NSG 3160 HEALTH ASSESSMENT FINAL
EXAM V3 QUESTIONS AND ANSWERS
1. When assessing a patient’s peripheral pulse, the nurse notes the rhythm is irregular. What
is the most appropriate next step for the nurse to take?
A. Measure the radial pulse for 15 seconds and multiply by 4.
B. Document the finding as a pulse deficit.
C. Auscultate the apical pulse for a full 60 seconds.
D. Assess the carotid pulse to verify the rate.
Answer: C
Conceptual Explanation: If a peripheral pulse is irregular, the nurse must auscultate the
apical pulse for one full minute to obtain an accurate heart rate and assess for a pulse
deficit.
2. Which assessment technique is used to determine the presence of fluid in the middle ear
or the mobility of the tympanic membrane?
A. Rinne test
B. Weber test
C. Pneumatic otoscopy
,D. Otoscopic inspection of the cone of light
Answer: C
Conceptual Explanation: Pneumatic otoscopy involves using a bulb attachment to puff air
into the ear canal; a lack of movement of the tympanic membrane suggests fluid or
pressure in the middle ear.
3. During a respiratory assessment, the nurse hears high-pitched, musical sounds primarily
during expiration. How should these sounds be documented?
A. Coarse crackles
B. Sibilant wheezes
C. Pleural friction rub
D. Sonorous rhonchi
Answer: B
Conceptual Explanation: Sibilant wheezes are high-pitched, musical sounds heard
primarily on expiration, often associated with narrowed bronchioles as seen in asthma.
4. When performing a physical assessment on an older adult, which finding is considered a
normal age-related change of the integumentary system?
A. Increased skin elasticity and turgor
B. Cherry angiomas and senile lentigines
C. Increased subcutaneous fat distribution
, D. Hyperactive sebaceous gland activity
Answer: B
Conceptual Explanation: Senile lentigines (liver spots) and cherry angiomas are common,
benign skin changes associated with aging due to sun exposure and vascular proliferation.
5. The nurse is assessing a patient for possible appendicitis. Which technique should the
nurse use to assess for rebound tenderness?
A. Blumberg’s sign
B. Murphy’s sign
C. Iliopsoas muscle test
D. Obturator test
Answer: A
Conceptual Explanation: Blumberg’s sign is the clinical term for rebound tenderness,
which involves pain upon the sudden release of pressure on the abdomen, suggesting
peritoneal inflammation.
6. A patient presents with a ‘strawberry tongue’ and a high fever. Which condition should the
nurse suspect?
A. Vitamin B12 deficiency
B. Scarlet fever
C. Oral candidiasis
EXAM V3 QUESTIONS AND ANSWERS
1. When assessing a patient’s peripheral pulse, the nurse notes the rhythm is irregular. What
is the most appropriate next step for the nurse to take?
A. Measure the radial pulse for 15 seconds and multiply by 4.
B. Document the finding as a pulse deficit.
C. Auscultate the apical pulse for a full 60 seconds.
D. Assess the carotid pulse to verify the rate.
Answer: C
Conceptual Explanation: If a peripheral pulse is irregular, the nurse must auscultate the
apical pulse for one full minute to obtain an accurate heart rate and assess for a pulse
deficit.
2. Which assessment technique is used to determine the presence of fluid in the middle ear
or the mobility of the tympanic membrane?
A. Rinne test
B. Weber test
C. Pneumatic otoscopy
,D. Otoscopic inspection of the cone of light
Answer: C
Conceptual Explanation: Pneumatic otoscopy involves using a bulb attachment to puff air
into the ear canal; a lack of movement of the tympanic membrane suggests fluid or
pressure in the middle ear.
3. During a respiratory assessment, the nurse hears high-pitched, musical sounds primarily
during expiration. How should these sounds be documented?
A. Coarse crackles
B. Sibilant wheezes
C. Pleural friction rub
D. Sonorous rhonchi
Answer: B
Conceptual Explanation: Sibilant wheezes are high-pitched, musical sounds heard
primarily on expiration, often associated with narrowed bronchioles as seen in asthma.
4. When performing a physical assessment on an older adult, which finding is considered a
normal age-related change of the integumentary system?
A. Increased skin elasticity and turgor
B. Cherry angiomas and senile lentigines
C. Increased subcutaneous fat distribution
, D. Hyperactive sebaceous gland activity
Answer: B
Conceptual Explanation: Senile lentigines (liver spots) and cherry angiomas are common,
benign skin changes associated with aging due to sun exposure and vascular proliferation.
5. The nurse is assessing a patient for possible appendicitis. Which technique should the
nurse use to assess for rebound tenderness?
A. Blumberg’s sign
B. Murphy’s sign
C. Iliopsoas muscle test
D. Obturator test
Answer: A
Conceptual Explanation: Blumberg’s sign is the clinical term for rebound tenderness,
which involves pain upon the sudden release of pressure on the abdomen, suggesting
peritoneal inflammation.
6. A patient presents with a ‘strawberry tongue’ and a high fever. Which condition should the
nurse suspect?
A. Vitamin B12 deficiency
B. Scarlet fever
C. Oral candidiasis
