NSG 3160 Final Exam V3 | NSG 3160 Health
Assessment | Actual Q&A with Rationale (NSG3160
Final Exam) | Galen
1. When conducting a health history, the nurse uses open-ended questions to achieve which
of the following goals?
A. To elicit specific facts and dates
B. To direct the patient to a specific topic
C. To limit the patient’s response to yes or no
D. To allow the patient to describe symptoms in their own words
Correct Answer: D
Explanation: Open-ended questions allow the patient to provide a narrative description of
their concerns. This technique encourages the patient to express their feelings and
perceptions without being led by the nurse. It is the preferred method for building rapport
and obtaining a comprehensive understanding of the patient’s health status.
2. Which of the following objective findings are indicative of dehydration in an elderly
patient? (Select All That Apply)
A. Dry mucous membranes
B. Pitting edema in lower extremities
C. Poor skin turgor over the sternum
,D. Increased urine output
E. Sunken appearance of the eyes
F. Tachycardia
Correct Answer: A, C, E, F
Explanation: Dry mucous membranes and sunken eyes are classic indicators of a fluid
volume deficit. Skin turgor is best assessed over the sternum or clavicle in the elderly
because skin on the hand often loses elasticity naturally with age. Tachycardia often occurs
as the body attempts to compensate for lower circulating blood volume.
3. When assessing a patient’s risk for pressure ulcers, which tool is most commonly utilized by
the nurse?
A. Glasgow Coma Scale
B. Morse Fall Scale
C. Snellen Chart
D. Norton Scale
E. Braden Scale
Correct Answer: E
Explanation: The Braden Scale is the most widely used evidence-based tool for assessing
pressure ulcer risk. It evaluates six categories including sensory perception, moisture,
,activity, mobility, nutrition, and friction/shear. A lower score on this scale indicates a
higher risk for developing a pressure injury.
4. The nurse is assessing the carotid arteries of an older adult. Which technique is correct for
auscultating for a bruit?
A. Apply the diaphragm of the stethoscope firmly over the artery
B. Palpate both carotid arteries simultaneously to compare rate
C. Lightly apply the bell of the stethoscope over the artery at three levels
D. Ask the patient to take a deep breath and hold it during auscultation
Correct Answer: C
Explanation: A bruit is a blowing or swishing sound indicating turbulent blood flow, which
is best heard with the bell of the stethoscope. The nurse should listen at the angle of the
jaw, the mid-cervical area, and the base of the neck. It is important to ask the patient to
exhale and hold their breath briefly so that tracheal breath sounds do not obscure the
arterial sounds.
5. Which cranial nerve is responsible for the movement of the tongue during speech and
swallowing?
A. CN IX (Glossopharyngeal)
B. CN XII (Hypoglossal)
C. CN XI (Spinal Accessory)
, D. CN X (Vagus)
Correct Answer: B
Explanation: Cranial Nerve XII, the Hypoglossal nerve, is purely motor and controls the
muscles of the tongue. Assessment involves asking the patient to protrude their tongue and
check for midline alignment or tremors. Damage to this nerve would result in tongue
deviation toward the side of the lesion.
6. When performing a cardiovascular assessment, where is the apical pulse (PMI) typically
located in a healthy adult?
A. Second intercostal space, right sternal border
B. Fifth intercostal space, left midclavicular line
C. Fourth intercostal space, left sternal border
D. Second intercostal space, left sternal border
Correct Answer: B
Explanation: The point of maximal impulse (PMI) is located at the apex of the heart. In
most adults, this is found at the fifth intercostal space at the left midclavicular line.
Displacement of the PMI laterally or inferiorly may indicate left ventricular hypertrophy or
heart failure.
7. The nurse notes a client has an enlarged, non-tender, and mobile lymph node in the
supraclavicular region. What does this finding most likely suggest?
A. Normal finding in most adults
Assessment | Actual Q&A with Rationale (NSG3160
Final Exam) | Galen
1. When conducting a health history, the nurse uses open-ended questions to achieve which
of the following goals?
A. To elicit specific facts and dates
B. To direct the patient to a specific topic
C. To limit the patient’s response to yes or no
D. To allow the patient to describe symptoms in their own words
Correct Answer: D
Explanation: Open-ended questions allow the patient to provide a narrative description of
their concerns. This technique encourages the patient to express their feelings and
perceptions without being led by the nurse. It is the preferred method for building rapport
and obtaining a comprehensive understanding of the patient’s health status.
2. Which of the following objective findings are indicative of dehydration in an elderly
patient? (Select All That Apply)
A. Dry mucous membranes
B. Pitting edema in lower extremities
C. Poor skin turgor over the sternum
,D. Increased urine output
E. Sunken appearance of the eyes
F. Tachycardia
Correct Answer: A, C, E, F
Explanation: Dry mucous membranes and sunken eyes are classic indicators of a fluid
volume deficit. Skin turgor is best assessed over the sternum or clavicle in the elderly
because skin on the hand often loses elasticity naturally with age. Tachycardia often occurs
as the body attempts to compensate for lower circulating blood volume.
3. When assessing a patient’s risk for pressure ulcers, which tool is most commonly utilized by
the nurse?
A. Glasgow Coma Scale
B. Morse Fall Scale
C. Snellen Chart
D. Norton Scale
E. Braden Scale
Correct Answer: E
Explanation: The Braden Scale is the most widely used evidence-based tool for assessing
pressure ulcer risk. It evaluates six categories including sensory perception, moisture,
,activity, mobility, nutrition, and friction/shear. A lower score on this scale indicates a
higher risk for developing a pressure injury.
4. The nurse is assessing the carotid arteries of an older adult. Which technique is correct for
auscultating for a bruit?
A. Apply the diaphragm of the stethoscope firmly over the artery
B. Palpate both carotid arteries simultaneously to compare rate
C. Lightly apply the bell of the stethoscope over the artery at three levels
D. Ask the patient to take a deep breath and hold it during auscultation
Correct Answer: C
Explanation: A bruit is a blowing or swishing sound indicating turbulent blood flow, which
is best heard with the bell of the stethoscope. The nurse should listen at the angle of the
jaw, the mid-cervical area, and the base of the neck. It is important to ask the patient to
exhale and hold their breath briefly so that tracheal breath sounds do not obscure the
arterial sounds.
5. Which cranial nerve is responsible for the movement of the tongue during speech and
swallowing?
A. CN IX (Glossopharyngeal)
B. CN XII (Hypoglossal)
C. CN XI (Spinal Accessory)
, D. CN X (Vagus)
Correct Answer: B
Explanation: Cranial Nerve XII, the Hypoglossal nerve, is purely motor and controls the
muscles of the tongue. Assessment involves asking the patient to protrude their tongue and
check for midline alignment or tremors. Damage to this nerve would result in tongue
deviation toward the side of the lesion.
6. When performing a cardiovascular assessment, where is the apical pulse (PMI) typically
located in a healthy adult?
A. Second intercostal space, right sternal border
B. Fifth intercostal space, left midclavicular line
C. Fourth intercostal space, left sternal border
D. Second intercostal space, left sternal border
Correct Answer: B
Explanation: The point of maximal impulse (PMI) is located at the apex of the heart. In
most adults, this is found at the fifth intercostal space at the left midclavicular line.
Displacement of the PMI laterally or inferiorly may indicate left ventricular hypertrophy or
heart failure.
7. The nurse notes a client has an enlarged, non-tender, and mobile lymph node in the
supraclavicular region. What does this finding most likely suggest?
A. Normal finding in most adults
