NUR600/NUR 600 Exam 1 V2 | Advanced
Health Assess Q&A with Rationale |
William Paterson University
1. Which of the following constitutes objective data collected during a physical examination?
A. The patient reports a throbbing headache.
B. The patient describes feeling nauseated for two days.
C. The patient states they are allergic to penicillin.
D. The nurse observes a 2-cm ulcer on the left lateral malleolus.
Correct Answer: D
Expert Explanation: Objective data is what the health professional observes by inspecting,
palpating, percussing, and auscultating during the physical examination. Subjective data is
what the person says about himself or herself during history taking. Observing a specific
lesion like an ulcer is a measurable finding that can be verified by another examiner.
2. When assessing the abdomen, in which order should the nurse perform the physical
assessment techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Palpation, Percussion, Inspection, Auscultation
C. Inspection, Auscultation, Percussion, Palpation
D. Auscultation, Inspection, Palpation, Percussion
,Correct Answer: C
Expert Explanation: The sequence for abdominal assessment is modified to prevent false
findings. Percussion and palpation can increase peristalsis, which would falsely interpret
bowel sounds. Therefore, auscultation must occur immediately after inspection to ensure
accurate clinical data.
3. Which percussion note is typically heard over normal lung tissue in an adult?
A. Dullness
B. Resonance
C. Tympany
D. Hyperresonance
Correct Answer: B
Expert Explanation: Resonance is the clear, hollow sound heard over normal lung tissue.
Dullness is heard over dense organs like the liver, while tympany is heard over air-filled
structures like the stomach. Hyperresonance is found in cases of hyperinflation such as
emphysema.
4. What is the primary purpose of using the bell of the stethoscope during auscultation?
A. To hear low-pitched sounds such as heart murmurs
B. To hear high-pitched sounds like breath sounds
C. To measure blood pressure on small children
, D. To amplify the sound of normal bowel movements
Correct Answer: A
Expert Explanation: The bell of the stethoscope is best for low-pitched sounds like extra
heart sounds (S3, S4) or murmurs. It should be held lightly against the skin to avoid
flattening the skin and turning it into a diaphragm. The diaphragm is used for high-pitched
sounds like lung or normal heart sounds.
5. A patient presents with a ‘stiff neck.’ The nurse should first assess for which of the
following?
A. Thyroid enlargement
B. Cervical lymphadenopathy
C. Muscle strain from sleeping
D. Meningeal irritation
Correct Answer: D
Expert Explanation: A stiff neck (nuchal rigidity) combined with fever and headache is a
red flag for meningitis. While muscle strain is common, the nurse must prioritize checking
for life-threatening conditions first. Meningeal irritation should be ruled out through
specific tests like Brudzinski or Kernig signs.
6. What does the ‘A’ represent in the ABCDE rule for assessing skin lesions for potential
melanoma?
A. Atypical
Health Assess Q&A with Rationale |
William Paterson University
1. Which of the following constitutes objective data collected during a physical examination?
A. The patient reports a throbbing headache.
B. The patient describes feeling nauseated for two days.
C. The patient states they are allergic to penicillin.
D. The nurse observes a 2-cm ulcer on the left lateral malleolus.
Correct Answer: D
Expert Explanation: Objective data is what the health professional observes by inspecting,
palpating, percussing, and auscultating during the physical examination. Subjective data is
what the person says about himself or herself during history taking. Observing a specific
lesion like an ulcer is a measurable finding that can be verified by another examiner.
2. When assessing the abdomen, in which order should the nurse perform the physical
assessment techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Palpation, Percussion, Inspection, Auscultation
C. Inspection, Auscultation, Percussion, Palpation
D. Auscultation, Inspection, Palpation, Percussion
,Correct Answer: C
Expert Explanation: The sequence for abdominal assessment is modified to prevent false
findings. Percussion and palpation can increase peristalsis, which would falsely interpret
bowel sounds. Therefore, auscultation must occur immediately after inspection to ensure
accurate clinical data.
3. Which percussion note is typically heard over normal lung tissue in an adult?
A. Dullness
B. Resonance
C. Tympany
D. Hyperresonance
Correct Answer: B
Expert Explanation: Resonance is the clear, hollow sound heard over normal lung tissue.
Dullness is heard over dense organs like the liver, while tympany is heard over air-filled
structures like the stomach. Hyperresonance is found in cases of hyperinflation such as
emphysema.
4. What is the primary purpose of using the bell of the stethoscope during auscultation?
A. To hear low-pitched sounds such as heart murmurs
B. To hear high-pitched sounds like breath sounds
C. To measure blood pressure on small children
, D. To amplify the sound of normal bowel movements
Correct Answer: A
Expert Explanation: The bell of the stethoscope is best for low-pitched sounds like extra
heart sounds (S3, S4) or murmurs. It should be held lightly against the skin to avoid
flattening the skin and turning it into a diaphragm. The diaphragm is used for high-pitched
sounds like lung or normal heart sounds.
5. A patient presents with a ‘stiff neck.’ The nurse should first assess for which of the
following?
A. Thyroid enlargement
B. Cervical lymphadenopathy
C. Muscle strain from sleeping
D. Meningeal irritation
Correct Answer: D
Expert Explanation: A stiff neck (nuchal rigidity) combined with fever and headache is a
red flag for meningitis. While muscle strain is common, the nurse must prioritize checking
for life-threatening conditions first. Meningeal irritation should be ruled out through
specific tests like Brudzinski or Kernig signs.
6. What does the ‘A’ represent in the ABCDE rule for assessing skin lesions for potential
melanoma?
A. Atypical
