characteristics also require immediate professional evaluation to rule out skin cancer.
3. During a cardiac assessment, the nurse is attempting to auscultate the first heart sound
(S1). At which location will S1 be heard the loudest?
A. Second right intercostal space
B. Second left intercostal space
C. Base of the heart
D. Apex of the heart
Correct Answer: D
Explanation: The first heart sound, S1, is caused by the closure of the atrioventricular
valves (mitral and tricuspid) and is loudest at the apex of the heart. In contrast, the second
heart sound, S2, is loudest at the base of the heart due to the closure of the semilunar
,valves. Identifying the location of maximum intensity for S1 helps the nurse distinguish it
from S2 and other adventitious sounds.
4. The nurse is assessing a patient’s pupillary response and notes that both pupils constrict
when a light is shone into the right eye. What is the term for the constriction of the left pupil
in this scenario?
A. Consensual light reflex
B. Direct light reflex
C. Accommodation
D. Convergence
Correct Answer: A
Explanation: The consensual light reflex occurs when the pupil of one eye constricts in
response to light being shone into the opposite eye. This reflex indicates that the sensory
pathways of the optic nerve and the motor pathways of the oculomotor nerve are intact
bilaterally. A lack of consensual response could suggest a neurological deficit or damage to
the cranial nerves.
5. When assessing the respiratory system of an adult patient, the nurse auscultates low-
pitched, soft, rustling sounds over the peripheral lung fields. The nurse identifies these
sounds as:
A. Bronchial breath sounds
B. Vesicular breath sounds
, C. Bronchovesicular breath sounds
D. Adventitious breath sounds
Correct Answer: B
Explanation: Vesicular breath sounds are normal, soft, and low-pitched sounds heard over
the majority of the lung’s peripheral fields. They are characterized by a long inspiratory
phase and a short, quiet expiratory phase. Recognizing these as normal findings allows the
nurse to distinguish them from abnormal or adventitious sounds like wheezes or crackles.
6. A nurse is calculating a patient’s Glasgow Coma Scale (GCS) score. Which of the following
components are included in this assessment? (Select All That Apply)
A. Best eye-opening response
B. Best motor response
C. Best verbal response
D. Pupillary light reflex
E. Level of consciousness
F. Deep tendon reflexes
Correct Answer: A, B, C
Explanation: The Glasgow Coma Scale (GCS) specifically measures three categories: eye-
opening, verbal response, and motor response. Each category is assigned a numerical value,
with a total score ranging from 3 to 15. This standardized tool provides a consistent
Assessment | Actual Q&A with Rationale (NSG3160
Final Exam) | Galen
1. A nurse is preparing to perform a physical assessment of a patient’s abdomen. In which
order should the nurse perform the assessment techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Percussion, Palpation, Auscultation, Inspection
C. Auscultation, Inspection, Palpation, Percussion
D. Inspection, Auscultation, Percussion, Palpation
Correct Answer: D
Explanation: The correct sequence for an abdominal assessment is inspection followed by
auscultation, percussion, and finally palpation. This specific order is used because
palpation and percussion can stimulate bowel activity and alter the frequency of bowel
sounds. Auscultating first ensures that the sounds heard reflect the patient’s baseline
physiological state without external interference.
2. The nurse is educating a client on how to monitor skin lesions for potential malignancy
using the ABCDE rule. Which characteristics should the nurse instruct the client to look for?
(Select All That Apply)
A. Asymmetry of the lesion
B. Border irregularity
,C. Color variation or multicolored appearance
D. Diameter greater than 6 mm
E. Evolution or change in size, shape, or symptoms
F. Feeling of coldness when touched
Correct Answer: A, B, C, D, E
Explanation: The ABCDE mnemonic is a critical clinical tool used to identify warning signs
of melanoma. Asymmetry, irregular borders, and color variations are primary indicators
that a mole may be malignant. A diameter exceeding 6 mm and any evolution in the lesion’s
characteristics also require immediate professional evaluation to rule out skin cancer.
3. During a cardiac assessment, the nurse is attempting to auscultate the first heart sound
(S1). At which location will S1 be heard the loudest?
A. Second right intercostal space
B. Second left intercostal space
C. Base of the heart
D. Apex of the heart
Correct Answer: D
Explanation: The first heart sound, S1, is caused by the closure of the atrioventricular
valves (mitral and tricuspid) and is loudest at the apex of the heart. In contrast, the second
heart sound, S2, is loudest at the base of the heart due to the closure of the semilunar
,valves. Identifying the location of maximum intensity for S1 helps the nurse distinguish it
from S2 and other adventitious sounds.
4. The nurse is assessing a patient’s pupillary response and notes that both pupils constrict
when a light is shone into the right eye. What is the term for the constriction of the left pupil
in this scenario?
A. Consensual light reflex
B. Direct light reflex
C. Accommodation
D. Convergence
Correct Answer: A
Explanation: The consensual light reflex occurs when the pupil of one eye constricts in
response to light being shone into the opposite eye. This reflex indicates that the sensory
pathways of the optic nerve and the motor pathways of the oculomotor nerve are intact
bilaterally. A lack of consensual response could suggest a neurological deficit or damage to
the cranial nerves.
5. When assessing the respiratory system of an adult patient, the nurse auscultates low-
pitched, soft, rustling sounds over the peripheral lung fields. The nurse identifies these
sounds as:
A. Bronchial breath sounds
B. Vesicular breath sounds
, C. Bronchovesicular breath sounds
D. Adventitious breath sounds
Correct Answer: B
Explanation: Vesicular breath sounds are normal, soft, and low-pitched sounds heard over
the majority of the lung’s peripheral fields. They are characterized by a long inspiratory
phase and a short, quiet expiratory phase. Recognizing these as normal findings allows the
nurse to distinguish them from abnormal or adventitious sounds like wheezes or crackles.
6. A nurse is calculating a patient’s Glasgow Coma Scale (GCS) score. Which of the following
components are included in this assessment? (Select All That Apply)
A. Best eye-opening response
B. Best motor response
C. Best verbal response
D. Pupillary light reflex
E. Level of consciousness
F. Deep tendon reflexes
Correct Answer: A, B, C
Explanation: The Glasgow Coma Scale (GCS) specifically measures three categories: eye-
opening, verbal response, and motor response. Each category is assigned a numerical value,
with a total score ranging from 3 to 15. This standardized tool provides a consistent
