NSG 3160 HEALTH ASSESSMENT FINAL
EXAM V3 QUESTIONS AND ANSWERS
1. When assessing a patient with a suspected tension pneumothorax, which finding during
percussion of the affected side would the nurse most likely expect?
A. Dullness
B. Hyperresonance
C. Resonance
D. Flatness
Answer: B
Conceptual Explanation: Hyperresonance is a lower-pitched, booming sound found when
too much air is present, such as in pneumothorax or emphysema.
2. A nurse is performing a neurological assessment on a patient who has suffered a stroke.
The patient is unable to shrug their shoulders against resistance. Which cranial nerve is likely
affected?
A. CN IX (Glossopharyngeal)
B. CN X (Vagus)
C. CN XI (Spinal Accessory)
,D. CN XII (Hypoglossal)
Answer: C
Conceptual Explanation: Cranial Nerve XI, the Spinal Accessory nerve, innervates the
trapezius and sternomastoid muscles; testing involves shrugging shoulders and turning the
head against resistance.
3. During a cardiac assessment, the nurse notes a low-pitched, extra heart sound heard early
in diastole at the apex. This is most likely:
A. S3 (Ventricular gallop)
B. S4 (Atrial gallop)
C. Systolic click
D. Pericardial friction rub
Answer: A
Conceptual Explanation: S3 occurs early in diastole during the rapid ventricular filling
phase and is often associated with heart failure or fluid overload in adults.
4. Which assessment technique is correct when the nurse is evaluating a patient for the
presence of orthostatic hypotension?
A. Measure BP while the patient is supine, then immediately after they stand up.
B. Measure BP supine, then sitting, then standing, waiting 1-3 minutes between positions.
C. Measure BP in the sitting position only, three times consecutively.
, D. Measure BP in both arms and record the highest reading.
Answer: B
Conceptual Explanation: Orthostatic vitals require sequential measurements (supine,
sitting, standing) with a rest period in between to allow the vascular system to adapt.
5. While assessing the abdomen, the nurse notes a positive Murphy’s sign. This finding is
highly suggestive of:
A. Acute Cholecystitis
B. Splenomegaly
C. Acute Appendicitis
D. Peritonitis
Answer: A
Conceptual Explanation: Murphy sign is a test for gallbladder inflammation; pain occurs
when the patient takes a deep breath while the examiner’s fingers are under the liver
border.
6. The nurse is assessing a 75-year-old patient’s skin turgor. Where is the most reliable
location to check for tenting in this age group?
A. Back of the hand
B. Under the clavicle
C. Abdomen
EXAM V3 QUESTIONS AND ANSWERS
1. When assessing a patient with a suspected tension pneumothorax, which finding during
percussion of the affected side would the nurse most likely expect?
A. Dullness
B. Hyperresonance
C. Resonance
D. Flatness
Answer: B
Conceptual Explanation: Hyperresonance is a lower-pitched, booming sound found when
too much air is present, such as in pneumothorax or emphysema.
2. A nurse is performing a neurological assessment on a patient who has suffered a stroke.
The patient is unable to shrug their shoulders against resistance. Which cranial nerve is likely
affected?
A. CN IX (Glossopharyngeal)
B. CN X (Vagus)
C. CN XI (Spinal Accessory)
,D. CN XII (Hypoglossal)
Answer: C
Conceptual Explanation: Cranial Nerve XI, the Spinal Accessory nerve, innervates the
trapezius and sternomastoid muscles; testing involves shrugging shoulders and turning the
head against resistance.
3. During a cardiac assessment, the nurse notes a low-pitched, extra heart sound heard early
in diastole at the apex. This is most likely:
A. S3 (Ventricular gallop)
B. S4 (Atrial gallop)
C. Systolic click
D. Pericardial friction rub
Answer: A
Conceptual Explanation: S3 occurs early in diastole during the rapid ventricular filling
phase and is often associated with heart failure or fluid overload in adults.
4. Which assessment technique is correct when the nurse is evaluating a patient for the
presence of orthostatic hypotension?
A. Measure BP while the patient is supine, then immediately after they stand up.
B. Measure BP supine, then sitting, then standing, waiting 1-3 minutes between positions.
C. Measure BP in the sitting position only, three times consecutively.
, D. Measure BP in both arms and record the highest reading.
Answer: B
Conceptual Explanation: Orthostatic vitals require sequential measurements (supine,
sitting, standing) with a rest period in between to allow the vascular system to adapt.
5. While assessing the abdomen, the nurse notes a positive Murphy’s sign. This finding is
highly suggestive of:
A. Acute Cholecystitis
B. Splenomegaly
C. Acute Appendicitis
D. Peritonitis
Answer: A
Conceptual Explanation: Murphy sign is a test for gallbladder inflammation; pain occurs
when the patient takes a deep breath while the examiner’s fingers are under the liver
border.
6. The nurse is assessing a 75-year-old patient’s skin turgor. Where is the most reliable
location to check for tenting in this age group?
A. Back of the hand
B. Under the clavicle
C. Abdomen
