Health Assessment for Nursing Practice 7th Edition by
Susan Fickertt Wilson & Jean Foret Giddens EXAM with
Questions and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
EXAM COVERAGE
1. Foundations of Health Assessment
2. Evidence-Based Practice and Critical Thinking
3. Cultural and Developmental Considerations
4. Interviewing and Health History
5. Physical Examination Techniques (Inspection, Palpation, Percussion, Auscultation)
6. Assessment of General Status and Vital Signs
7. Pain Assessment and Management
8. Skin, Hair, and Nails Assessment
9. Head, Neck, and Lymphatics Assessment
10. Eye and Ear Assessment
11. Nose, Mouth, and Throat Assessment
12. Respiratory System Assessment
,13. Cardiovascular System Assessment
14. Abdominal and Gastrointestinal Assessment
15. Musculoskeletal System Assessment
16. Neurological System Assessment
17. Assessment of Mental Status
1. A 72-year-old patient presents with a persistent, non-healing ulcer on the left temporal region
with rolled, pearly borders. Given the high suspicion of basal cell carcinoma, what is the most
appropriate initial nursing action during the physical assessment?
A. Perform a punch biopsy to determine the extent of tissue involvement.
B. Document the lesion's precise location, size, border characteristics, and any associated
drainage or crusting.
C. Palpate the preauricular and postauricular lymph nodes for firm, fixed enlargement.
D. Apply a topical antibiotic ointment and schedule a follow-up in two weeks to reassess for
changes.
CORRECT ANSWER : B
Rationale: The nurse's primary role during assessment is meticulous documentation of clinical
findings to provide a baseline for the multidisciplinary team. Punch biopsies are outside the
scope of nursing practice, and applying antibiotics without a diagnosis may mask symptoms or
delay necessary intervention; systemic nodal assessment is important, but descriptive
documentation is the immediate priority.
2. During an abdominal assessment of a patient with suspected ascites, the nurse notes a tympanic
sound at the top of the abdomen that transitions to dullness as the nurse moves toward the flanks.
What does this finding indicate?
A. The presence of a large, fluid-filled ovarian cyst.
B. The shifting of free fluid within the peritoneal cavity due to gravity.
C. Normal bowel gas distribution throughout the abdomen.
, D. Possible enlargement of the spleen or liver displacing bowel loops.
CORRECT ANSWER : B
Rationale: In the presence of ascites, gravity causes fluid to accumulate in the flanks, while gas-
filled loops of bowel float anteriorly. The shifting dullness test confirms that the fluid is free
within the peritoneal cavity, unlike a localized mass or organomegaly which would present with
fixed dullness.
3. A patient presents with acute onset of severe left-sided chest pain radiating to the jaw. Upon
auscultation, the nurse identifies a new S3 heart sound. What is the clinical significance of this
finding in this context?
A. It is a normal physiological variant in older adults.
B. It represents turbulent blood flow across a stenotic mitral valve.
C. It indicates increased ventricular filling pressure, often associated with heart failure.
D. It suggests an underlying pericardial friction rub due to inflammation.
CORRECT ANSWER : C
Rationale: An S3, or ventricular gallop, occurs shortly after S2 and is caused by the rapid filling
of a stiff or overfilled ventricle. In the context of acute chest pain, it is a critical sign of potential
left ventricular dysfunction and high filling pressures, necessitating immediate intervention; it is
never a normal finding in adults.
4. During a respiratory assessment, the nurse identifies tactile fremitus that is significantly
increased in the right lower lobe. Which underlying pathology is most consistent with this
finding?
A. Pneumothorax.
B. Pleural effusion.
C. Lobar pneumonia.
D. Chronic obstructive pulmonary disease.
CORRECT ANSWER : C
Rationale: Tactile fremitus increases in areas where lung tissue is consolidated, as solid tissue
transmits vibrations more effectively than air-filled tissue. Pleural effusion and pneumothorax
decrease fremitus due to the presence of fluid or air acting as a barrier, while COPD typically
shows decreased or normal fremitus due to hyperinflation.
, 5. A nurse is assessing a patient’s cranial nerves. When the patient is asked to shrug their shoulders
against resistance, the nurse is testing which nerve and what is the expected outcome?
A. CN IX; the patient should be able to swallow without difficulty.
B. CN X; the patient should demonstrate a symmetrical gag reflex.
C. CN XI; the patient should demonstrate equal strength in the trapezius muscles.
D. CN XII; the patient should demonstrate full tongue protrusion.
CORRECT ANSWER : C
Rationale: The accessory nerve (CN XI) innervates the sternocleidomastoid and trapezius
muscles, which are tested by shrugging shoulders against resistance. Options A, B, and D test
different cranial nerves (glossopharyngeal, vagus, and hypoglossal, respectively).
6. When performing a focused neurological assessment on a patient who has suffered a stroke, the
nurse uses the Glasgow Coma Scale (GCS). Which of the following findings would result in the
lowest possible score for this scale?
A. The patient follows simple commands but is disoriented to time.
B. The patient opens eyes to pain, mumbles incomprehensible sounds, and demonstrates
decorticate posturing.
C. The patient does not open eyes, makes no sound, and shows no motor response to any
stimulus.
D. The patient opens eyes spontaneously but is unable to verbalize any words.
CORRECT ANSWER : C
Rationale: The GCS measures eye opening, verbal response, and motor response. A score of 3
(the lowest possible) is assigned when there is no response in any of these three categories. Any
other response, however minimal, would result in a score higher than 3.
7. A patient with type 2 diabetes mellitus presents with a foot wound. Assessment reveals a deep
ulcer on the heel with visible bone and necrotic tissue. Which component of the Wagner Ulcer
Classification system best describes this wound?
