Penn State University
2 MAXE 152 SRUN
PSU
Ross and Carol Nese College of Nursing · BSN Program
NURSING
MAKING LIFE BETTER
EST. 1855
NURS 251 — Exam 2: Health Assessment & Physical
Examination
H E E N T · R E S P I R ATO R Y · LY M P H AT I C · C R A N I A L N E R V E S · T H O R A X · LU N G A U S CU LTAT I O N
INSTITUTION Penn State University COURSE CODE NURS 251
PROGRAM Bachelor of Science in Nursing (BSN) ACADEMIC YEAR
EXAM TITLE NURS 251 — Exam 2: Health Assessment & TOTAL QUESTIONS 40 Questions
Physical Examination
COURSE TITLE Foundations of Professional Nursing · FORMAT Multiple Choice — Select the Single Best
Health Assessment Across the Lifespan Answer
EXAMINATION INSTRUCTIONS
▸ Questions cover HEENT assessment, respiratory examination, lymphatic system, cranial nerves, thorax/lung auscultation, and
developmental considerations.
▸ Select the single best answer based on health assessment and physical examination fundamentals.
▸ Pay careful attention to normal vs. abnormal findings, cranial nerve functions, and breath sound characteristics.
▸ Correct answers and detailed rationales appear below each question for comprehensive exam preparation.
HEENT · RESPIRATORY · LYMPHATIC · CRANIAL NERVES · THORAX · Questions 1
LUNG AUSCULTATION – 40
1. What are the five moments of hand hygiene?
A. Before shift, after shift, before lunch, after lunch, before leaving
B. Before touching a patient, before clean/aseptic procedure, after body fluid exposure/risk, after touching a patient,
after touching patient surroundings
C. Before assessment, after assessment, before medication, after medication, before documentation
D. Only when hands are visibly soiled
CORRECT ANSWER B. Before touching a patient, before clean/aseptic procedure, after body fluid exposure/risk, after
touching a patient, after touching patient surroundings
RATIONALE The WHO's "Five Moments for Hand Hygiene" provide evidence-based moments when hand hygiene must be
performed to prevent healthcare-associated infections: (1) Before patient contact, (2) Before aseptic task, (3)
After body fluid exposure risk, (4) After patient contact, (5) After contact with patient surroundings. These
apply to every patient encounter.
, 2. What does the acronym WIPES stand for in patient care?
A. Wash, Inspect, Palpate, Evaluate, Screen
B. Wash hands, Introduce self & identify patient with 2 identifiers, Provide privacy, Explain what you're doing, Smile
C. Wait, Inspect, Percuss, Evaluate, Summarize
D. Wash, Identify, Prepare, Educate, Screen
CORRECT ANSWER B. Wash hands, Introduce self & identify patient with 2 identifiers, Provide privacy, Explain what you're
doing, Smile
RATIONALE WIPES is a pre-procedure safety and communication framework: W—Wash hands; I—Introduce yourself and
verify patient identity using TWO identifiers (name, DOB); P—Provide privacy (close curtain/door); E—Explain
the procedure to the patient; S—Smile (demonstrates caring and builds rapport). This ensures patient safety,
dignity, and understanding before any nursing intervention.
3. Which cranial nerve innervates the sternomastoid and trapezius muscles?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve VII (Facial)
C. Cranial Nerve XI (Spinal Accessory)
D. Cranial Nerve XII (Hypoglossal)
CORRECT ANSWER C. Cranial Nerve XI (Spinal Accessory)
RATIONALE CN XI (Spinal Accessory) innervates the sternomastoid (head rotation and flexion) and trapezius (shoulder
movement, head extension/turning) muscles. CN V (Trigeminal) provides facial sensation and mastication. CN
VII (Facial) controls facial expression. CN XII (Hypoglossal) controls tongue movement. Testing CN XI: ask
patient to shrug shoulders against resistance and turn head against resistance.
4. Where are the preauricular lymph nodes located?
A. Behind the ear
B. In front of the ear
C. Under the jaw
D. At the base of the skull
CORRECT ANSWER B. In front of the ear
RATIONALE Preauricular nodes are located IN FRONT OF the ear. Posterior auricular (mastoid) nodes are behind the ear.
Occipital nodes are at the base of the skull. Submental nodes are midline behind the mandible tip.
Submandibular nodes are halfway between the angle and tip of the mandible. Knowing node locations is
essential for identifying the source of infection or malignancy.
5. When does the anterior fontanel typically close?
A. At birth
B. By 1–2 months
C. Between 9 months and 2 years
D. By 5 years
CORRECT ANSWER C. Between 9 months and 2 years
RATIONALE The anterior fontanel (diamond-shaped, at the junction of frontal and parietal bones) closes between 9
months and 2 years. The posterior fontanel (triangular, at the junction of parietal and occipital bones) closes
much earlier—by 1–2 months. Fontanels allow brain growth during the first year. Delayed closure may
indicate hypothyroidism or increased intracranial pressure. Measure head circumference at each visit up to
age 2.
