NSG 3160 ADVANCED HEALTH
ASSESSMENT EXAM QUESTIONS AND
ANSWERS AND EXPLANATIONS
1. A patient reports a deep, throbbing pain in their leg that worsens with activity and
improves with rest. The nurse suspects intermittent claudication. This is primarily a finding
related to which of the following?
A. Venous insufficiency
B. Lymphedema
C. Deep vein thrombosis
D. Arterial insufficiency
Answer: D
Conceptual Explanation: Intermittent claudication is a classic symptom of peripheral
arterial disease where oxygen demand exceeds supply during exercise.
2. During an abdominal assessment, the nurse notes a loud, blowing, whistling sound over
the renal arteries. How should the nurse document this finding?
A. Borborygmi
,B. Bruit
C. Friction rub
D. Venous hum
Answer: B
Conceptual Explanation: A bruit is a vascular sound reflecting turbulent blood flow, often
indicating narrowing or aneurysm of an artery.
3. When assessing the cranial nerves, the nurse asks the patient to stick out their tongue. The
tongue deviates to the right side. Which cranial nerve is likely impaired?
A. CN IX (Glossopharyngeal)
B. CN XII (Hypoglossal)
C. CN X (Vagus)
D. CN VII (Facial)
Answer: B
Conceptual Explanation: The hypoglossal nerve (CN XII) controls tongue movement;
weakness causes the tongue to deviate toward the side of the lesion.
4. While percussing the lungs of a patient with a known large pneumothorax, what
percussion note does the nurse expect to hear?
A. Resonance
B. Hyperresonance
, C. Dullness
D. Tympany
Answer: B
Conceptual Explanation: Hyperresonance occurs when there is an excess of air in the
pleural space, as seen in pneumothorax or emphysema.
5. The nurse is performing a cardiac assessment and identifies a murmur that is moderately
loud, easily heard, but has no palpable thrill. What grade is this murmur?
A. Grade 2
B. Grade 5
C. Grade 4
D. Grade 3
Answer: D
Conceptual Explanation: Grade 3 murmurs are moderately loud and easily heard; Grade 4
and above require the presence of a thrill.
6. In the ‘ABCDE’ assessment of skin lesions, what does the ‘D’ represent?
A. Depth
B. Duration
C. Density
ASSESSMENT EXAM QUESTIONS AND
ANSWERS AND EXPLANATIONS
1. A patient reports a deep, throbbing pain in their leg that worsens with activity and
improves with rest. The nurse suspects intermittent claudication. This is primarily a finding
related to which of the following?
A. Venous insufficiency
B. Lymphedema
C. Deep vein thrombosis
D. Arterial insufficiency
Answer: D
Conceptual Explanation: Intermittent claudication is a classic symptom of peripheral
arterial disease where oxygen demand exceeds supply during exercise.
2. During an abdominal assessment, the nurse notes a loud, blowing, whistling sound over
the renal arteries. How should the nurse document this finding?
A. Borborygmi
,B. Bruit
C. Friction rub
D. Venous hum
Answer: B
Conceptual Explanation: A bruit is a vascular sound reflecting turbulent blood flow, often
indicating narrowing or aneurysm of an artery.
3. When assessing the cranial nerves, the nurse asks the patient to stick out their tongue. The
tongue deviates to the right side. Which cranial nerve is likely impaired?
A. CN IX (Glossopharyngeal)
B. CN XII (Hypoglossal)
C. CN X (Vagus)
D. CN VII (Facial)
Answer: B
Conceptual Explanation: The hypoglossal nerve (CN XII) controls tongue movement;
weakness causes the tongue to deviate toward the side of the lesion.
4. While percussing the lungs of a patient with a known large pneumothorax, what
percussion note does the nurse expect to hear?
A. Resonance
B. Hyperresonance
, C. Dullness
D. Tympany
Answer: B
Conceptual Explanation: Hyperresonance occurs when there is an excess of air in the
pleural space, as seen in pneumothorax or emphysema.
5. The nurse is performing a cardiac assessment and identifies a murmur that is moderately
loud, easily heard, but has no palpable thrill. What grade is this murmur?
A. Grade 2
B. Grade 5
C. Grade 4
D. Grade 3
Answer: D
Conceptual Explanation: Grade 3 murmurs are moderately loud and easily heard; Grade 4
and above require the presence of a thrill.
6. In the ‘ABCDE’ assessment of skin lesions, what does the ‘D’ represent?
A. Depth
B. Duration
C. Density
