NSG 3160 Final Exam V2 | NSG 3160 Health
Assessment | Actual Q&A with Rationale (NSG3160
Final Exam) | Galen
1. A nurse is performing a physical assessment on a client with suspected dehydration. Which
of the following assessment findings should the nurse anticipate? (Select All That Apply)
A. Tenting of the skin when pinched
B. Dry mucous membranes
C. Capillary refill less than 2 seconds
D. Sunken eyeballs
E. Tachycardia
F. Decreased urine output
Correct Answer: A, B, D, E, F
Explanation: Skin turgor assessment reflects hydration status; tenting indicates fluid
volume deficit. Dry mucous membranes and sunken eyeballs are classic signs of systemic
dehydration. Tachycardia occurs as a compensatory mechanism for decreased circulating
volume, while kidneys conserve fluid resulting in low output.
2. During a respiratory assessment, the nurse hears high-pitched, musical sounds primarily
during expiration. How should the nurse document this finding?
A. Wheezes
,B. Crackles
C. Pleural friction rub
D. Stridor
Correct Answer: A
Explanation: Wheezes are high-pitched musical sounds caused by air passing through
narrowed airways, commonly seen in asthma. Crackles are popping sounds often
associated with fluid, while a pleural friction rub sounds like leather rubbing together.
Stridor is a harsh, high-pitched sound indicating upper airway obstruction.
3. When assessing the abdomen, which sequence of techniques must the nurse follow to
ensure accurate findings?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: C
Explanation: The specific sequence for abdominal assessment is inspection followed by
auscultation. Percussion and palpation are performed last because they can stimulate
bowel activity and alter bowel sounds. Following this order prevents the nurse from
obtaining false-positive results regarding bowel motility.
, 4. A nurse is evaluating a client’s risk for melanoma using the ABCDE mnemonic. Which
characteristic would be considered a warning sign?
A. Symmetry of the mole’s shape
B. Diameter less than 6 mm
C. Smooth, well-defined borders
D. Color variation within the lesion
Correct Answer: D
Explanation: The ‘C’ in ABCDE stands for color variation, which is a significant indicator of
potential malignancy. A stands for Asymmetry, B for Border irregularity, D for Diameter
greater than 6mm, and E for Evolving. Lesions that show multiple shades of brown, black,
or red require further dermatological evaluation.
5. The nurse asks the client to shrug their shoulders against resistance. Which cranial nerve is
being tested?
A. CN VII (Facial)
B. CN IX (Glossopharyngeal)
C. CN XI (Spinal Accessory)
D. CN XII (Hypoglossal)
Correct Answer: C
Assessment | Actual Q&A with Rationale (NSG3160
Final Exam) | Galen
1. A nurse is performing a physical assessment on a client with suspected dehydration. Which
of the following assessment findings should the nurse anticipate? (Select All That Apply)
A. Tenting of the skin when pinched
B. Dry mucous membranes
C. Capillary refill less than 2 seconds
D. Sunken eyeballs
E. Tachycardia
F. Decreased urine output
Correct Answer: A, B, D, E, F
Explanation: Skin turgor assessment reflects hydration status; tenting indicates fluid
volume deficit. Dry mucous membranes and sunken eyeballs are classic signs of systemic
dehydration. Tachycardia occurs as a compensatory mechanism for decreased circulating
volume, while kidneys conserve fluid resulting in low output.
2. During a respiratory assessment, the nurse hears high-pitched, musical sounds primarily
during expiration. How should the nurse document this finding?
A. Wheezes
,B. Crackles
C. Pleural friction rub
D. Stridor
Correct Answer: A
Explanation: Wheezes are high-pitched musical sounds caused by air passing through
narrowed airways, commonly seen in asthma. Crackles are popping sounds often
associated with fluid, while a pleural friction rub sounds like leather rubbing together.
Stridor is a harsh, high-pitched sound indicating upper airway obstruction.
3. When assessing the abdomen, which sequence of techniques must the nurse follow to
ensure accurate findings?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: C
Explanation: The specific sequence for abdominal assessment is inspection followed by
auscultation. Percussion and palpation are performed last because they can stimulate
bowel activity and alter bowel sounds. Following this order prevents the nurse from
obtaining false-positive results regarding bowel motility.
, 4. A nurse is evaluating a client’s risk for melanoma using the ABCDE mnemonic. Which
characteristic would be considered a warning sign?
A. Symmetry of the mole’s shape
B. Diameter less than 6 mm
C. Smooth, well-defined borders
D. Color variation within the lesion
Correct Answer: D
Explanation: The ‘C’ in ABCDE stands for color variation, which is a significant indicator of
potential malignancy. A stands for Asymmetry, B for Border irregularity, D for Diameter
greater than 6mm, and E for Evolving. Lesions that show multiple shades of brown, black,
or red require further dermatological evaluation.
5. The nurse asks the client to shrug their shoulders against resistance. Which cranial nerve is
being tested?
A. CN VII (Facial)
B. CN IX (Glossopharyngeal)
C. CN XI (Spinal Accessory)
D. CN XII (Hypoglossal)
Correct Answer: C
