WGU health assessment OA 9/2025 (correct answers)

Heart sounds are loudest for S1 at the _______ and for S2 at the________.

Base of the heart

Right side of the heart

Center of the heart

Left side of the heart

Apex of the heart

Apex of the heart

Base of the heart

3 multiple choice options

When preparing a female client for an abdominal examination, the nurse should provide her with which instruction?

A. Empty your bladder just prior to the examination

B. refrain from eating or drinking for at least thirty minutes

C. Lie in a prone position with slightly flexed knees

D. Exhale slowly through your mouth then hold your breath

Empty your bladder just prior to examination

3 multiple choice options

The nurse learns in report that a client is stuporous. Which assessment should the nurse perform to confirm this report?

A. Observe for facial asymmetry

B. Determine the response to stimuli

C. Assess for a positive Romberg sign

D Check the pupillary response to light

Determine the response to stimuli

3 multiple choice options

The nurse begins a clients musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? Select all that apply

A. Atrophy

B. Crepitus

C. Kyphosis

D. Osteopenia

E. Contracture

A. Atrophy

C. Kyphosis

E. Contracture

2 multiple choice options

An older client comes to the healthcare provider's office for a routine follow-up exam for high blood pressure, osteoarthritis, constipation, and chronic sinusitis. The client recently had a cataract removed from the left eye, Which is the MOST important for the nurse to assess when obtaining the clients health history.

A. Obtain a medication history including prescription and non prescription drugs.

B. Conduct an assessment of functional capacity and environmental hazards.

C. Emphasize the need to place advance directives in the medical record.

D. Distinguish between symptoms caused by disease and those due to aging.

A. Obtain a medication history including prescription and non prescription drugs.

The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?

A. Collect a urine sample and strain for granules or calculi.

B. Use a standard pain assessment questionnaire and scale.

C. Observe for nonverbal signs to measure pain intensity.

D. Ask the client if he took any pain medicine at home.

B. Use a standard pain assessment questionnaire and scale

During a health assessment, the client reports being treated for osteoarthritis. The nurse examines a client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record?

A. Frozen, non-movable phalangeal joints

B. Proximal intertarsal joint swelling of big toe

C. Distal interphalangeal joint nodules that deviate

D. Non-painful enlarged interphalangeal joints

C. Distal interphalangeal joint nodules that deviate

The nurse is assessing a client with gallstones for jaundice. Which action should the nurse perform to confirm this information?

A. Examine client's sclera for icterus

B. Review recent serum bilirubin levels

C. Assess conjunctival sacs of lower lids for pallor

D. Observe the client's urine for dark orange color

A. Examine client's sclera for icterus

When assessing heart sounds of a client with rheumatic valvular heart disease, where should the nurse place the stethoscope to auscultate the tricuspid valve?

A. Third left intercostal space

B. Left fourth intercostal space next to the sternal border

C. Second right intercostal space

D. Left fifth intercostal space, midclavicular line

B. Left fourth intercostal space next to the sternal border

The client is a 35 year old male with no history of any medical conditions is in the clinic for an annual physical, which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply

A. Ensure the room is as quiet as possible

B. Reach under a gown to listen and take care that no clothing rubs on the stethoscope

C. Wet the chest hair before auscultating

D. Document the roaring and crackles

E. Keep the examination room warm, and a warm stethoscope

A. Ensure the room is as quiet as possible

B. Reach under a gown to listen and take care that no clothing rubs on the stethoscope

D. Document the roaring and crackles

E. Keep the examination room warm, and a warm stethoscope

During the precordium assessment, the nurse palpates the apical impulse of a client on the 5th intercostal space left mid-clavicular line. The pulse is more vigorous than expected. Which action should the nurse take in response to this finding?

A. Record the findings as a normal response

B. Compare the apical pulse force to the carotid pulse force

C. Obtain the clients' blood pressure

D. Determine if the client has a history of heart disease

D. Determine if the client has a history of heart disease

The nurse is doing a health assessment of a client who smoked three packs of cigarettes every day for the last twenty years before quitting two years ago. How should the nurse documentthe clients pack-years? (enter numerical value only)

60

The nurse notes an enlarged, visible lymph node on the clients neck. Which action should the nurse take next?

D. Ask the client about any localized tenderness at the site.

An older client is being evaluated for admission to an assisted living facility. During the health assessment, the nurse implementa which technique to determine the clients ability to reside in this environment?