2 MAXE 152 SRUN
PSU
Ross and Carol Nese College of Nursing · BSN Program
NURSING
MAKING LIFE BETTER
EST. 1855
NURS 251 — Exam 2: Health Assessment & Physical
Examination
H E E N T · R E S P I R ATO R Y · LY M P H AT I C · C R A N I A L N E R V E S · T H O R A X · LU N G A U S CU LTAT I O N
INSTITUTION Penn State University COURSE CODE NURS 251
PROGRAM Bachelor of Science in Nursing (BSN) ACADEMIC YEAR
EXAM TITLE NURS 251 — Exam 2: Health Assessment & TOTAL QUESTIONS 40 Questions
Physical Examination
COURSE TITLE Foundations of Professional Nursing · FORMAT Multiple Choice — Select the Single Best
Health Assessment Across the Lifespan Answer
EXAMINATION INSTRUCTIONS
▸ Questions cover HEENT assessment, respiratory examination, lymphatic system, cranial nerves, thorax/lung auscultation, and
developmental considerations.
▸ Select the single best answer based on health assessment and physical examination fundamentals.
▸ Pay careful attention to normal vs. abnormal findings, cranial nerve functions, and breath sound characteristics.
▸ Correct answers and detailed rationales appear below each question for comprehensive exam preparation.
HEENT · RESPIRATORY · LYMPHATIC · CRANIAL NERVES · THORAX · Questions 1
LUNG AUSCULTATION – 40
1. What are the five moments of hand hygiene?
A. Before shift, after shift, before lunch, after lunch, before leaving
B. Before touching a patient, before clean/aseptic procedure, after body fluid exposure/risk, after touching a patient,
after touching patient surroundings
C. Before assessment, after assessment, before medication, after medication, before documentation
D. Only when hands are visibly soiled
CORRECT ANSWER B. Before touching a patient, before clean/aseptic procedure, after body fluid exposure/risk, after
touching a patient, after touching patient surroundings
RATIONALE The WHO's "Five Moments for Hand Hygiene" provide evidence-based moments when hand hygiene must be
performed to prevent healthcare-associated infections: (1) Before patient contact, (2) Before aseptic task, (3)
After body fluid exposure risk, (4) After patient contact, (5) After contact with patient surroundings. These
apply to every patient encounter.
, 2. What does the acronym WIPES stand for in patient care?
A. Wash, Inspect, Palpate, Evaluate, Screen
B. Wash hands, Introduce self & identify patient with 2 identifiers, Provide privacy, Explain what you're doing, Smile
C. Wait, Inspect, Percuss, Evaluate, Summarize
D. Wash, Identify, Prepare, Educate, Screen
CORRECT ANSWER B. Wash hands, Introduce self & identify patient with 2 identifiers, Provide privacy, Explain what you're
doing, Smile
RATIONALE WIPES is a pre-procedure safety and communication framework: W—Wash hands; I—Introduce yourself and
verify patient identity using TWO identifiers (name, DOB); P—Provide privacy (close curtain/door); E—Explain
the procedure to the patient; S—Smile (demonstrates caring and builds rapport). This ensures patient safety,
dignity, and understanding before any nursing intervention.
3. Which cranial nerve innervates the sternomastoid and trapezius muscles?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve VII (Facial)
C. Cranial Nerve XI (Spinal Accessory)
D. Cranial Nerve XII (Hypoglossal)
CORRECT ANSWER C. Cranial Nerve XI (Spinal Accessory)
RATIONALE CN XI (Spinal Accessory) innervates the sternomastoid (head rotation and flexion) and trapezius (shoulder
movement, head extension/turning) muscles. CN V (Trigeminal) provides facial sensation and mastication. CN
VII (Facial) controls facial expression. CN XII (Hypoglossal) controls tongue movement. Testing CN XI: ask
patient to shrug shoulders against resistance and turn head against resistance.
4. Where are the preauricular lymph nodes located?
A. Behind the ear
B. In front of the ear
C. Under the jaw
D. At the base of the skull
CORRECT ANSWER B. In front of the ear
RATIONALE Preauricular nodes are located IN FRONT OF the ear. Posterior auricular (mastoid) nodes are behind the ear.
Occipital nodes are at the base of the skull. Submental nodes are midline behind the mandible tip.
Submandibular nodes are halfway between the angle and tip of the mandible. Knowing node locations is
essential for identifying the source of infection or malignancy.
5. When does the anterior fontanel typically close?
A. At birth
B. By 1–2 months
C. Between 9 months and 2 years
D. By 5 years
CORRECT ANSWER C. Between 9 months and 2 years
RATIONALE The anterior fontanel (diamond-shaped, at the junction of frontal and parietal bones) closes between 9
months and 2 years. The posterior fontanel (triangular, at the junction of parietal and occipital bones) closes
much earlier—by 1–2 months. Fontanels allow brain growth during the first year. Delayed closure may
indicate hypothyroidism or increased intracranial pressure. Measure head circumference at each visit up to
age 2.
