NSG 3160 Final Exam V1 | NSG 3160 Health
Assessment | Actual Q&A with Rationale (NSG3160
Final Exam) | Galen
1. During a physical examination, the nurse uses the dorsal surface of the hand to assess
which of the following parameters?
A. Vibrations and tactile fremitus
B. Pulsations and skin texture
C. Position of organs and presence of masses
D. Skin temperature
Correct Answer: D
Explanation: The dorsal surface of the hand is the most sensitive area for assessing skin
temperature because the skin is thinner than on the palms. Assessing for vibrations or
tactile fremitus is best performed using the ulnar surface or the base of the fingers. The
finger pads are more suitable for fine tactile discrimination such as texture and pulsation.
2. When assessing a mole for potential malignancy, the nurse should utilize the ABCDE
mnemonic. Which of the following findings would be considered warning signs? Select all that
apply.
A. Asymmetry of the lesion
B. Borders that are irregular or notched
,C. Color variation within the single lesion
D. Diameter less than 4 mm
E. Evolving or changing in appearance
F. Smooth, well-defined margins
Correct Answer: A, B, C, E
Explanation: The ABCDE assessment for melanoma includes Asymmetry, Border
irregularity, Color variation, Diameter greater than 6 mm, and Evolving or Elevation. A
diameter of less than 6 mm is generally not a warning sign, although all changes should be
monitored. Smooth, well-defined margins are typically associated with benign nevi rather
than malignant lesions.
3. The nurse is preparing to percuss the patient’s liver. Which percussion note does the nurse
expect to hear over this solid organ?
A. Resonance
B. Hyperresonance
C. Dullness
D. Tympany
Correct Answer: C
Explanation: Dullness is the characteristic sound heard when percussing over dense
organs such as the liver or spleen. Resonance is heard over normal lung tissue, while
, hyperresonance is heard in conditions like emphysema. Tympany is typically heard over
air-filled structures like the stomach or intestines.
4. A nurse is performing a pupillary assessment. Which cranial nerves are responsible for the
pupillary light reflex?
A. CN II and CN III
B. CN III and CN IV
C. CN V and CN VII
D. CN II and CN VI
Correct Answer: A
Explanation: Cranial Nerve II (Optic) is the sensory nerve that carries the light stimulus to
the brain. Cranial Nerve III (Oculomotor) is the motor nerve responsible for the pupillary
constriction response. Assessing these nerves together determines the integrity of the
midbrain reflex arc.
5. When auscultating the lungs of a patient with pleuritis, the nurse hears a low-pitched,
coarse, grating sound during both inspiration and expiration. How should the nurse
document this finding?
A. Pleural friction rub
B. Wheezes
C. Fine crackles
Assessment | Actual Q&A with Rationale (NSG3160
Final Exam) | Galen
1. During a physical examination, the nurse uses the dorsal surface of the hand to assess
which of the following parameters?
A. Vibrations and tactile fremitus
B. Pulsations and skin texture
C. Position of organs and presence of masses
D. Skin temperature
Correct Answer: D
Explanation: The dorsal surface of the hand is the most sensitive area for assessing skin
temperature because the skin is thinner than on the palms. Assessing for vibrations or
tactile fremitus is best performed using the ulnar surface or the base of the fingers. The
finger pads are more suitable for fine tactile discrimination such as texture and pulsation.
2. When assessing a mole for potential malignancy, the nurse should utilize the ABCDE
mnemonic. Which of the following findings would be considered warning signs? Select all that
apply.
A. Asymmetry of the lesion
B. Borders that are irregular or notched
,C. Color variation within the single lesion
D. Diameter less than 4 mm
E. Evolving or changing in appearance
F. Smooth, well-defined margins
Correct Answer: A, B, C, E
Explanation: The ABCDE assessment for melanoma includes Asymmetry, Border
irregularity, Color variation, Diameter greater than 6 mm, and Evolving or Elevation. A
diameter of less than 6 mm is generally not a warning sign, although all changes should be
monitored. Smooth, well-defined margins are typically associated with benign nevi rather
than malignant lesions.
3. The nurse is preparing to percuss the patient’s liver. Which percussion note does the nurse
expect to hear over this solid organ?
A. Resonance
B. Hyperresonance
C. Dullness
D. Tympany
Correct Answer: C
Explanation: Dullness is the characteristic sound heard when percussing over dense
organs such as the liver or spleen. Resonance is heard over normal lung tissue, while
, hyperresonance is heard in conditions like emphysema. Tympany is typically heard over
air-filled structures like the stomach or intestines.
4. A nurse is performing a pupillary assessment. Which cranial nerves are responsible for the
pupillary light reflex?
A. CN II and CN III
B. CN III and CN IV
C. CN V and CN VII
D. CN II and CN VI
Correct Answer: A
Explanation: Cranial Nerve II (Optic) is the sensory nerve that carries the light stimulus to
the brain. Cranial Nerve III (Oculomotor) is the motor nerve responsible for the pupillary
constriction response. Assessing these nerves together determines the integrity of the
midbrain reflex arc.
5. When auscultating the lungs of a patient with pleuritis, the nurse hears a low-pitched,
coarse, grating sound during both inspiration and expiration. How should the nurse
document this finding?
A. Pleural friction rub
B. Wheezes
C. Fine crackles