A. Instruct client to demonstrate activities of daily living

B. Evaluate client for side effects of routine medications

C. Focus questions to evaluate long term memory

D. Screen client for alcohol or controlled drug abuse

A. Instruct client to demonstrate activities of daily living

The nurse assesses a young adult female who was brought to the emergency department by her boyfriend because she has not been feeling well all day and believes she is getting worse. Which finding supports the nurses suspicions that the client is experiencing appendicitis?

A. Anorexia progressing to nausea, vomiting and fever

B. Sudden onset of severe anxiety, fear and concern

C. Periumbilical pain localizing to right lower quadrant

D. Diffuse abdominal pain with elevated neutrophip count

​

C. Periumbilical pain localizing to right lower quadrant

A client arriving to the emergency department reports trouble breathing and tightness in the chest that started while exercising at the gym. The nurse observes the client is febrile, heart rate is 96 beats/minute, respirations 32 breaths/minute and pulse oximeterreading of 85%. Audible wheezing is heard on expiration with a decrease in tactile fremitus and bilateral breath sounds. The client displays intercostal retracting and prolonged expiration. Based on the findings, the nurse should recognize the client is exhibiting symptoms of which condition?

A. Bronchitis

B. Asthma

C. Pneumothorax

D. Pneumonia

B. Asthma

When conducting a physical examination the nurse is assessing a clients abdomen and identifies centrally localized distention that is pulsating. This finding should direct the nurse to consider which pathology?

A. Typany

B. Aneurysm

C. Appendicitis

D. Hernia

B. Aneurysm

The nurse is obtaining a health history for a client during an annual physical examination. When evaluating the client for menopausal symptoms, which finding indicates the client is perimenopausal?

A. Cessation of menstruation

B. Excessive vaginas moisture

C. Drenching night sweats

D. Increase in sexual desire

C. Drenching night sweats

When conducting a physical examination, the nurse uses a tuning fork to assess for which condition?

A. Tinnitus

B. Hearing loss

C. Otitis media

D. Neurological pathology

B. Hearing loss

Which assessment finding, obtained during chest auscultation, should the nurse consider a normal finding?

A. Blowing hollow sounds above sternum

B. Faint whistling over both lung bases

C. Slight crackling throught lung fields

D. Right breath sounds louder than the left

​

A. Blowing hollow sounds above sternum

Which question by the nurse is likely to elicit the most information regarding the clients use of medications to treat chronic cough?

A. Have you tried any generic brand cough syrups?

B. Have you been prescribed any medications for your cough?

C. What medications are you currently taking?

D. What medications have you taken for your cough?

D. What medications have you taken for you cough?

The nurse is performing oral inspection of a client with pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?

A. Document the finding in the medical record.

B. Ask if the client recently received any antibiotics.

C. Ask the client about the use of irritating chemical agents.

D. Schedule an appointment with a dermatologist.

A. Document the finding in the medical record.

In assessing an adult client, the nurse calculates the body mass index (BMI) as 14 kg/m. Which nursing problem should be included in this clients plan of care?

Reference Range:

Body mass index (BMI)- normal 18.0 to 24.9 kg/m

A. Excess fluid volume

B. Imbalanced nutrition, greater than body requirements

C. Deficient fluid volume.

D. Imbalanced nutrition, less than body requirements.

D. Imbalanced nutrition, less than body requirements.

When assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

A. The client is obese

B. Deeper palpation technique is needed

C. The gallbladder is normal

D. Palpating in the wrong abdominal quadrant.

C. The gallbladder is normal

When performing a skin and nail exam on an older adult female client, the nurse notes that she has longitudinal ridges on her fingernails. What does this finding indicate?

A. Fungal infection

B. An expected variation

C. Chronic obstructive pulmonary disease (COPD)

D. Psoriasis

B. An expected variation

A client states '' I am legally blind'' Which assessment technique should the nurse use to obtain subjective data to support the client's statement?

A. Assess the client's ability to read a Snellen chart from a distance of 20 feet

B. Observe the client's optic disc through an ophthalmoscope

C. Observe the client's pupillary response to a pen light

D. Observe the client's movements through the cardinal fields of vision.

A. Assess the client's ability to read a Snellen chart from a distance of 20 feet

The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?

A. Oxygen saturation of 85%

B. Absent deep tendon reflexes

C. Capillary refill less than 3 seconds

D. 3+ peripheral dependent edema

A. Oxygen saturation of 85%

When assessing an older adult client, which finding is most indicative of dehydration?

