GCU NSG 316 EXAM 2 – HEALTH
ASSESSMENT PRACTICE QUESTIONS
AND ANSWERS
1. When assessing a patient’s skin turgor to evaluate for dehydration, where is the most
appropriate location to perform this assessment in an elderly adult?
A. The back of the hand
B. Beneath the clavicle
C. The forearm
D. The abdomen
Answer: B
Conceptual Explanation: In older adults, skin on the hands and forearms loses elasticity
due to aging. The subclavicular area or the sternum provides a more accurate assessment
of systemic hydration status.
2. A nurse observes a ‘clubbing’ appearance of a patient’s fingernails with a profile sign angle
greater than 180 degrees. This finding is most characteristic of:
A. Chronic iron deficiency anemia
,B. Chronic hypoxia or pulmonary disease
C. Acute bacterial infection
D. Normal aging process
Answer: B
Conceptual Explanation: Clubbing occurs with congenital cyanotic heart disease, lung
cancer, and chronic pulmonary diseases where oxygenation is chronically impaired.
3. During a fundoscopic examination, the nurse identifies the ‘red reflex.’ What does this
finding indicate?
A. Presence of cataracts
B. Retinal detachment
C. Increased intraocular pressure
D. A normal finding reflecting light off the retina
Answer: D
Conceptual Explanation: The red reflex is a normal finding caused by the reflection of the
ophthalmoscope light off the inner retina.
4. When performing the Weber test, the patient reports that the sound is heard better in the
right ear. This ‘lateralization’ to the impaired ear suggests which type of hearing loss?
A. Sensorineural hearing loss in the right ear
B. Central deafness
, C. Conductive hearing loss in the right ear
D. Normal hearing
Answer: C
Conceptual Explanation: In conductive hearing loss, the sound lateralizes to the ‘bad’ ear
because the background noise is blocked, allowing the vibrations to be heard more clearly.
5. The nurse is palpating the cervical lymph nodes and finds they are small, mobile, discrete,
and nontender. How should the nurse document this?
A. Lymphadenopathy
B. Possible malignancy
C. Normal findings
D. Acute infection
Answer: C
Conceptual Explanation: Normal lymph nodes are typically non-palpable in adults, but if
they are felt, they should be small, mobile, discrete, and nontender.
6. While assessing the chest, the nurse notes a coarse, low-pitched, ‘snoring’ sound that
clears with coughing. This breath sound is documented as:
A. Wheezes
B. Rhonchi
C. Fine crackles
ASSESSMENT PRACTICE QUESTIONS
AND ANSWERS
1. When assessing a patient’s skin turgor to evaluate for dehydration, where is the most
appropriate location to perform this assessment in an elderly adult?
A. The back of the hand
B. Beneath the clavicle
C. The forearm
D. The abdomen
Answer: B
Conceptual Explanation: In older adults, skin on the hands and forearms loses elasticity
due to aging. The subclavicular area or the sternum provides a more accurate assessment
of systemic hydration status.
2. A nurse observes a ‘clubbing’ appearance of a patient’s fingernails with a profile sign angle
greater than 180 degrees. This finding is most characteristic of:
A. Chronic iron deficiency anemia
,B. Chronic hypoxia or pulmonary disease
C. Acute bacterial infection
D. Normal aging process
Answer: B
Conceptual Explanation: Clubbing occurs with congenital cyanotic heart disease, lung
cancer, and chronic pulmonary diseases where oxygenation is chronically impaired.
3. During a fundoscopic examination, the nurse identifies the ‘red reflex.’ What does this
finding indicate?
A. Presence of cataracts
B. Retinal detachment
C. Increased intraocular pressure
D. A normal finding reflecting light off the retina
Answer: D
Conceptual Explanation: The red reflex is a normal finding caused by the reflection of the
ophthalmoscope light off the inner retina.
4. When performing the Weber test, the patient reports that the sound is heard better in the
right ear. This ‘lateralization’ to the impaired ear suggests which type of hearing loss?
A. Sensorineural hearing loss in the right ear
B. Central deafness
, C. Conductive hearing loss in the right ear
D. Normal hearing
Answer: C
Conceptual Explanation: In conductive hearing loss, the sound lateralizes to the ‘bad’ ear
because the background noise is blocked, allowing the vibrations to be heard more clearly.
5. The nurse is palpating the cervical lymph nodes and finds they are small, mobile, discrete,
and nontender. How should the nurse document this?
A. Lymphadenopathy
B. Possible malignancy
C. Normal findings
D. Acute infection
Answer: C
Conceptual Explanation: Normal lymph nodes are typically non-palpable in adults, but if
they are felt, they should be small, mobile, discrete, and nontender.
6. While assessing the chest, the nurse notes a coarse, low-pitched, ‘snoring’ sound that
clears with coughing. This breath sound is documented as:
A. Wheezes
B. Rhonchi
C. Fine crackles
