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Final Exam : NSG 3160 / NSG3160 (NEW 2026–2027)
Health Assessment Review | Questions with Multiple
Choices & Answers | Guaranteed Grade A- Galen
Q. a patient has neck and shoulder pain and is unable to turn her head. which nerve maybe damaged and
how will the RN assess it? a. XII; assess for a positive rornberg sign b. XI; palpate the anterior and posterior triangles c. XI; have the patient shrug their shoulders against resistance d. XII; percuss the sternomastoid and submandibular neck muscles ANSWERS C
Q. What muscles would the nurse assess to assess the function of CN XI?
a. sternomastoid and trapezius b. spinal accessory and omohyoid c. trapezius and sternomandibular d. sternomandibular and spinal accessory ANSWERS A
Q. A patients lab data reveal an elevated thyroxine level. What gland would the nurse assess?
a. thyroid b. parotid c. adrenal d. parathyroid ANSWERS A
Q. What finding would lead the nurse to suspect that a thyroid nodule maybe cancerous?
a. it is tender b. it is mobile and soft c. it disappears when the patient smiles d. it is hard and fixed to the surrounding structures ANSWERS B
Q. What are the four areas in the body where lymph nodes are accessible?
a. head, breasts, groin, and abdomen b. arms, breasts, inguinal area, and legs c. head and neck, arms, breasts, and axillae d. head and neck, arms, inguinal area, and axillae ANSWERS D
Q. Where is the temporomandibular joint located?
a. just below the hyoid bone and posterior to the tragus b. just below the vagus nerve and posterior to the mandible c. just below the temporal artery and anterior to the tragus d. just below the temporal artery and anterior to the mandible ANSWERS C
Q. What technique would the nurse use to assess for a thyroid bruit?
a. palpate the thyroid while the patient is swallowing b. auscultate the thyroid with the bell of the stethoscope c. palpate the thyroid while the pt holds their breath d. auscultate the thyroid with the diaphragm of the stethoscope ANSWERS B
Q. what would the nurse keep in mind regarding the movement of the extra ocular muscles?
a. Is decreased in the older adult. b. Is stimulated by the cranial nerves III, IV and VI c. Is impaired in a patient with cataracts. d. Is stimulated by cranial nerves I and II ANSWERS B
Q. when examining a patient's eyes, the RN would be aware that stimulation of the sympathetic nervous
system causes a. Pupillary constriction b. adjusts the eye for near vision. c. Causes contraction of the ciliary body. d. Elevates the eyelid and dilates the pupil. ANSWERS D
Q. how was visual accommodation assessed?
a. Pupillary dilation when looking at a distant object. b. Involuntary blinking in the presence of bright light. c. Pupillary constriction when looking at a near object. d. Changes in peripheral vision in response to a bright light. ANSWERS C
Q. Which physiologic change is responsible for presbyopia?
a. loss of lens elasticity. b. Degeneration of the cornea. c. Decreased adaption to darkness. d. Decreased distance vision abilities. ANSWERS A
Q. how would the nurse interpret 20/30 when a Snellen eye chart is used?
a. At 30 feet the patient can read the entire chart. b. the patient can read at 20 feet a patient with normal vision can read at 30 feet c. patient can read from 30 feet. What a patient with normal vision can read 20 feet. ANSWERS B
Q. The nurse is performing an eye assessment on an 80-year-old patient which of these findings is
considered abnormal? a. decrease and tear production b. Unequal pupillary constriction in response to light. c. Presence of arcus senilis observed around the cornea. ANSWERS B
Q. In a patient who has anisocria, what would the nurse expect to observe?
a. dilated pupils. b. Excessive tearing. c. Pupils of unequal size. d. Uneven curvature of the lens. ANSWERS C
Q. which cranial nerve is responsible for conducting nerve impulses to the brain from the organ of Corti?
a. I b. III c. VIII d. XI ANSWERS C
when examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process? a. Teeth appearing shorter. b. Tongue that looks smoother in appearance. c. buccal mucosa that is beefy red in appearance d. Small painless lump on the dorsum of the tongue. B A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handle bars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation? An enlarged spleen should not be palpated because it can easily rupture. While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. What does the nurse suspect? Normal abdominal aortic pulsations A patient is having difficulty swallowing medications and food. How should the nurse document this? dysphagia During the change-of-shift report, the student nurse hears that a patient has hepatomegaly. What should the student recognizes that this term means? enlarged liver During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes this finding could indicate a problem with what structure? appendix During the examination portion of a patient's visit, she will be in lithotomy position. Which statement reflects some things that the nurse can do to make this position more comfortable for her? Elevate her head and shoulders to maintain eye contact. The nurse is preparing to interview a postmenopausal woman. Which of these statements is true as it applies to obtaining the health history of a postmenopausal woman? The nurse should ask a postmenopausal woman if she has ever had vaginal bleeding. The nurse is performing a genital examination on a male patient and notices urethral drainage. What should the nurse do when collecting urethral discharge for microscopic examination and culture? compress the glans between the examiner's thumb and forefinger and collect any discharge. Which of these statements is most appropriate when the nurse is obtaining a genitourinary history from an older man?