A. Skin is warm and dry

B. Thinning hair in lower extremities

C. Loss of skin elasticity in the hand

D. Tenting noted in subclavian area

D. Tenting noted in subclavian area

The nurse is obtaining a health history for a client being admitted for new onset seizures. Which action should the nurse implement to accurately record the health history findings?

A. Enter subjective data in the note section of the client's electronic medical record

B. Enter the information in the electronic medical record at the client's bedside

C. Document the client's history that is directly related to the current admission diagnoses

D. Document the assessment findings in the computer at the nursing station.

B. Enter the information in the electronic medical record at the client's bedside

The school nurse is interviewing a 13-year-old girl who wants to go home from school because of ''back pain. Which question should the nurse ask the adolescent first?

A. Have you taken any medications to relieve the pain?

B. What were you doing when you first noticed the problem?

C. Do you remember ever having this type of pain in the past?

D. Does changing your position make the pain worse?

B. What were you doing when you first noticed the problem?

A 20-year-old nulliparous female college student sees the nurse because she has missed her last two menstrual periods. She reports she has not had sexual intercourse in one month. The nurse requests a pregnancy test, which is negative. Based on this client's history, which assessment is most important for the nurse to obtain?

A. Breast tenderness, tremors, high blood pressure

B. Vaginal discharge, presence of genital warts, abdominal tenderness

C. Body weight, hirsutism, thyroid enlargement

D. Urinary frequency, unsteady gait, dental enamel erosion

C. Body weight, hirsutism, thyroid enlargement

An adult male client tells the nurse that he smokes approximately one pack of cigarettes daily. How can the nurse expect smoking to affect the client's sleep?

A. Decrease the need for rapid eye movement (REM) sleep.

B. He would have difficulty falling asleep, and sleep very lightly with more frequent arousals.

C. He would sleep soundly for the first half of the night, with increased arousals during the second half.

D. Increased sleep latency and reduced total sleep time.

B. He would have difficulty falling asleep, and sleep very lightly with more frequent arousals.

When assessing a client's range of motion, the nurse notes crepitation with movement of the left knee. Which information in the client's history is the most likely related to this finding?

A. Needle aspiration of the synovial space.

B. History of a fractured patella.

C. Knee arthroplasty surgery.

D. Degenerative disease

D. Degenerative disease

The client is a 76-year-old female who arrived at the emergency department via ambulance from an assisted living facility after a fall. The client called for help using her medical alert necklace. Reports feeling dizzy and lightheaded for the past two days. The client is unable to recall the events that led up to the fall and states. ''I do not know how long I was down.'' Pat's medical history includes chronic obstructive pulmonary disease (COPD), hypertension (HTN), and carotid artery stenosis. Smoke half a pack of cigarettes daily for 40 years. Attempted to quit smoking a few years ago.

Which assessment(s) should the nurse conduct? SATA

A. Glasgow coma scale

B. Cranial nerves

C. Muscle tone

D. Romberg test

E. Pupil size

F. Brudzinski reflexes

G. Level of consciousness

B. Cranial nerves

C. Muscle tone

E. Pupil size

G. Level of consciousness

A. Glasgow coma scale

A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

A. Ask the client to see his healthcare provider immediately

B. Ask the client if he often spends time outside in the sun without a shirt.

C. Offer to teach a family member how to monitor the skin around the mole.

D. Encourage the client to keep checking the mole with a magnifying mirror.

A. Ask the client to see his healthcare provider immediately

A nurse performs a Tinetti assessment on an older adult client and calculates a balance score of 12 and a gait score of 8. Which do these results indicate?

A. Increased risk for falling

B. Likely onset of Parkinson's disease

C. Need for a walker to aid in ambulation

D. Expected results for an older adult

A. Increased risk for falling

While conducting a physical assessment, the nurse shines a pen light into the client's right eye and moves the light source to check the client's left eye. Which finding indicates the need for further evaluation?

A. Both pupils are equal size and constrict readily to the light source.

B. The right pupil constricts and the left consensually responds.

C. Bilateral pupil size changes as the distance of the light source varies.

D. The left iris is ''notched'' and the pupil size changes minimally.

D. The left iris is ''notched'' and the pupil size changes minimally.

The nurse observes that the lower legs of a client with diabetes mellitus are shiny, and with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?

A. Compare the range of motion of both legs

B. Ask if the client often feels weak or hungry

C. Measure the client's capillary glucose

D. Palpate the client's dorsalis pedis pulses

D. Palpate the client's dorsalis pedis pulses

Which finding, obtained during a skin assessment, should the school nurse report to the healthcare provider?

