NRS 420 Exam 3 V2 | NRS 420 Health Assessment |
Actual Q&A with Rationale (NRS420 Exam 3) |
Grand Canyon University
1. A nurse is performing an abdominal assessment. Which sequence of techniques should the
nurse follow to ensure accurate findings?
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 order for abdominal assessment is inspection, auscultation,
percussion, and then palpation. This sequence is unique because percussion and palpation
can alter bowel sounds by increasing peristalsis. By auscultating immediately after
inspection, the nurse obtains the most accurate representation of the patient’s bowel
activity.
2. During a neurological assessment, the nurse evaluates the function of the cranial nerves.
Which of the following cranial nerves are responsible for eye movement? (Select All That
Apply)
A. CN II (Optic)
B. CN III (Oculomotor)
,C. CN IV (Trochlear)
D. CN V (Trigeminal)
E. CN VI (Abducens)
F. CN VIII (Vestibulocochlear)
Correct Answer: B, C, E
Explanation: Cranial nerves III (Oculomotor), IV (Trochlear), and VI (Abducens) are
primarily responsible for the extraocular movements of the eye. CN II is responsible for
vision (acuity and fields) rather than movement. CN V handles facial sensation and
mastication, while CN VIII is involved in hearing and balance.
3. A patient presents with suspected appendicitis. Which of the following clinical signs or
tests should the nurse assess for? (Select All That Apply)
A. Murphy’s Sign
B. McBurney’s Point Tenderness
C. Rebound Tenderness (Blumberg Sign)
D. Iliopsoas Muscle Test
E. Fluid Wave Test
Correct Answer: B, C, D
Explanation: McBurney’s point tenderness, rebound tenderness, and the Iliopsoas muscle
test are classic indicators of appendicitis or peritoneal irritation. Murphy’s sign is
, specifically used to assess for cholecystitis (gallbladder inflammation). The fluid wave test
is used to detect ascites, which is the accumulation of fluid in the peritoneal cavity.
4. When assessing the musculoskeletal system, the nurse notes a grating or crackling sound
when the patient moves their knee. This finding is documented as:
A. Crepitus
B. Borborygmi
C. Kyphosis
D. Subluxation
Correct Answer: A
Explanation: Crepitus refers to the audible or palpable crunching or grating sound
produced by joint motion, often signifying articular surface degradation. Borborygmi are
hyperactive bowel sounds. Kyphosis is an exaggerated posterior curvature of the thoracic
spine, and subluxation refers to partial dislocation of a joint.
5. The nurse is assessing a patient’s deep tendon reflexes and finds them to be very brisk with
rhythmic oscillations (clonus). How should the nurse grade this finding?
A. 4+
B. 2+
C. 3+
D. 1+
Actual Q&A with Rationale (NRS420 Exam 3) |
Grand Canyon University
1. A nurse is performing an abdominal assessment. Which sequence of techniques should the
nurse follow to ensure accurate findings?
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 order for abdominal assessment is inspection, auscultation,
percussion, and then palpation. This sequence is unique because percussion and palpation
can alter bowel sounds by increasing peristalsis. By auscultating immediately after
inspection, the nurse obtains the most accurate representation of the patient’s bowel
activity.
2. During a neurological assessment, the nurse evaluates the function of the cranial nerves.
Which of the following cranial nerves are responsible for eye movement? (Select All That
Apply)
A. CN II (Optic)
B. CN III (Oculomotor)
,C. CN IV (Trochlear)
D. CN V (Trigeminal)
E. CN VI (Abducens)
F. CN VIII (Vestibulocochlear)
Correct Answer: B, C, E
Explanation: Cranial nerves III (Oculomotor), IV (Trochlear), and VI (Abducens) are
primarily responsible for the extraocular movements of the eye. CN II is responsible for
vision (acuity and fields) rather than movement. CN V handles facial sensation and
mastication, while CN VIII is involved in hearing and balance.
3. A patient presents with suspected appendicitis. Which of the following clinical signs or
tests should the nurse assess for? (Select All That Apply)
A. Murphy’s Sign
B. McBurney’s Point Tenderness
C. Rebound Tenderness (Blumberg Sign)
D. Iliopsoas Muscle Test
E. Fluid Wave Test
Correct Answer: B, C, D
Explanation: McBurney’s point tenderness, rebound tenderness, and the Iliopsoas muscle
test are classic indicators of appendicitis or peritoneal irritation. Murphy’s sign is
, specifically used to assess for cholecystitis (gallbladder inflammation). The fluid wave test
is used to detect ascites, which is the accumulation of fluid in the peritoneal cavity.
4. When assessing the musculoskeletal system, the nurse notes a grating or crackling sound
when the patient moves their knee. This finding is documented as:
A. Crepitus
B. Borborygmi
C. Kyphosis
D. Subluxation
Correct Answer: A
Explanation: Crepitus refers to the audible or palpable crunching or grating sound
produced by joint motion, often signifying articular surface degradation. Borborygmi are
hyperactive bowel sounds. Kyphosis is an exaggerated posterior curvature of the thoracic
spine, and subluxation refers to partial dislocation of a joint.
5. The nurse is assessing a patient’s deep tendon reflexes and finds them to be very brisk with
rhythmic oscillations (clonus). How should the nurse grade this finding?
A. 4+
B. 2+
C. 3+
D. 1+
