NRS 420 Exam 1 V1 | NRS 420 Health Assessment |
Actual Q&A with Rationale (NRS420 Exam 1) |
Grand Canyon University
1. When conducting a health history interview with an older adult, which action should the
nurse prioritize to ensure effective communication?
A. Speak in a high-pitched, loud voice to ensure they can hear.
B. Direct all questions to the family member accompanying the patient.
C. Avoid eye contact to minimize the patient’s anxiety.
D. Allow extra time for the patient to respond to questions.
Correct Answer: D
Explanation: Older adults often require more time to process information and formulate
responses due to physiological changes. Speaking in a high-pitched voice can actually make
it harder for those with presbycusis to understand. It is essential to maintain eye contact
and treat the patient as the primary source of information whenever possible.
2. The nurse is performing a physical assessment on a client. Which technique should the
nurse use first for most body systems, excluding the abdomen?
A. Palpation
B. Percussion
C. Auscultation
,D. Inspection
Correct Answer: D
Explanation: Inspection is the first step in the physical assessment process and involves a
visual examination of the client. This initial step allows the nurse to gather significant data
before touching the patient. Following inspection, the sequence typically proceeds to
palpation, percussion, and then auscultation, except in abdominal exams.
3. Which of the following are considered ‘Select All That Apply’ (SATA): A nurse is preparing
to conduct a health assessment. Which environmental factors should be controlled to ensure
a successful exam?
A. Provide a comfortable room temperature.
B. Ensure adequate lighting for visualization.
C. Keep the room door open for safety and visibility.
D. Minimize background noise and distractions.
E. Provide privacy by using curtains or a private room.
F. Allow multiple family members to remain in the room during the physical exam.
Correct Answer: A, B, D, E
Explanation: A conducive environment is critical for an accurate and respectful health
assessment. The room should be warm, well-lit, and quiet to allow for proper observation
, and auscultation. Privacy is a legal and ethical requirement, whereas keeping the door open
or having a crowd in the room compromises patient confidentiality.
4. A nurse is assessing a patient’s blood pressure and finds the cuff is too small for the
patient’s arm. What effect will this have on the reading?
A. The blood pressure reading will be falsely low.
B. Only the diastolic pressure will be affected.
C. The reading will be accurate regardless of cuff size.
D. The blood pressure reading will be falsely high.
Correct Answer: D
Explanation: Using a blood pressure cuff that is too small for the patient’s limb will result
in a falsely elevated blood pressure reading. The cuff must be the correct size to properly
occlude the artery without excessive pressure. Conversely, a cuff that is too large will yield
a falsely low reading.
5. While assessing a patient’s skin, the nurse notes a lesion that is asymmetrical, has irregular
borders, and has changed color recently. Which condition should the nurse suspect?
A. Basal cell carcinoma
B. Psoriasis
C. Contact dermatitis
D. Melanoma
Actual Q&A with Rationale (NRS420 Exam 1) |
Grand Canyon University
1. When conducting a health history interview with an older adult, which action should the
nurse prioritize to ensure effective communication?
A. Speak in a high-pitched, loud voice to ensure they can hear.
B. Direct all questions to the family member accompanying the patient.
C. Avoid eye contact to minimize the patient’s anxiety.
D. Allow extra time for the patient to respond to questions.
Correct Answer: D
Explanation: Older adults often require more time to process information and formulate
responses due to physiological changes. Speaking in a high-pitched voice can actually make
it harder for those with presbycusis to understand. It is essential to maintain eye contact
and treat the patient as the primary source of information whenever possible.
2. The nurse is performing a physical assessment on a client. Which technique should the
nurse use first for most body systems, excluding the abdomen?
A. Palpation
B. Percussion
C. Auscultation
,D. Inspection
Correct Answer: D
Explanation: Inspection is the first step in the physical assessment process and involves a
visual examination of the client. This initial step allows the nurse to gather significant data
before touching the patient. Following inspection, the sequence typically proceeds to
palpation, percussion, and then auscultation, except in abdominal exams.
3. Which of the following are considered ‘Select All That Apply’ (SATA): A nurse is preparing
to conduct a health assessment. Which environmental factors should be controlled to ensure
a successful exam?
A. Provide a comfortable room temperature.
B. Ensure adequate lighting for visualization.
C. Keep the room door open for safety and visibility.
D. Minimize background noise and distractions.
E. Provide privacy by using curtains or a private room.
F. Allow multiple family members to remain in the room during the physical exam.
Correct Answer: A, B, D, E
Explanation: A conducive environment is critical for an accurate and respectful health
assessment. The room should be warm, well-lit, and quiet to allow for proper observation
, and auscultation. Privacy is a legal and ethical requirement, whereas keeping the door open
or having a crowd in the room compromises patient confidentiality.
4. A nurse is assessing a patient’s blood pressure and finds the cuff is too small for the
patient’s arm. What effect will this have on the reading?
A. The blood pressure reading will be falsely low.
B. Only the diastolic pressure will be affected.
C. The reading will be accurate regardless of cuff size.
D. The blood pressure reading will be falsely high.
Correct Answer: D
Explanation: Using a blood pressure cuff that is too small for the patient’s limb will result
in a falsely elevated blood pressure reading. The cuff must be the correct size to properly
occlude the artery without excessive pressure. Conversely, a cuff that is too large will yield
a falsely low reading.
5. While assessing a patient’s skin, the nurse notes a lesion that is asymmetrical, has irregular
borders, and has changed color recently. Which condition should the nurse suspect?
A. Basal cell carcinoma
B. Psoriasis
C. Contact dermatitis
D. Melanoma
