NRS 420 Exam 3 V3 | NRS 420 Health Assessment |
Actual Q&A with Rationale (NRS420 Exam 3) |
Grand Canyon University
1. When conducting a clinical breast examination on a 50-year-old female patient, which of
the following findings would the nurse identify as suspicious for malignancy? (Select all that
apply.)
A. A mobile, soft, non-tender mass in the upper outer quadrant
B. Persistent skin dimpling or retraction when the patient raises her arms
C. Unilateral nipple retraction of recent onset
D. Spontaneous serosanguineous nipple discharge
E. Peau d’orange appearance of the skin
F. Bilateral cyclic breast tenderness related to menses
Correct Answer: B,C,D,E
Explanation: Skin dimpling and recent nipple retraction are classic indicators of
underlying fibrosis often associated with malignant tumors. Spontaneous discharge and
peau d’orange, which results from lymphatic obstruction, are also significant warning signs.
The nurse must prioritize these findings for further diagnostic testing such as
mammography or biopsy.
,2. The nurse is performing an abdominal assessment. What is the correct sequence of
physical examination techniques for this specific body system?
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 standard sequence for abdominal assessment is inspection followed by
auscultation to ensure bowel sounds are not altered by physical contact. Percussion and
palpation are performed last as they can stimulate peristalsis or cause discomfort that
interferes with accurate auscultation. Following this order ensures the most valid
assessment of the gastrointestinal system.
3. During a musculoskeletal assessment, the nurse asks the patient to move their arm away
from the midline of the body. Which term correctly describes this movement?
A. Adduction
B. Flexion
C. Abduction
D. Extension
Correct Answer: C
, Explanation: Abduction is the movement of a limb away from the body’s midline in the
frontal plane. Adduction is the opposite movement, bringing the limb toward the midline.
Understanding these anatomical terms is essential for documenting range of motion
accurately during a physical exam.
4. When testing Cranial Nerve XII (Hypoglossal), what action should the nurse ask the patient
to perform?
A. Shrug the shoulders against resistance
B. Smile, frown, and puff out the cheeks
C. Stick out the tongue and move it from side to side
D. Identify common scents with eyes closed
Correct Answer: C
Explanation: The Hypoglossal nerve (CN XII) controls the muscles of the tongue, and its
function is assessed by observing tongue movement and symmetry. The nurse looks for
tremors or deviation to one side when the patient protrudes the tongue. Intact function is
indicated if the tongue remains midline and moves easily without fasciculation.
5. A nurse is assessing a patient for a suspected gallbladder inflammation (cholecystitis).
Which special percussion/palpation maneuver should the nurse perform?
A. McBurney’s Point palpation
B. Rovsing’s Sign
C. Murphy’s Sign
Actual Q&A with Rationale (NRS420 Exam 3) |
Grand Canyon University
1. When conducting a clinical breast examination on a 50-year-old female patient, which of
the following findings would the nurse identify as suspicious for malignancy? (Select all that
apply.)
A. A mobile, soft, non-tender mass in the upper outer quadrant
B. Persistent skin dimpling or retraction when the patient raises her arms
C. Unilateral nipple retraction of recent onset
D. Spontaneous serosanguineous nipple discharge
E. Peau d’orange appearance of the skin
F. Bilateral cyclic breast tenderness related to menses
Correct Answer: B,C,D,E
Explanation: Skin dimpling and recent nipple retraction are classic indicators of
underlying fibrosis often associated with malignant tumors. Spontaneous discharge and
peau d’orange, which results from lymphatic obstruction, are also significant warning signs.
The nurse must prioritize these findings for further diagnostic testing such as
mammography or biopsy.
,2. The nurse is performing an abdominal assessment. What is the correct sequence of
physical examination techniques for this specific body system?
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 standard sequence for abdominal assessment is inspection followed by
auscultation to ensure bowel sounds are not altered by physical contact. Percussion and
palpation are performed last as they can stimulate peristalsis or cause discomfort that
interferes with accurate auscultation. Following this order ensures the most valid
assessment of the gastrointestinal system.
3. During a musculoskeletal assessment, the nurse asks the patient to move their arm away
from the midline of the body. Which term correctly describes this movement?
A. Adduction
B. Flexion
C. Abduction
D. Extension
Correct Answer: C
, Explanation: Abduction is the movement of a limb away from the body’s midline in the
frontal plane. Adduction is the opposite movement, bringing the limb toward the midline.
Understanding these anatomical terms is essential for documenting range of motion
accurately during a physical exam.
4. When testing Cranial Nerve XII (Hypoglossal), what action should the nurse ask the patient
to perform?
A. Shrug the shoulders against resistance
B. Smile, frown, and puff out the cheeks
C. Stick out the tongue and move it from side to side
D. Identify common scents with eyes closed
Correct Answer: C
Explanation: The Hypoglossal nerve (CN XII) controls the muscles of the tongue, and its
function is assessed by observing tongue movement and symmetry. The nurse looks for
tremors or deviation to one side when the patient protrudes the tongue. Intact function is
indicated if the tongue remains midline and moves easily without fasciculation.
5. A nurse is assessing a patient for a suspected gallbladder inflammation (cholecystitis).
Which special percussion/palpation maneuver should the nurse perform?
A. McBurney’s Point palpation
B. Rovsing’s Sign
C. Murphy’s Sign
