NSG 3160 HEALTH ASSESSMENT FINAL
EXAM V3 QUESTIONS AND ANSWERS
1. During an abdominal assessment, the nurse elicits tenderness at McBurney’s point. This
finding is most indicative of which condition?
A. Acute cholecystitis
B. Diverticulitis
C. Acute appendicitis
D. Splenic rupture
Answer: C
Conceptual Explanation: McBurney’s point is located one-third of the distance from the
anterior superior iliac spine to the umbilicus; tenderness here is a classic sign of
appendicitis.
2. When auscultating the heart of a 70-year-old patient, the nurse hears a soft, low-pitched
sound immediately following S2 at the apex. What is the most likely interpretation of this
sound?
A. A normal physiological S3
B. An atrial gallop (S4)
,C. A split S2
D. A ventricular gallop (S3) indicating heart failure
Answer: D
Conceptual Explanation: In older adults, an S3 (ventricular gallop) is often a sign of
decreased ventricular compliance and early heart failure, occurring during the rapid filling
phase of diastole.
3. The nurse is performing a neurological assessment on a patient who can identify a key
placed in their hand with their eyes closed. This ability is known as:
A. Graphesthesia
B. Two-point discrimination
C. Stereognosis
D. Proprioception
Answer: C
Conceptual Explanation: Stereognosis is the ability to recognize the form and nature of
objects by touch. Graphesthesia is the ability to ‘read’ a number traced on the skin.
4. Which technique should the nurse use to assess for the presence of a fluid wave in a
patient with suspected ascites?
A. Percuss from the umbilicus to the flanks for dullness
B. Perform deep palpation in all four quadrants
, C. Auscultate for borborygmi while the patient is supine
D. Place one hand on the flank and strike the opposite flank with the other hand
Answer: D
Conceptual Explanation: The fluid wave test involves tapping one side of the abdomen
and feeling for the wave on the other side, requiring a second person’s hand to be placed
firmly on the midline to stop fat-substance vibration.
5. A patient presents with a ‘shifting dullness’ during abdominal percussion. What does this
clinical finding suggest?
A. Ascites
B. Large fecal mass
C. Intestinal obstruction
D. Hepatomegaly
Answer: A
Conceptual Explanation: Shifting dullness occurs when tympany changes to dullness as
the patient turns from supine to the side, indicating free fluid (ascites) moving to the
dependent side.
6. While assessing the respiratory system, the nurse notes a ‘dull’ percussion note over the
lower left lobe. Which condition is most consistent with this finding?
A. Pneumothorax
EXAM V3 QUESTIONS AND ANSWERS
1. During an abdominal assessment, the nurse elicits tenderness at McBurney’s point. This
finding is most indicative of which condition?
A. Acute cholecystitis
B. Diverticulitis
C. Acute appendicitis
D. Splenic rupture
Answer: C
Conceptual Explanation: McBurney’s point is located one-third of the distance from the
anterior superior iliac spine to the umbilicus; tenderness here is a classic sign of
appendicitis.
2. When auscultating the heart of a 70-year-old patient, the nurse hears a soft, low-pitched
sound immediately following S2 at the apex. What is the most likely interpretation of this
sound?
A. A normal physiological S3
B. An atrial gallop (S4)
,C. A split S2
D. A ventricular gallop (S3) indicating heart failure
Answer: D
Conceptual Explanation: In older adults, an S3 (ventricular gallop) is often a sign of
decreased ventricular compliance and early heart failure, occurring during the rapid filling
phase of diastole.
3. The nurse is performing a neurological assessment on a patient who can identify a key
placed in their hand with their eyes closed. This ability is known as:
A. Graphesthesia
B. Two-point discrimination
C. Stereognosis
D. Proprioception
Answer: C
Conceptual Explanation: Stereognosis is the ability to recognize the form and nature of
objects by touch. Graphesthesia is the ability to ‘read’ a number traced on the skin.
4. Which technique should the nurse use to assess for the presence of a fluid wave in a
patient with suspected ascites?
A. Percuss from the umbilicus to the flanks for dullness
B. Perform deep palpation in all four quadrants
, C. Auscultate for borborygmi while the patient is supine
D. Place one hand on the flank and strike the opposite flank with the other hand
Answer: D
Conceptual Explanation: The fluid wave test involves tapping one side of the abdomen
and feeling for the wave on the other side, requiring a second person’s hand to be placed
firmly on the midline to stop fat-substance vibration.
5. A patient presents with a ‘shifting dullness’ during abdominal percussion. What does this
clinical finding suggest?
A. Ascites
B. Large fecal mass
C. Intestinal obstruction
D. Hepatomegaly
Answer: A
Conceptual Explanation: Shifting dullness occurs when tympany changes to dullness as
the patient turns from supine to the side, indicating free fluid (ascites) moving to the
dependent side.
6. While assessing the respiratory system, the nurse notes a ‘dull’ percussion note over the
lower left lobe. Which condition is most consistent with this finding?
A. Pneumothorax
