NUR600/NUR 600 Final Exam V3 |
Advanced Health Assess Q&A with
Rationale | William Paterson University
1. When performing an abdominal assessment, which is the correct order of examination
techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: A
Expert Explanation: The abdominal exam must begin with inspection to observe the
surface. Auscultation follows immediately to ensure bowel sounds are heard in their
natural state before they are altered by manual manipulation. Percussion and palpation are
done last because they can stimulate peristalsis and create false bowel sound readings.
2. A patient exhibits a low-pitched, snoring sound in the lungs that clears with a cough. This is
best described as:
A. Fine crackles
B. Rhonchi
C. Wheezes
,D. Stridor
Correct Answer: B
Expert Explanation: Rhonchi are continuous, low-pitched rattling sounds that often
resemble snoring. They are typically caused by secretions or obstructions in the larger
airways. A key characteristic of rhonchi is that they frequently clear or change significantly
after the patient coughs.
3. Which cranial nerve is being tested when the nurse asks the patient to shrug their
shoulders against resistance?
A. CN IX (Glossopharyngeal)
B. CN XI (Spinal Accessory)
C. CN X (Vagus)
D. CN XII (Hypoglossal)
Correct Answer: B
Expert Explanation: The Spinal Accessory nerve (CN XI) innervates the trapezius and
sternocleidomastoid muscles. To test this nerve, the clinician assesses the patient’s ability
to shrug their shoulders and turn their head against resistance. Weakness or asymmetry
during this maneuver may indicate nerve damage or muscle dysfunction.
4. The first heart sound (S1) is produced by the closure of which valves?
A. Aortic and Pulmonic
, B. Tricuspid and Pulmonic
C. Aortic and Mitral
D. Mitral and Tricuspid
Correct Answer: D
Expert Explanation: S1 represents the ‘lub’ sound in the cardiac cycle and marks the
beginning of systole. It is caused by the simultaneous closure of the atrioventricular valves,
which are the mitral and tricuspid valves. This sound is usually loudest at the apex of the
heart.
5. When assessing for Murphy’s sign, the nurse is checking for inflammation of which organ?
A. Appendix
B. Liver
C. Spleen
D. Gallbladder
Correct Answer: D
Expert Explanation: Murphy’s sign is a clinical test used to identify acute cholecystitis or
gallbladder inflammation. The nurse asks the patient to take a deep breath while applying
pressure under the right costal margin. A positive sign occurs when the patient experiences
sharp pain and abruptly stops inhaling.
Advanced Health Assess Q&A with
Rationale | William Paterson University
1. When performing an abdominal assessment, which is the correct order of examination
techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: A
Expert Explanation: The abdominal exam must begin with inspection to observe the
surface. Auscultation follows immediately to ensure bowel sounds are heard in their
natural state before they are altered by manual manipulation. Percussion and palpation are
done last because they can stimulate peristalsis and create false bowel sound readings.
2. A patient exhibits a low-pitched, snoring sound in the lungs that clears with a cough. This is
best described as:
A. Fine crackles
B. Rhonchi
C. Wheezes
,D. Stridor
Correct Answer: B
Expert Explanation: Rhonchi are continuous, low-pitched rattling sounds that often
resemble snoring. They are typically caused by secretions or obstructions in the larger
airways. A key characteristic of rhonchi is that they frequently clear or change significantly
after the patient coughs.
3. Which cranial nerve is being tested when the nurse asks the patient to shrug their
shoulders against resistance?
A. CN IX (Glossopharyngeal)
B. CN XI (Spinal Accessory)
C. CN X (Vagus)
D. CN XII (Hypoglossal)
Correct Answer: B
Expert Explanation: The Spinal Accessory nerve (CN XI) innervates the trapezius and
sternocleidomastoid muscles. To test this nerve, the clinician assesses the patient’s ability
to shrug their shoulders and turn their head against resistance. Weakness or asymmetry
during this maneuver may indicate nerve damage or muscle dysfunction.
4. The first heart sound (S1) is produced by the closure of which valves?
A. Aortic and Pulmonic
, B. Tricuspid and Pulmonic
C. Aortic and Mitral
D. Mitral and Tricuspid
Correct Answer: D
Expert Explanation: S1 represents the ‘lub’ sound in the cardiac cycle and marks the
beginning of systole. It is caused by the simultaneous closure of the atrioventricular valves,
which are the mitral and tricuspid valves. This sound is usually loudest at the apex of the
heart.
5. When assessing for Murphy’s sign, the nurse is checking for inflammation of which organ?
A. Appendix
B. Liver
C. Spleen
D. Gallbladder
Correct Answer: D
Expert Explanation: Murphy’s sign is a clinical test used to identify acute cholecystitis or
gallbladder inflammation. The nurse asks the patient to take a deep breath while applying
pressure under the right costal margin. A positive sign occurs when the patient experiences
sharp pain and abruptly stops inhaling.