A. Grade 1.
B. Grade 2.
C. Grade 3.
Susan Fickertt Wilson & Jean Foret Giddens EXAM with
Questions and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
EXAM COVERAGE
1. Foundations of Health Assessment
2. Evidence-Based Practice and Critical Thinking
3. Cultural and Developmental Considerations
4. Interviewing and Health History
5. Physical Examination Techniques (Inspection, Palpation, Percussion, Auscultation)
6. Assessment of General Status and Vital Signs
7. Pain Assessment and Management
8. Skin, Hair, and Nails Assessment
9. Head, Neck, and Lymphatics Assessment
10. Eye and Ear Assessment
11. Nose, Mouth, and Throat Assessment
12. Respiratory System Assessment
,13. Cardiovascular System Assessment
14. Abdominal and Gastrointestinal Assessment
15. Musculoskeletal System Assessment
16. Neurological System Assessment
17. Assessment of Mental Status
1. A 72-year-old patient presents with a persistent, non-healing ulcer on the left temporal region
with rolled, pearly borders. Given the high suspicion of basal cell carcinoma, what is the most
appropriate initial nursing action during the physical assessment?
A. Perform a punch biopsy to determine the extent of tissue involvement.
B. Document the lesion's precise location, size, border characteristics, and any associated
drainage or crusting.
C. Palpate the preauricular and postauricular lymph nodes for firm, fixed enlargement.
D. Apply a topical antibiotic ointment and schedule a follow-up in two weeks to reassess for
changes.
CORRECT ANSWER : B
Rationale: The nurse's primary role during assessment is meticulous documentation of clinical
findings to provide a baseline for the multidisciplinary team. Punch biopsies are outside the
scope of nursing practice, and applying antibiotics without a diagnosis may mask symptoms or
delay necessary intervention; systemic nodal assessment is important, but descriptive
documentation is the immediate priority.
2. During an abdominal assessment of a patient with suspected ascites, the nurse notes a tympanic
sound at the top of the abdomen that transitions to dullness as the nurse moves toward the flanks.
What does this finding indicate?
A. The presence of a large, fluid-filled ovarian cyst.
B. The shifting of free fluid within the peritoneal cavity due to gravity.
C. Normal bowel gas distribution throughout the abdomen.
, D. Possible enlargement of the spleen or liver displacing bowel loops.
CORRECT ANSWER : B
Rationale: In the presence of ascites, gravity causes fluid to accumulate in the flanks, while gas-
filled loops of bowel float anteriorly. The shifting dullness test confirms that the fluid is free
within the peritoneal cavity, unlike a localized mass or organomegaly which would present with
fixed dullness.
3. A patient presents with acute onset of severe left-sided chest pain radiating to the jaw. Upon
auscultation, the nurse identifies a new S3 heart sound. What is the clinical significance of this
finding in this context?
A. It is a normal physiological variant in older adults.
B. It represents turbulent blood flow across a stenotic mitral valve.
C. It indicates increased ventricular filling pressure, often associated with heart failure.
D. It suggests an underlying pericardial friction rub due to inflammation.
CORRECT ANSWER : C
Rationale: An S3, or ventricular gallop, occurs shortly after S2 and is caused by the rapid filling
of a stiff or overfilled ventricle. In the context of acute chest pain, it is a critical sign of potential
left ventricular dysfunction and high filling pressures, necessitating immediate intervention; it is
never a normal finding in adults.
4. During a respiratory assessment, the nurse identifies tactile fremitus that is significantly
increased in the right lower lobe. Which underlying pathology is most consistent with this
finding?
A. Pneumothorax.
B. Pleural effusion.
C. Lobar pneumonia.
D. Chronic obstructive pulmonary disease.
CORRECT ANSWER : C
Rationale: Tactile fremitus increases in areas where lung tissue is consolidated, as solid tissue
transmits vibrations more effectively than air-filled tissue. Pleural effusion and pneumothorax
decrease fremitus due to the presence of fluid or air acting as a barrier, while COPD typically
shows decreased or normal fremitus due to hyperinflation.
, 5. A nurse is assessing a patient’s cranial nerves. When the patient is asked to shrug their shoulders
against resistance, the nurse is testing which nerve and what is the expected outcome?
A. CN IX; the patient should be able to swallow without difficulty.
B. CN X; the patient should demonstrate a symmetrical gag reflex.
C. CN XI; the patient should demonstrate equal strength in the trapezius muscles.
D. CN XII; the patient should demonstrate full tongue protrusion.
CORRECT ANSWER : C
Rationale: The accessory nerve (CN XI) innervates the sternocleidomastoid and trapezius
muscles, which are tested by shrugging shoulders against resistance. Options A, B, and D test
different cranial nerves (glossopharyngeal, vagus, and hypoglossal, respectively).
6. When performing a focused neurological assessment on a patient who has suffered a stroke, the
nurse uses the Glasgow Coma Scale (GCS). Which of the following findings would result in the
lowest possible score for this scale?
A. The patient follows simple commands but is disoriented to time.
B. The patient opens eyes to pain, mumbles incomprehensible sounds, and demonstrates
decorticate posturing.
C. The patient does not open eyes, makes no sound, and shows no motor response to any
stimulus.
D. The patient opens eyes spontaneously but is unable to verbalize any words.
CORRECT ANSWER : C
Rationale: The GCS measures eye opening, verbal response, and motor response. A score of 3
(the lowest possible) is assigned when there is no response in any of these three categories. Any
other response, however minimal, would result in a score higher than 3.
7. A patient with type 2 diabetes mellitus presents with a foot wound. Assessment reveals a deep
ulcer on the heel with visible bone and necrotic tissue. Which component of the Wagner Ulcer
Classification system best describes this wound?
A. Grade 1.
B. Grade 2.
C. Grade 3.