A. Red, swollen, painful nodule located on upper back on a school-aged boy

B. Multiple maculopapular pustules over forehead and chin on an adolescent

C. Small, white flecks on the hair shafts throughout scalp on a school-aged girl

D. Bilateral patellar abrasions with eschar formation on a preschool-aged child.

A. Red, swollen, painful nodule located on upper back on a school-aged boy

The college health clinic nurse is preparing a seminar on testicular self examination (TSE). Which instruction should be included in the content of this seminar?

A. Compare both testicles concurrently

B. Examine the testicles during bathing

C. Manipulate the testicles upon rising

D. Inspect the testicles using a mirror

B. Examine the testicles during bathing

To assess for the presence of egophony, which instruction should the nurse give to the client who has a lung abscess?

A. Repeat vocalizing the letter ''E'' while the thorax is auscultated

B. Repeat the number ''99'' during a systematic auscultation of the thorax

C. Whisper '' on, two, three'' in sequence during auscultation of the thorax

D. Breathe in and out while all lobes of both lungs are auscultated

A. Repeat vocalizing the letter ''E'' while the thorax is auscultated

While obtaining the health history of a client, the nurse learns the client's father was diagnosed with schizophrenia in his twenties, the same age the client is now. The client hesitates to discuss the topic and answer questions about the father. Which approach is best for the nurse to use to interview the client about mental health concerns?

A. Get the most difficult questions over with first

B. Share personal values to put the client at ease

C. Begin with questions that are less sensitive in nature

D. Ask questions in a vague, nonspecific format

C. Begin with questions that are less sensitive in nature

A 16-year-old client with a history of chronic ear infections when younger comes to the clinic for a health exam. No ear pain, vertigo or hearing loss is reported during history taking. Inspection of the tympanic membranes (TM) reveals the presence of dense white patches on the TMs in both ears. Both TMs are translucent gray with a light reflex at 5:00. All landmarks are visible. Based on these findings, which action should the nurse take?

A. Record the findings in the client's chart

B. Clean the ears to remove excess buildup

C. Referral to an audiologist for hearing evaluation

D. Culture the white patches for possible fungal growth

A. Record the findings in the client's chart

While completing the assessment for a client with rectal bleeding, the nurse observes dark red blood on the surface of a purple, shiny tissue mass that extrudes from the anal opening. When documenting in the client's electronic health record, which finding should the nurse enter in the client's physical assessment?

A. Serosanguinous and purulent exudate from anus

B. Tears in the anal mucosa with old blood around the anus

C. Anal mucosa prolapse and loose sphincter tone

D. Dried dark red blood on swollen external hemorrhoids

D. Dried dark red blood on swollen external hemorrhoids

While completing an admission assessment for a client with fatigue, weakness, and unexpected weight loss, the nurse notes scleral jaundice. Which finding during percussion of the abdomen should the nurse document indicating hepatomegaly?

A. Areas of tympany within the liver region

B. A hollow sound over the lower abdomen

C. A dull percussion tone outside the costal margins

D. Tympany noted boarding the margins of the liver

C. A dull percussion tone outside the costal margins

The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

A. Auscultate for one minute with the stethoscope diaphragm

B. Use a Doppler ultrasound to hear the heartbeat

C. Obtain a pulse oximeter reading from two extremities

D. Listen to the heart sounds with the bell of the stethoscope

D. Listen to the heart sounds with the bell of the stethoscope

The nurse continues the respiratory assessment of a client's chest excursion by placing both hands as seen in the picture. Which instruction should the nurse give the client?

A. Cough vigorously

B. Hold your breath

C. Take a deep breath

D. Lean forward

C. Take a deep breath

Which subjective assessment data supports the nurse's conclusion that a client is experiencing orthopnea?

A. ''I sleep on three pillows at night''

B. ''It doesn't take much activity before I am out of breath''

C. ''I have multiple attacks of wheezing almost daily''

D. ''I cough a lot at night and it keeps me up half the night''

A. ''I sleep on three pillows at night''

When assessing the left foot plantar reflex of an adult client, the nurse observes an extension of the great toe and fanning of other toes. Which interpretation of this finding is accurate?

A. Beginning meningeal irritation

B. Normal reflex response for age

C. Pyramidal tract disease

D. Exaggerated reflex response

C. Pyramidal tract disease

CASE STUDY

For each joint click to specify what type of range of motion was being assessed based on findings. Pick one.

