NSG 3160 Final Exam V3 | NSG 3160 Health
Assessment | Actual Q&A with Rationale (NSG3160
Final Exam) | Galen
1. When assessing a patient’s blood pressure, the nurse notes that the cuff is too small for the
patient’s arm circumference. Which result should the nurse anticipate?
A. A falsely high systolic and diastolic reading
B. A falsely low systolic reading
C. A reading that is only accurate for the diastolic pressure
D. No significant change in the blood pressure reading
Correct Answer: A
Explanation: Using a blood pressure cuff that is too small for the patient’s arm results in a
falsely high reading because the cuff must be inflated to a higher pressure to occlude the
artery. This occurs because the pressure is not evenly distributed across the artery. It is
critical for the nurse to select the appropriate cuff size, which should have a bladder width
of approximately 40% of the arm circumference.
2. A nurse is assessing a patient exhibiting signs of respiratory distress. Which clinical findings
should the nurse document as indicators of increased work of breathing? (Select All That
Apply)
A. Nasal flaring
B. Suprasternal retractions
,C. Use of accessory muscles
D. Eupnea
E. Pursed-lip breathing
F. Respiratory rate of 16 breaths per minute
Correct Answer: A, B, C, E
Explanation: Nasal flaring and the use of accessory muscles like the sternocleidomastoid
are hallmark signs of respiratory distress. Suprasternal retractions indicate that the patient
is struggling to pull air into the lungs against resistance. Pursed-lip breathing is a
compensatory mechanism used to maintain airway pressure and improve oxygenation,
whereas eupnea and a rate of 16 are normal findings.
3. During a cardiac assessment, the nurse auscultates a low-pitched sound at the apex of the
heart immediately following the S2 sound. How should the nurse document this finding?
A. S3 heart sound (Ventricular Gallop)
B. S1 heart sound
C. S4 heart sound (Atrial Gallop)
D. Pericardial friction rub
Correct Answer: A
Explanation: An S3 heart sound, also known as a ventricular gallop, occurs early in
diastole during the rapid ventricular filling phase. It is heard best at the apex with the bell
, of the stethoscope and follows S2. While it can be normal in children and athletes, in older
adults it often indicates fluid overload or heart failure.
4. The nurse is preparing to perform a physical assessment of a patient’s abdomen. In which
sequence should the nurse perform the assessment techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: B
Explanation: The correct sequence for abdominal assessment is inspection, auscultation,
percussion, and then palpation. Auscultation is performed before percussion and palpation
to avoid altering bowel sounds through mechanical stimulation. This ensures that the nurse
hears the natural activity of the gastrointestinal tract before manipulation occurs.
5. A nurse is testing the function of Cranial Nerve VII (Facial Nerve). Which action should the
nurse ask the patient to perform?
A. Shrug the shoulders against resistance
B. Smile, frown, and puff out the cheeks
C. Protrude the tongue and move it side to side
D. Follow a moving object with the eyes
Assessment | Actual Q&A with Rationale (NSG3160
Final Exam) | Galen
1. When assessing a patient’s blood pressure, the nurse notes that the cuff is too small for the
patient’s arm circumference. Which result should the nurse anticipate?
A. A falsely high systolic and diastolic reading
B. A falsely low systolic reading
C. A reading that is only accurate for the diastolic pressure
D. No significant change in the blood pressure reading
Correct Answer: A
Explanation: Using a blood pressure cuff that is too small for the patient’s arm results in a
falsely high reading because the cuff must be inflated to a higher pressure to occlude the
artery. This occurs because the pressure is not evenly distributed across the artery. It is
critical for the nurse to select the appropriate cuff size, which should have a bladder width
of approximately 40% of the arm circumference.
2. A nurse is assessing a patient exhibiting signs of respiratory distress. Which clinical findings
should the nurse document as indicators of increased work of breathing? (Select All That
Apply)
A. Nasal flaring
B. Suprasternal retractions
,C. Use of accessory muscles
D. Eupnea
E. Pursed-lip breathing
F. Respiratory rate of 16 breaths per minute
Correct Answer: A, B, C, E
Explanation: Nasal flaring and the use of accessory muscles like the sternocleidomastoid
are hallmark signs of respiratory distress. Suprasternal retractions indicate that the patient
is struggling to pull air into the lungs against resistance. Pursed-lip breathing is a
compensatory mechanism used to maintain airway pressure and improve oxygenation,
whereas eupnea and a rate of 16 are normal findings.
3. During a cardiac assessment, the nurse auscultates a low-pitched sound at the apex of the
heart immediately following the S2 sound. How should the nurse document this finding?
A. S3 heart sound (Ventricular Gallop)
B. S1 heart sound
C. S4 heart sound (Atrial Gallop)
D. Pericardial friction rub
Correct Answer: A
Explanation: An S3 heart sound, also known as a ventricular gallop, occurs early in
diastole during the rapid ventricular filling phase. It is heard best at the apex with the bell
, of the stethoscope and follows S2. While it can be normal in children and athletes, in older
adults it often indicates fluid overload or heart failure.
4. The nurse is preparing to perform a physical assessment of a patient’s abdomen. In which
sequence should the nurse perform the assessment techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: B
Explanation: The correct sequence for abdominal assessment is inspection, auscultation,
percussion, and then palpation. Auscultation is performed before percussion and palpation
to avoid altering bowel sounds through mechanical stimulation. This ensures that the nurse
hears the natural activity of the gastrointestinal tract before manipulation occurs.
5. A nurse is testing the function of Cranial Nerve VII (Facial Nerve). Which action should the
nurse ask the patient to perform?
A. Shrug the shoulders against resistance
B. Smile, frown, and puff out the cheeks
C. Protrude the tongue and move it side to side
D. Follow a moving object with the eyes
