NUR600/NUR 600 Exam 3 V2 | Advanced
Health Assess Q&A with Rationale |
William Paterson University
1. During a cardiac assessment, the nurse hears a low-pitched sound in early diastole at the
apex. How should this be documented?
A. S3 heart sound
B. S4 heart sound
C. Systolic murmur
D. Pericardial friction rub
Correct Answer: A
Expert Explanation: The S3 heart sound occurs early in diastole during the rapid
ventricular filling phase. It is often associated with conditions like heart failure or volume
overload in older adults. The sound is best heard with the bell of the stethoscope at the
apex.
2. Which physical examination technique is most appropriate for assessing the presence of
fluid in the abdominal cavity?
A. Checking for a fluid wave
B. Auscultating for bowel sounds
C. Palpating the spleen edge
,D. Percussing the costovertebral angle
Correct Answer: A
Expert Explanation: The fluid wave test is specifically used to detect ascites or free fluid in
the abdomen. It involves having the patient or an assistant place their hand on the midline
while the examiner taps one side. A positive result is felt as a shock wave on the opposite
side.
3. A patient presents with a ‘stabbing’ chest pain that worsens with deep inspiration and
coughing. Which condition is most likely?
A. Myocardial infarction
B. Stable angina
C. Gastroesophageal reflux
D. Pleuritic chest pain
Correct Answer: D
Expert Explanation: Pleuritic chest pain is characterized by sharp, stabbing sensations
that intensify during respiratory movements. This typically indicates inflammation of the
pleura, which is the lining of the lungs. Unlike cardiac pain, it is highly dependent on the
breathing cycle.
4. When assessing cranial nerve VII, which action should the nurse ask the patient to
perform?
A. Smile and puff out cheeks
, B. Stick out the tongue
C. Shrug the shoulders
D. Follow a finger with their eyes
Correct Answer: A
Expert Explanation: Cranial nerve VII is the facial nerve, which is responsible for the
muscles of facial expression. Asking the patient to smile, frown, or puff out their cheeks
tests the motor function of this nerve. Asymmetry in these movements can indicate a stroke
or Bell’s palsy.
5. Which finding is considered a positive Murphy’s sign?
A. Pain during deep palpation of the RUQ that causes the patient to stop breathing
B. Pain upon release of pressure in the LLQ
C. Pain in the RLQ when the LLQ is palpated
D. Bruising around the umbilicus
Correct Answer: A
Expert Explanation: Murphy’s sign is used to assess for acute cholecystitis, which is
inflammation of the gallbladder. The examiner palpates the right upper quadrant while the
patient takes a deep breath. If the patient abruptly stops inhaling due to pain, the test is
positive.
Health Assess Q&A with Rationale |
William Paterson University
1. During a cardiac assessment, the nurse hears a low-pitched sound in early diastole at the
apex. How should this be documented?
A. S3 heart sound
B. S4 heart sound
C. Systolic murmur
D. Pericardial friction rub
Correct Answer: A
Expert Explanation: The S3 heart sound occurs early in diastole during the rapid
ventricular filling phase. It is often associated with conditions like heart failure or volume
overload in older adults. The sound is best heard with the bell of the stethoscope at the
apex.
2. Which physical examination technique is most appropriate for assessing the presence of
fluid in the abdominal cavity?
A. Checking for a fluid wave
B. Auscultating for bowel sounds
C. Palpating the spleen edge
,D. Percussing the costovertebral angle
Correct Answer: A
Expert Explanation: The fluid wave test is specifically used to detect ascites or free fluid in
the abdomen. It involves having the patient or an assistant place their hand on the midline
while the examiner taps one side. A positive result is felt as a shock wave on the opposite
side.
3. A patient presents with a ‘stabbing’ chest pain that worsens with deep inspiration and
coughing. Which condition is most likely?
A. Myocardial infarction
B. Stable angina
C. Gastroesophageal reflux
D. Pleuritic chest pain
Correct Answer: D
Expert Explanation: Pleuritic chest pain is characterized by sharp, stabbing sensations
that intensify during respiratory movements. This typically indicates inflammation of the
pleura, which is the lining of the lungs. Unlike cardiac pain, it is highly dependent on the
breathing cycle.
4. When assessing cranial nerve VII, which action should the nurse ask the patient to
perform?
A. Smile and puff out cheeks
, B. Stick out the tongue
C. Shrug the shoulders
D. Follow a finger with their eyes
Correct Answer: A
Expert Explanation: Cranial nerve VII is the facial nerve, which is responsible for the
muscles of facial expression. Asking the patient to smile, frown, or puff out their cheeks
tests the motor function of this nerve. Asymmetry in these movements can indicate a stroke
or Bell’s palsy.
5. Which finding is considered a positive Murphy’s sign?
A. Pain during deep palpation of the RUQ that causes the patient to stop breathing
B. Pain upon release of pressure in the LLQ
C. Pain in the RLQ when the LLQ is palpated
D. Bruising around the umbilicus
Correct Answer: A
Expert Explanation: Murphy’s sign is used to assess for acute cholecystitis, which is
inflammation of the gallbladder. The examiner palpates the right upper quadrant while the
patient takes a deep breath. If the patient abruptly stops inhaling due to pain, the test is
positive.