Joint:

Wrist- able to bend wrist back toward forearm

-Flexion

-Abduction

-Extension

-Adduction

Flexion

CASE STUDY

For each joint click to specify what type of range of motion was being assessed based on findings. Pick one.

Joint:

Elbow-only able to straighten joint 20 degrees

-Abduction

-Adduction

-Extension

-Flexion

Extension

CASE STUDY

For each joint click to specify what type of range of motion was being assessed based on findings. Pick one.

Joint:

Shoulder-unable to move the arm away from the body

-Flexion

-Abduction

-Adduction

-Extension

Abduction

The nurse assesses that the client has nail clubbing. Which additional information is consistent with this finding?

A. Absent deep tendon reflexes.

B. Capillary refills in less than 3 seconds.

C. Oxygen saturation of 85%.

D. 3-plus peripheral dependent edema.

Oxygen saturation of 85%.

To assess a client's ability to think abstractly, which question or statement is likely to provide the best information about the client's abstract thinking?

A. In what year were you born?

B. Has anyone come to visit you today?

C. Count backwards by 7, starting with 100.

D. What does "The early bird catches the worm" mean?

What does "The early bird catches the worm" mean?

The nurse observes that a client who is intoxicated has an ataxic gait. Which finding does the nurse expect to be positive upon further assessment of the client?

A. Romberg sign.

B. Babinski sign.

C. Chvostek's sign.

D. Battle sign.

Romberg sign.

Noticating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?

A. Normal bowel sounds.

B. Hyperactive bowel sounds.

C. Hypoactive bowel sounds.

D. Or igneous sounds.

Normal bowel sounds.

A nurse is caring for a 57-year-old client in the emergency department who presents with joint pain and stiffness in their hands. The client has a history of hypertension and type 2 diabetes.

A nurse is analyzing the assessment findings. Which findings are indicative of rheumatoid arthritis? Select all that apply.

A. Symmetrical involvement

B. Joint swelling

C. Pain increases with motion

D. Fatigue and fever

E. Small joints of the hand

F. Morning stiffness quickly resolves

G. Heberden's nodes

A.Symmetrical involvement

B.Joint swelling

C. Pain increases with motion

D. Fatigue and fever

E. Small joints of the hand

The nurse is performing a head-to-toe physical examination on a known victim of intimate partner violence. The visual exam reveals several round, flat, pinpoint, red spots. How should the nurse document this finding?

A. Hematoma

B. Vesicle

C. Ecchymosis

D. Petechiae

Petechiae

Use a client's laboratory results for a client admitted with gastrointestinal GI bleeding who has no visible hemorrhoids on inspection of the anal area. Which laboratory test indicates that the client's bleeding is not yet resolved?

Reference range.Somatic RIT, HCT 42% to 52%, 0.42 to 0.52 volume fraction.Prothrombin time, PT, 11.0 to 12.5 seconds,glycosylated hemoglobin 85% to 100%,A1c4% to 5.9%.

A. Prothrombin time, PT, changes from 12 seconds to 18 seconds.

B. Hemoglobin A1c changes from 10% to 8%.

C. GYAC test changes from positive to negative.

D. Somatic RIT changes from 36% to 32%.

B. Hemoglobin A1c changes from 10% to 8%.

When assessing an older adult client with a history of cardiovascular disease, dyspnea, and peripheral edema, which method is best for the nurse to use to assess the client's pulse rate?

A. Auscultate the apical pulse at the point of maximal impulse.

B. Palpate the radial pulses in both arms for a deficit.

C. Feel the volume of the dorsalis medis and posterior tibialis pulses.

D. Use the stethoscope to listen over the carotid artery.

A. Auscultate the apical pulse at the point of maximal impulse.

Which instruction should the nurse give the client who has a lung abscess?

A. Repeat the number 99 during a systematic auscultation of the thorax.

B. Repeat vocalizing the letter E while the thorax is auscultated.

C. Breathe in and out while all lobes of both lungs are auscultated.

D. Whisper 1, 2, 3 in sequence during auscultation of the thorax.

B. Repeat vocalizing the letter E while the thorax is auscultated.

When the nurse is obtaining health history during an annual physical examination, the client reports having difficulty with erections for the past 8 months. Which information in the client's history should the nurse consider as a potential reason for erectile dysfunction?

A. A phosphodiesterase inhibitor on the medication list.

B. Works more than 12 hours in a day.

C. A lifestyle with minimal physical activity.

D. History of type 2 diabetes mellitus.

History of type 2 diabetes mellitus.