NUR 3270/NUR3270 Final Exam V3 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing skin turgor in an adult client, which technique should the nurse use?
A. Press firmly on the client’s shins.
B. Rub the skin vigorously to check for redness.
C. Observe for tenting on the back of the hand.
D. Pinch the skin over the clavicle or sternum.
Answer: D
Rationale: Skin turgor is best assessed by pinching a fold of skin over the sternum or
under the clavicle. This technique measures the skin’s elasticity and provides information
about the client’s hydration status. Tenting of the skin indicates dehydration, whereas
immediate return to the original position indicates normal hydration.
2. Which heart sound is caused by the closure of the mitral and tricuspid valves?
A. S1
B. S2
C. S3
D. S4
,Answer: A
Rationale: The first heart sound, S1, is produced by the closure of the atrioventricular
valves, which are the mitral and tricuspid valves. It marks the beginning of systole and is
usually heard loudest at the apex of the heart. Distinguishing S1 from S2 is a fundamental
skill in cardiac auscultation.
3. In what sequence should the nurse perform an abdominal assessment?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Percussion, Palpation, Auscultation
C. Inspection, Palpation, Percussion, Auscultation
D. Auscultation, Inspection, Percussion, Palpation
Answer: A
Rationale: The correct order for abdominal assessment is inspection, auscultation,
percussion, and palpation. Auscultation is performed second to prevent manual
manipulation from altering the frequency of bowel sounds. This sequence ensures that the
nurse hears the most accurate representation of the client’s bowel activity.
4. The nurse observes a client’s pupil constricting when looking at a near object. What is this
phenomenon called?
A. Convergence
B. Consensual response
, C. Accommodation
D. Direct response
Answer: C
Rationale: Accommodation is the process by which the eyes change focus from distant to
near objects, involving pupillary constriction. This test is part of the PERRLA assessment
used to evaluate cranial nerve function. It demonstrates the ability of the lens and iris to
adjust to varying focal lengths.
5. Which cranial nerve is responsible for the movement of the tongue?
A. Cranial Nerve XII (Hypoglossal)
B. Cranial Nerve X (Vagus)
C. Cranial Nerve XI (Spinal Accessory)
D. Cranial Nerve IX (Glossopharyngeal)
Answer: A
Rationale: Cranial nerve XII, the hypoglossal nerve, is responsible for motor control of the
tongue. Assessment involves asking the client to stick out their tongue and move it from
side to side. Any deviation to one side or tremors during the movement may indicate nerve
damage.
6. What is the significance of hearing a ‘bruit’ during carotid artery auscultation?
A. It is a normal finding in older adults.
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing skin turgor in an adult client, which technique should the nurse use?
A. Press firmly on the client’s shins.
B. Rub the skin vigorously to check for redness.
C. Observe for tenting on the back of the hand.
D. Pinch the skin over the clavicle or sternum.
Answer: D
Rationale: Skin turgor is best assessed by pinching a fold of skin over the sternum or
under the clavicle. This technique measures the skin’s elasticity and provides information
about the client’s hydration status. Tenting of the skin indicates dehydration, whereas
immediate return to the original position indicates normal hydration.
2. Which heart sound is caused by the closure of the mitral and tricuspid valves?
A. S1
B. S2
C. S3
D. S4
,Answer: A
Rationale: The first heart sound, S1, is produced by the closure of the atrioventricular
valves, which are the mitral and tricuspid valves. It marks the beginning of systole and is
usually heard loudest at the apex of the heart. Distinguishing S1 from S2 is a fundamental
skill in cardiac auscultation.
3. In what sequence should the nurse perform an abdominal assessment?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Percussion, Palpation, Auscultation
C. Inspection, Palpation, Percussion, Auscultation
D. Auscultation, Inspection, Percussion, Palpation
Answer: A
Rationale: The correct order for abdominal assessment is inspection, auscultation,
percussion, and palpation. Auscultation is performed second to prevent manual
manipulation from altering the frequency of bowel sounds. This sequence ensures that the
nurse hears the most accurate representation of the client’s bowel activity.
4. The nurse observes a client’s pupil constricting when looking at a near object. What is this
phenomenon called?
A. Convergence
B. Consensual response
, C. Accommodation
D. Direct response
Answer: C
Rationale: Accommodation is the process by which the eyes change focus from distant to
near objects, involving pupillary constriction. This test is part of the PERRLA assessment
used to evaluate cranial nerve function. It demonstrates the ability of the lens and iris to
adjust to varying focal lengths.
5. Which cranial nerve is responsible for the movement of the tongue?
A. Cranial Nerve XII (Hypoglossal)
B. Cranial Nerve X (Vagus)
C. Cranial Nerve XI (Spinal Accessory)
D. Cranial Nerve IX (Glossopharyngeal)
Answer: A
Rationale: Cranial nerve XII, the hypoglossal nerve, is responsible for motor control of the
tongue. Assessment involves asking the client to stick out their tongue and move it from
side to side. Any deviation to one side or tremors during the movement may indicate nerve
damage.
6. What is the significance of hearing a ‘bruit’ during carotid artery auscultation?
A. It is a normal finding in older adults.
