NRS 420 Exam 1 V2 | NRS 420 Health Assessment |
Actual Q&A with Rationale (NRS420 Exam 1) |
Grand Canyon University
1. During the working phase of the patient interview, which action by the nurse is most
appropriate?
A. Introducing oneself and explaining the purpose of the visit
B. Using open-ended questions to gather data about the patient’s health
C. Summarizing the key points discussed during the session
D. Reviewing the medical record before entering the room
Correct Answer: B
Explanation: The working phase is the data-gathering portion of the interview where the
nurse uses communication skills to collect a health history. This phase focuses on the
patient’s specific health concerns and the nurse’s observations. Introducing oneself occurs
in the introductory phase, while summarizing occurs in the closing phase.
2. Which of the following findings are considered subjective data? (Select all that apply)
A. Patient reports a pain level of 8/10 on the scale
B. Blood pressure reading of 140/90 mmHg
C. Patient states they feel nauseated after eating
D. Nurse observes the patient grimacing during movement
,E. Patient describes a burning sensation in the chest
F. Presence of a 2 cm laceration on the left forearm
Correct Answer: A, C, E
Explanation: Subjective data consists of information provided by the patient that cannot
be directly observed by the nurse, such as feelings, perceptions, or symptoms like pain and
nausea. In contrast, objective data is measurable and observable, such as blood pressure
readings, physical wounds, or visible grimacing. Correctly identifying subjective data is
essential for accurate health history documentation and symptom analysis.
3. The nurse is assessing a patient’s radial pulse and notes the rhythm is irregular. What is the
next best action by the nurse?
A. Document the finding and move to the next assessment
B. Auscultate the apical pulse for one full minute
C. Palpate the carotid pulse for thirty seconds
D. Notify the healthcare provider immediately
Correct Answer: B
Explanation: When a peripheral pulse is irregular, the nurse must assess the apical pulse
for a full 60 seconds to determine the actual heart rate and identify any pulse deficit. This
provides a more accurate assessment of the heart’s electrical and mechanical activity.
Simply documenting an irregular pulse without further investigation is insufficient for
professional nursing practice.
, 4. When assessing a patient’s abdomen, in which order should the nurse perform the physical
examination techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: A
Explanation: The standard order of assessment is Inspection, Palpation, Percussion, and
Auscultation, but the abdomen is the exception to this rule. Percussion and palpation can
stimulate bowel sounds and alter the findings if done before auscultation. Therefore, the
nurse must auscultate immediately after inspection to ensure the most accurate
assessment of bowel activity.
5. A nurse is assessing a 75-year-old patient. Which of the following are normal age-related
changes of the skin? (Select all that apply)
A. Decreased skin elasticity and turgor
B. Increased subcutaneous fat distribution
C. Thinning of the epidermal layer
D. Increased vascularity and redness
E. Presence of senile lentigines (age spots)
Actual Q&A with Rationale (NRS420 Exam 1) |
Grand Canyon University
1. During the working phase of the patient interview, which action by the nurse is most
appropriate?
A. Introducing oneself and explaining the purpose of the visit
B. Using open-ended questions to gather data about the patient’s health
C. Summarizing the key points discussed during the session
D. Reviewing the medical record before entering the room
Correct Answer: B
Explanation: The working phase is the data-gathering portion of the interview where the
nurse uses communication skills to collect a health history. This phase focuses on the
patient’s specific health concerns and the nurse’s observations. Introducing oneself occurs
in the introductory phase, while summarizing occurs in the closing phase.
2. Which of the following findings are considered subjective data? (Select all that apply)
A. Patient reports a pain level of 8/10 on the scale
B. Blood pressure reading of 140/90 mmHg
C. Patient states they feel nauseated after eating
D. Nurse observes the patient grimacing during movement
,E. Patient describes a burning sensation in the chest
F. Presence of a 2 cm laceration on the left forearm
Correct Answer: A, C, E
Explanation: Subjective data consists of information provided by the patient that cannot
be directly observed by the nurse, such as feelings, perceptions, or symptoms like pain and
nausea. In contrast, objective data is measurable and observable, such as blood pressure
readings, physical wounds, or visible grimacing. Correctly identifying subjective data is
essential for accurate health history documentation and symptom analysis.
3. The nurse is assessing a patient’s radial pulse and notes the rhythm is irregular. What is the
next best action by the nurse?
A. Document the finding and move to the next assessment
B. Auscultate the apical pulse for one full minute
C. Palpate the carotid pulse for thirty seconds
D. Notify the healthcare provider immediately
Correct Answer: B
Explanation: When a peripheral pulse is irregular, the nurse must assess the apical pulse
for a full 60 seconds to determine the actual heart rate and identify any pulse deficit. This
provides a more accurate assessment of the heart’s electrical and mechanical activity.
Simply documenting an irregular pulse without further investigation is insufficient for
professional nursing practice.
, 4. When assessing a patient’s abdomen, in which order should the nurse perform the physical
examination techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: A
Explanation: The standard order of assessment is Inspection, Palpation, Percussion, and
Auscultation, but the abdomen is the exception to this rule. Percussion and palpation can
stimulate bowel sounds and alter the findings if done before auscultation. Therefore, the
nurse must auscultate immediately after inspection to ensure the most accurate
assessment of bowel activity.
5. A nurse is assessing a 75-year-old patient. Which of the following are normal age-related
changes of the skin? (Select all that apply)
A. Decreased skin elasticity and turgor
B. Increased subcutaneous fat distribution
C. Thinning of the epidermal layer
D. Increased vascularity and redness
E. Presence of senile lentigines (age spots)
