NUR612/NUR 612 Exam 1 V2 | Advanced
Nursing II Q&A with Rationale | William
Paterson University
1. When assessing visual acuity using the Snellen chart, what does a result of 20/40 indicate?
A. The patient can see at 40 feet what a normal person sees at 20 feet.
B. The patient’s vision is twice as good as the average person.
C. The patient can see at 20 feet what a normal person sees at 40 feet.
D. The patient has perfect vision in the right eye but poor vision in the left.
Correct Answer: C
Expert Explanation: In the Snellen fraction, the top number represents the distance from
the chart, which is typically 20 feet. The bottom number indicates the distance at which a
person with normal vision could read that same line. Therefore, 20/40 means the patient
sees at 20 feet what a normal eye sees at 40 feet, indicating decreased acuity.
2. Which cranial nerve is being tested when the nurse asks the patient to shrug their
shoulders against resistance?
A. Cranial Nerve XI (Spinal Accessory)
B. Cranial Nerve X (Vagus)
C. Cranial Nerve VII (Facial)
D. Cranial Nerve XII (Hypoglossal)
,Correct Answer: A
Expert Explanation: Cranial Nerve XI, the spinal accessory nerve, innervates the trapezius
and sternocleidomastoid muscles. To test its function, the clinician observes for symmetry
and strength during shoulder shrugging and neck rotation. Weakness or asymmetry may
indicate nerve damage or muscle pathology.
3. An S3 heart sound is frequently associated with which of the following conditions in older
adults?
A. Aortic stenosis
B. Heart failure or fluid overload
C. Hypertension and stiff ventricles
D. Normal physiological aging
Correct Answer: B
Expert Explanation: The S3 heart sound, or ventricular gallop, occurs early in diastole
during the rapid ventricular filling phase. While it can be normal in children and athletes, in
older adults, it often signifies ventricular non-compliance or volume overload. It is a
hallmark finding in patients experiencing acute congestive heart failure.
4. During a respiratory assessment, the clinician notes increased tactile fremitus over the
right lower lobe. This most likely suggests:
A. Lobar pneumonia
B. Pleural effusion
, C. Pneumothorax
D. Asthmatic bronchospasm
Correct Answer: A
Expert Explanation: Tactile fremitus is the vibration felt on the chest wall when a patient
speaks. Consolidation of lung tissue, such as in pneumonia, increases the transmission of
these vibrations because sound travels better through solids than air. Conversely,
conditions like pneumothorax or pleural effusion decrease or eliminate fremitus.
5. A positive Murphy sign is an indicator for which of the following clinical conditions?
A. Acute cholecystitis
B. Acute appendicitis
C. Splenic rupture
D. Nephrolithiasis
Correct Answer: A
Expert Explanation: Murphy’s sign is performed by asking the patient to inhale while the
clinician applies pressure under the right costal margin. A positive sign occurs when the
patient abruptly stops breathing (inspiratory arrest) due to pain from the inflamed
gallbladder hitting the examiner’s hand. This test has high specificity for identifying acute
cholecystitis.
Nursing II Q&A with Rationale | William
Paterson University
1. When assessing visual acuity using the Snellen chart, what does a result of 20/40 indicate?
A. The patient can see at 40 feet what a normal person sees at 20 feet.
B. The patient’s vision is twice as good as the average person.
C. The patient can see at 20 feet what a normal person sees at 40 feet.
D. The patient has perfect vision in the right eye but poor vision in the left.
Correct Answer: C
Expert Explanation: In the Snellen fraction, the top number represents the distance from
the chart, which is typically 20 feet. The bottom number indicates the distance at which a
person with normal vision could read that same line. Therefore, 20/40 means the patient
sees at 20 feet what a normal eye sees at 40 feet, indicating decreased acuity.
2. Which cranial nerve is being tested when the nurse asks the patient to shrug their
shoulders against resistance?
A. Cranial Nerve XI (Spinal Accessory)
B. Cranial Nerve X (Vagus)
C. Cranial Nerve VII (Facial)
D. Cranial Nerve XII (Hypoglossal)
,Correct Answer: A
Expert Explanation: Cranial Nerve XI, the spinal accessory nerve, innervates the trapezius
and sternocleidomastoid muscles. To test its function, the clinician observes for symmetry
and strength during shoulder shrugging and neck rotation. Weakness or asymmetry may
indicate nerve damage or muscle pathology.
3. An S3 heart sound is frequently associated with which of the following conditions in older
adults?
A. Aortic stenosis
B. Heart failure or fluid overload
C. Hypertension and stiff ventricles
D. Normal physiological aging
Correct Answer: B
Expert Explanation: The S3 heart sound, or ventricular gallop, occurs early in diastole
during the rapid ventricular filling phase. While it can be normal in children and athletes, in
older adults, it often signifies ventricular non-compliance or volume overload. It is a
hallmark finding in patients experiencing acute congestive heart failure.
4. During a respiratory assessment, the clinician notes increased tactile fremitus over the
right lower lobe. This most likely suggests:
A. Lobar pneumonia
B. Pleural effusion
, C. Pneumothorax
D. Asthmatic bronchospasm
Correct Answer: A
Expert Explanation: Tactile fremitus is the vibration felt on the chest wall when a patient
speaks. Consolidation of lung tissue, such as in pneumonia, increases the transmission of
these vibrations because sound travels better through solids than air. Conversely,
conditions like pneumothorax or pleural effusion decrease or eliminate fremitus.
5. A positive Murphy sign is an indicator for which of the following clinical conditions?
A. Acute cholecystitis
B. Acute appendicitis
C. Splenic rupture
D. Nephrolithiasis
Correct Answer: A
Expert Explanation: Murphy’s sign is performed by asking the patient to inhale while the
clinician applies pressure under the right costal margin. A positive sign occurs when the
patient abruptly stops breathing (inspiratory arrest) due to pain from the inflamed
gallbladder hitting the examiner’s hand. This test has high specificity for identifying acute
cholecystitis.
