NSG 3160 Final Exam V3 | NSG 3160 Health
Assessment | Actual Q&A with Rationale (NSG3160
Final Exam) | Galen
1. During a physical examination, the nurse percusses over the patient’s liver. Which sound
does the nurse expect to hear?
A. Resonance
B. Dullness
C. Tympany
D. Hyperresonance
Correct Answer: B
Explanation: Dullness is the characteristic sound heard when percussing over dense
organs such as the liver or spleen. Resonance is typically heard over normal lung tissue,
while tympany is expected over air-filled structures like the stomach. Hyperresonance is an
abnormal finding in adults often associated with hyperinflated lungs.
2. A nurse is conducting a health history interview. Which of the following findings are
considered subjective data? (Select all that apply)
A. Patient reports a ‘throbbing’ headache
B. Blood pressure reading of 140/90 mmHg
C. Patient states they feel nauseated
,D. Pitting edema noted in the lower extremities
E. Patient describes feeling anxious about surgery
F. Patient complains of itching on their back
Correct Answer: ACEF
Explanation: Subjective data consists of information that the patient perceives and
reports, which cannot be directly measured by the examiner. Pain, nausea, anxiety, and
itching are all internal sensations that only the patient can verify. Objective data, such as
blood pressure and edema, are observable and measurable signs detected during the
physical exam.
3. The nurse is assessing a patient’s pupillary response. Which cranial nerves are primarily
responsible for the pupillary light reflex?
A. CN IV (Trochlear) and CN VI (Abducens)
B. CN III (Oculomotor) and CN IV (Trochlear)
C. CN II (Optic) and CN III (Oculomotor)
D. CN V (Trigeminal) and CN VII (Facial)
Correct Answer: C
Explanation: The pupillary light reflex involves the sensory pathway of the optic nerve
(CN II) and the motor pathway of the oculomotor nerve (CN III). The optic nerve carries the
, light stimulus to the brain, while the oculomotor nerve carries the signal to constrict the
pupil. Dysfunction in either nerve can lead to an abnormal or absent pupillary response.
4. When assessing the carotid arteries, which action by the nurse is correct to avoid
compromising cerebral blood flow?
A. Palpate both carotid arteries simultaneously
B. Auscultate for bruits using the diaphragm of the stethoscope
C. Palpate one carotid artery at a time
D. Instruct the patient to take deep breaths during palpation
Correct Answer: C
Explanation: The nurse must palpate only one carotid artery at a time to prevent
accidental occlusion of blood flow to the brain, which could cause syncope. Simultaneous
palpation could also trigger the carotid sinus reflex, leading to a dangerous drop in heart
rate or blood pressure. Auscultation for bruits should be done with the bell, not the
diaphragm, and the patient should briefly hold their breath.
5. A patient presents with a ‘2+’ rating for peripheral pulses. How should the nurse interpret
this finding?
A. The pulse is weak and thready
B. The pulse is absent
C. The pulse is bounding and full
Assessment | Actual Q&A with Rationale (NSG3160
Final Exam) | Galen
1. During a physical examination, the nurse percusses over the patient’s liver. Which sound
does the nurse expect to hear?
A. Resonance
B. Dullness
C. Tympany
D. Hyperresonance
Correct Answer: B
Explanation: Dullness is the characteristic sound heard when percussing over dense
organs such as the liver or spleen. Resonance is typically heard over normal lung tissue,
while tympany is expected over air-filled structures like the stomach. Hyperresonance is an
abnormal finding in adults often associated with hyperinflated lungs.
2. A nurse is conducting a health history interview. Which of the following findings are
considered subjective data? (Select all that apply)
A. Patient reports a ‘throbbing’ headache
B. Blood pressure reading of 140/90 mmHg
C. Patient states they feel nauseated
,D. Pitting edema noted in the lower extremities
E. Patient describes feeling anxious about surgery
F. Patient complains of itching on their back
Correct Answer: ACEF
Explanation: Subjective data consists of information that the patient perceives and
reports, which cannot be directly measured by the examiner. Pain, nausea, anxiety, and
itching are all internal sensations that only the patient can verify. Objective data, such as
blood pressure and edema, are observable and measurable signs detected during the
physical exam.
3. The nurse is assessing a patient’s pupillary response. Which cranial nerves are primarily
responsible for the pupillary light reflex?
A. CN IV (Trochlear) and CN VI (Abducens)
B. CN III (Oculomotor) and CN IV (Trochlear)
C. CN II (Optic) and CN III (Oculomotor)
D. CN V (Trigeminal) and CN VII (Facial)
Correct Answer: C
Explanation: The pupillary light reflex involves the sensory pathway of the optic nerve
(CN II) and the motor pathway of the oculomotor nerve (CN III). The optic nerve carries the
, light stimulus to the brain, while the oculomotor nerve carries the signal to constrict the
pupil. Dysfunction in either nerve can lead to an abnormal or absent pupillary response.
4. When assessing the carotid arteries, which action by the nurse is correct to avoid
compromising cerebral blood flow?
A. Palpate both carotid arteries simultaneously
B. Auscultate for bruits using the diaphragm of the stethoscope
C. Palpate one carotid artery at a time
D. Instruct the patient to take deep breaths during palpation
Correct Answer: C
Explanation: The nurse must palpate only one carotid artery at a time to prevent
accidental occlusion of blood flow to the brain, which could cause syncope. Simultaneous
palpation could also trigger the carotid sinus reflex, leading to a dangerous drop in heart
rate or blood pressure. Auscultation for bruits should be done with the bell, not the
diaphragm, and the patient should briefly hold their breath.
5. A patient presents with a ‘2+’ rating for peripheral pulses. How should the nurse interpret
this finding?
A. The pulse is weak and thready
B. The pulse is absent
C. The pulse is bounding and full
