NSG 1524: Comprehensive Health
Assessment & Foundations of Care
Section I: Multiple Choice (1 Point Each)
Select the best answer for each question.
1. A nurse is performing a cardiac assessment on a client. In which
anatomical location should the nurse place the stethoscope to best
auscultate the point of maximal impulse (PMI)?
A. Second intercostal space, right sternal border
B. Second intercostal space, left sternal border
C. Fourth intercostal space, left sternal border
D. Fifth intercostal space, left midclavicular line
Answer u& uRationale:
Correct uAnswer: uD
Rationale: uThe uPoint uof uMaximal uImpulse u(PMI), ualso uknown uas uthe
uapical upulse, uis ulocated uat uthe ufifth uintercostal uspace uat uthe uleft
umidclavicular uline. uThis uis uwhere uthe uleft uventricle ucontracts
uagainst uthe u chest uwall. uOption uA uis uthe uaortic uarea, uB uis uthe
upulmonic uarea, uand uC uis uthe utricuspid uarea.
2. uA uclient ureports usevere upain urated u9/10. uThe unurse uadministers
umorphine usulfate u4 umg uIV upush. uWhich uassessment ufinding uis uthe
uhighest upriority u15 uminutes upost-administration?
A. uPain urating udecreased uto u3/10
B. uPupils uare uequal uand ureactive uto ulight
C. uRespiratory urate uof u10 ubreaths uper uminute
D. uBlood upressure uof u110/70 umm uHg
Answer u& uRationale:
Correct uAnswer: uC
, Rationale: uMorphine usulfate uis uan uopioid uanalgesic uthat ucan ucause
urespiratory udepression uas ua ulife-threatening uadverse ueffect. uA
urespiratory urate uof u10 ubreaths/min uis ubelow uthe u normal uthreshold
u(12–20) uand uindicates uhypoventilation. uAirway uand ubreathing u are
ualways uthe upriority u(Maslow’s uHierarchy uof uNeeds). uWhile upain
urelief u(A) uis udesired, uit uis unot uthe upriority uover usafety.
3. uA unurse uis uassessing ua uclient’s uskin uturgor uand ufinds uthat uwhen
uthe uskin uover uthe usternum uis upinched, uit uremains utented ufor useveral
useconds. uThis ufinding uis uindicative uof:
A. uJaundice
B. uDehydration
C. uEdema
D. uEcchymosis
Answer u& uRationale:
Correct uAnswer: uB
Rationale: uPoor uskin uturgor u(tenting) uoccurs uwhen uthe uskin ulacks
uelasticity udue uto ufluid uvolume udeficit u(dehydration). uJaundice u (A)
urefers uto uyellowing uof uthe uskin. uEdema u(C) uis uswelling udue uto ufluid
uretention. uEcchymosis u(D) uis ubruising.
4. uDuring ua uneurologic uassessment, uthe unurse uasks uthe uclient uto
ustand uwith ufeet utogether uand ueyes uclosed. uThe uclient ubegins uto
usway uand uloses ubalance. uThe u nurse u documents uthis uas ua upositive:
A. uBabinski usign
B. uKernig usign
C. uRomberg usign
D. uBrudzinski usign
Answer u& uRationale:
Correct uAnswer: uC
Rationale: uThe uRomberg utest uassesses ubalance uand uproprioception.
uA upositive uRomberg usign u(swaying uor ulosing ubalance uwith ueyes
uclosed) uindicates ua udysfunction uin uthe udorsal ucolumn
u(proprioception) uor uvestibular usystem. uBabinski u(A) uis ua uplantar
Assessment & Foundations of Care
Section I: Multiple Choice (1 Point Each)
Select the best answer for each question.
1. A nurse is performing a cardiac assessment on a client. In which
anatomical location should the nurse place the stethoscope to best
auscultate the point of maximal impulse (PMI)?
A. Second intercostal space, right sternal border
B. Second intercostal space, left sternal border
C. Fourth intercostal space, left sternal border
D. Fifth intercostal space, left midclavicular line
Answer u& uRationale:
Correct uAnswer: uD
Rationale: uThe uPoint uof uMaximal uImpulse u(PMI), ualso uknown uas uthe
uapical upulse, uis ulocated uat uthe ufifth uintercostal uspace uat uthe uleft
umidclavicular uline. uThis uis uwhere uthe uleft uventricle ucontracts
uagainst uthe u chest uwall. uOption uA uis uthe uaortic uarea, uB uis uthe
upulmonic uarea, uand uC uis uthe utricuspid uarea.
2. uA uclient ureports usevere upain urated u9/10. uThe unurse uadministers
umorphine usulfate u4 umg uIV upush. uWhich uassessment ufinding uis uthe
uhighest upriority u15 uminutes upost-administration?
A. uPain urating udecreased uto u3/10
B. uPupils uare uequal uand ureactive uto ulight
C. uRespiratory urate uof u10 ubreaths uper uminute
D. uBlood upressure uof u110/70 umm uHg
Answer u& uRationale:
Correct uAnswer: uC
, Rationale: uMorphine usulfate uis uan uopioid uanalgesic uthat ucan ucause
urespiratory udepression uas ua ulife-threatening uadverse ueffect. uA
urespiratory urate uof u10 ubreaths/min uis ubelow uthe u normal uthreshold
u(12–20) uand uindicates uhypoventilation. uAirway uand ubreathing u are
ualways uthe upriority u(Maslow’s uHierarchy uof uNeeds). uWhile upain
urelief u(A) uis udesired, uit uis unot uthe upriority uover usafety.
3. uA unurse uis uassessing ua uclient’s uskin uturgor uand ufinds uthat uwhen
uthe uskin uover uthe usternum uis upinched, uit uremains utented ufor useveral
useconds. uThis ufinding uis uindicative uof:
A. uJaundice
B. uDehydration
C. uEdema
D. uEcchymosis
Answer u& uRationale:
Correct uAnswer: uB
Rationale: uPoor uskin uturgor u(tenting) uoccurs uwhen uthe uskin ulacks
uelasticity udue uto ufluid uvolume udeficit u(dehydration). uJaundice u (A)
urefers uto uyellowing uof uthe uskin. uEdema u(C) uis uswelling udue uto ufluid
uretention. uEcchymosis u(D) uis ubruising.
4. uDuring ua uneurologic uassessment, uthe unurse uasks uthe uclient uto
ustand uwith ufeet utogether uand ueyes uclosed. uThe uclient ubegins uto
usway uand uloses ubalance. uThe u nurse u documents uthis uas ua upositive:
A. uBabinski usign
B. uKernig usign
C. uRomberg usign
D. uBrudzinski usign
Answer u& uRationale:
Correct uAnswer: uC
Rationale: uThe uRomberg utest uassesses ubalance uand uproprioception.
uA upositive uRomberg usign u(swaying uor ulosing ubalance uwith ueyes
uclosed) uindicates ua udysfunction uin uthe udorsal ucolumn
u(proprioception) uor uvestibular usystem. uBabinski u(A) uis ua uplantar
