NUR600/NUR 600 Exam 2 V3 | Advanced
Health Assess Q&A with Rationale |
William Paterson University
1. When performing a skin assessment using the ABCDE criteria for melanoma, what does the
‘E’ stand for?
A. Elevation
B. Erythema
C. Evolving
D. Exudate
Correct Answer: C
Expert Explanation: In the ABCDE mnemonic for melanoma, ‘E’ stands for evolving, which
refers to any change in size, shape, color, or symptoms. This is a critical factor because
benign moles typically stay the same over time while malignant ones change. Monitoring
evolution helps in early detection and improving the prognosis for patients with skin
cancer.
2. A patient presents with a ‘barrel chest’ during a respiratory exam. Which condition is this
finding most commonly associated with?
A. Acute Pneumonia
B. Pulmonary Embolism
,C. Chronic Obstructive Pulmonary Disease (COPD)
D. Congestive Heart Failure
Correct Answer: C
Expert Explanation: A barrel chest is characterized by an increased anteroposterior
diameter of the thorax, often reaching a 1:1 ratio. This physical finding is typically
associated with COPD or chronic emphysema due to long-term air trapping and
hyperinflation of the lungs. The change in chest wall shape reflects the underlying
structural changes in the pulmonary system caused by chronic respiratory disease.
3. During auscultation of the heart, the S2 sound is caused by the closure of which valves?
A. Mitral and Tricuspid
B. Aortic and Pulmonary
C. Mitral and Aortic
D. Tricuspid and Pulmonary
Correct Answer: B
Expert Explanation: The second heart sound (S2) marks the beginning of diastole and is
produced by the closure of the semilunar valves, which are the aortic and pulmonary
valves. It is usually higher pitched and shorter than S1 and is best heard at the base of the
heart. Understanding the valve closures associated with S1 and S2 is fundamental for
identifying cardiac abnormalities and murmurs.
, 4. Which cranial nerve is primarily responsible for the sense of smell?
A. Cranial Nerve VII
B. Cranial Nerve II
C. Cranial Nerve V
D. Cranial Nerve I
Correct Answer: D
Expert Explanation: Cranial Nerve I, also known as the Olfactory nerve, is purely sensory
and transmits smells to the brain. Assessment is performed by asking the patient to identify
non-irritating odors like coffee or vanilla with their eyes closed. Loss of this sense, known
as anosmia, can occur due to head trauma, smoking, or neurodegenerative diseases.
5. When assessing tactile fremitus, the nurse expects to find increased vibrations over which
condition?
A. Pneumothorax
B. Pleural Effusion
C. Asthma
D. Pneumonia with consolidation
Correct Answer: D
Expert Explanation: Tactile fremitus is the palpable vibration of the chest wall produced
by vocalization. Vibrations increase in the presence of consolidation, such as pneumonia,
Health Assess Q&A with Rationale |
William Paterson University
1. When performing a skin assessment using the ABCDE criteria for melanoma, what does the
‘E’ stand for?
A. Elevation
B. Erythema
C. Evolving
D. Exudate
Correct Answer: C
Expert Explanation: In the ABCDE mnemonic for melanoma, ‘E’ stands for evolving, which
refers to any change in size, shape, color, or symptoms. This is a critical factor because
benign moles typically stay the same over time while malignant ones change. Monitoring
evolution helps in early detection and improving the prognosis for patients with skin
cancer.
2. A patient presents with a ‘barrel chest’ during a respiratory exam. Which condition is this
finding most commonly associated with?
A. Acute Pneumonia
B. Pulmonary Embolism
,C. Chronic Obstructive Pulmonary Disease (COPD)
D. Congestive Heart Failure
Correct Answer: C
Expert Explanation: A barrel chest is characterized by an increased anteroposterior
diameter of the thorax, often reaching a 1:1 ratio. This physical finding is typically
associated with COPD or chronic emphysema due to long-term air trapping and
hyperinflation of the lungs. The change in chest wall shape reflects the underlying
structural changes in the pulmonary system caused by chronic respiratory disease.
3. During auscultation of the heart, the S2 sound is caused by the closure of which valves?
A. Mitral and Tricuspid
B. Aortic and Pulmonary
C. Mitral and Aortic
D. Tricuspid and Pulmonary
Correct Answer: B
Expert Explanation: The second heart sound (S2) marks the beginning of diastole and is
produced by the closure of the semilunar valves, which are the aortic and pulmonary
valves. It is usually higher pitched and shorter than S1 and is best heard at the base of the
heart. Understanding the valve closures associated with S1 and S2 is fundamental for
identifying cardiac abnormalities and murmurs.
, 4. Which cranial nerve is primarily responsible for the sense of smell?
A. Cranial Nerve VII
B. Cranial Nerve II
C. Cranial Nerve V
D. Cranial Nerve I
Correct Answer: D
Expert Explanation: Cranial Nerve I, also known as the Olfactory nerve, is purely sensory
and transmits smells to the brain. Assessment is performed by asking the patient to identify
non-irritating odors like coffee or vanilla with their eyes closed. Loss of this sense, known
as anosmia, can occur due to head trauma, smoking, or neurodegenerative diseases.
5. When assessing tactile fremitus, the nurse expects to find increased vibrations over which
condition?
A. Pneumothorax
B. Pleural Effusion
C. Asthma
D. Pneumonia with consolidation
Correct Answer: D
Expert Explanation: Tactile fremitus is the palpable vibration of the chest wall produced
by vocalization. Vibrations increase in the presence of consolidation, such as pneumonia,