Do you need to get up at night to urinate? During a group discussion on men's health, what group should the nurse inform them has the highest incidence of prostate cancer? Blacks A 30-year-old woman is visiting the clinic because of "pain in my bottom when I have a bowel movement." The nurse should assess for which problem? Hemorrhoids The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation. The nurse is describing a scaphoid abdomen. When assessing the contour of the abdomen from the rib margin to the pubic bone, what would the contour look like? concave During an assessment, the nurse notices that a patient's umbilicus is enlarged and everted. It is positioned midline with no change in skin color. The nurse recognizes that the patient may have which condition? Umbilical hernia During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. How long should the nurse listen before reporting absent bowel sounds? 5 minutes During an abdominal assessment, the nurse would consider which of these findings as normal? Tympanic percussion note in the umbilical region During the interview with a female patient, the nurse gathers data that indicates the patient is perimenopausal. Which of these statements made by this patient leads to this conclusion? "I have been noticing that I sweat a lot more than I used to, especially at night." During the interview, a patient reveals that she has some vaginal discharge. She is worried that it may be a sexually transmitted infection. What would be the most appropriate response by the nurse? "I'd like more information about the discharge. What color is it?" The nurse is performing a genitourinary assessment on a 50-year-old obese male laborer. On examination, the nurse notices a painless round swelling close to the pubis in the area of the internal inguinal ring that is easily reduced when the individual is supine. What type of hernia do these findings suggest?
- Use line drawings to explain and record pertinent findings.
- Treat the health assessment as a legal document. The nurse is preparing to perform an examination of the eyes. Which test will the nurse conduct to assess the patient's vision? Snellen test While conducting a musculoskeletal assessment the nurse stands behind the patient and has the patient bend over and touch his or her toes. What is the nurse assessing? The spine The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? It helps determine how a person is managing day-to-day activities. A patient tells the nurse that he is allergic to penicillin. What is the best response by the nurse? "Describe what happens to you when you take penicillin." What are factors that affect wound healing?
- Nutrition (i.e. poor glycemic control, unstable weight, low albumin, dehydration, edema, prolonged NPO)
- Oxygenation, vascularity
- Inactivity
- MRSA, VRE colonization
- Advanced age
- Medications (NSAIDs, antineoplastics, anticoagulants, vasopressors, steroids)
- Comorbidities `What are components of a lower limb assessment?
- CWMS: Compare both limps bilaterally
- Peripheral pulses
- If abnormalities are present, Ankle Brachial Index may need to be assessed What are the characteristics of Varicose veins?
- Dilated veins found in the saphenous vein system that are small or bulging
- Caused by weakness of the veins and risk factors include chronic cough, constipation, family history of venous disease, obesity, pregnancy
- Clinical manifestations include: discomfort, cosmetic disfigurement, burning/cramp-like leg sensation, swelling, and pressure
- Diagnosed with an ultrasound and objective viewing of leg
- Treatment includes: rest, elevation, compression stockings, exercise, sclerotherapy
What are characteristics of Venous insufficiency? Valves in veins are not functioning properly which impedes or reverses venous return; blood subsequently pools in the legs and edema may be present
- Chronic venous insufficiency can cause venous stasis ulcers which can be very painful, debilitating, costly to treat and negatively impact client's lives What are characteristics of venous ulcers?
- Typically located above the medial malleolus; usually superficial and irregular in shape
- Contains large amount of exudate due to edema
- Surrounding skin is often warm, itchy and prone to eczema
- If the ulcer is left untreated it can progress to wound enlargement, infection, cellulitis and possibly amputation
- Brownish skin discolouration (hemosiderin) due to leakage of blood and serum into surrounding tissues and thick, hard, leathery skin develops How are venous ulcers treated?
- Consistently monitor CWMS and ulcer status
- Compression therapy
- Manage pain and skin irritations
- Teach self care (i.e. nutrition, compression stockings, skin care, exercise and positioning) What are the characteristics of arterial/ischemic ulcers?
- Caused by poor blood flow; peripheral pulses may or may not be palpable and limbs exhibit compromised CWMS
- Arterial ulcers located on feet, toes and toe joints but can also be on heels and tibial surface
- Appearance can be punched out, deep, shiny/taut/hairless skin surrounding, pink to black wound bed with eschar and minimal drainage
- Pain increases nocturnally and with activity as well as intermittent claudication at rest What are complications of arterial ulcers?
- They are resistant to healing due to compromised blood flow and are therefore often considered maintenance or non-healing wounds How are Arterial ulcers treated?
- Protect wounds from extreme temperatures, trauma and wear loose clothing
- Elevate head of bed 10-15cms to maintain blood flow to limbs below heart level
- Support supervised exercise program
- If ulcer is dry with eschar, do NOT debride and paint the wound with an antiseptic (do not cleanse with saline or water)
- If ulcer is moist, it may be cleansed or irrigated gently with warm/room temperature saline or water What are characteristics of ABI? Ankle Brachial Index is a numeric figure that indicates the amount of arterial blood flow to the extremity; it is
