NUR600/NUR 600 Exam 2 V2 | Advanced
Health Assess Q&A with Rationale |
William Paterson University
1. During a cardiovascular assessment, the nurse hears a soft, low-pitched sound in early
diastole at the apex. How should this be documented?
A. S3 heart sound
B. Pericardial friction rub
C. S4 heart sound
D. Systolic murmur
Correct Answer: A
Expert Explanation: The S3 heart sound occurs in early diastole during the rapid
ventricular filling phase. It is often described as a ventricular gallop and is best heard with
the bell of the stethoscope at the apex. In older adults, this finding can be an early sign of
heart failure or fluid overload.
2. A patient presents with sudden, sharp pain in the right lower quadrant and rebound
tenderness at McBurney’s point. Which condition is most likely?
A. Cholecystitis
B. Appendicitis
C. Diverticulitis
,D. Pancreatitis
Correct Answer: B
Expert Explanation: McBurney’s point is located two-thirds of the distance from the
umbilicus to the anterior superior iliac spine. Rebound tenderness in this specific area is a
classic clinical indicator of acute appendicitis. The examiner must assess for other signs like
the Psoas or Obturator signs to confirm the diagnosis.
3. When performing a respiratory assessment, the nurse notes increased tactile fremitus over
the right lower lobe. This finding is consistent with:
A. Pneumothorax
B. Pleural effusion
C. Emphysema
D. Lobar pneumonia
Correct Answer: D
Expert Explanation: Tactile fremitus increases when the lung tissue becomes
consolidated, such as in lobar pneumonia. Solid tissue conducts sound vibrations more
efficiently than air-filled tissue. Conversely, conditions that trap air or put fluid in the
pleural space, like pneumothorax or effusion, will decrease fremitus.
4. A 55-year-old patient reports difficulty seeing objects up close, requiring them to hold
reading material at arm’s length. What is this condition called?
A. Myopia
, B. Presbyopia
C. Hyperopia
D. Astigmatism
Correct Answer: B
Expert Explanation: Presbyopia is the age-related loss of lens elasticity, which impairs the
eye’s ability to focus on near objects. This condition typically begins in the mid-40s and
progresses as the lens becomes stiffer. It is a normal part of aging and is usually corrected
with reading glasses or bifocals.
5. Which cranial nerve is being assessed when the nurse asks the patient to shrug their
shoulders against resistance?
A. Cranial Nerve XI
B. Cranial Nerve X
C. Cranial Nerve IX
D. Cranial Nerve XII
Correct Answer: A
Expert Explanation: Cranial Nerve XI, the Spinal Accessory nerve, innervates the trapezius
and sternocleidomastoid muscles. To test this nerve, the nurse assesses the strength of
shoulder shrugging and head turning against resistance. Asymmetry or weakness may
indicate nerve damage or muscle pathology.
Health Assess Q&A with Rationale |
William Paterson University
1. During a cardiovascular assessment, the nurse hears a soft, low-pitched sound in early
diastole at the apex. How should this be documented?
A. S3 heart sound
B. Pericardial friction rub
C. S4 heart sound
D. Systolic murmur
Correct Answer: A
Expert Explanation: The S3 heart sound occurs in early diastole during the rapid
ventricular filling phase. It is often described as a ventricular gallop and is best heard with
the bell of the stethoscope at the apex. In older adults, this finding can be an early sign of
heart failure or fluid overload.
2. A patient presents with sudden, sharp pain in the right lower quadrant and rebound
tenderness at McBurney’s point. Which condition is most likely?
A. Cholecystitis
B. Appendicitis
C. Diverticulitis
,D. Pancreatitis
Correct Answer: B
Expert Explanation: McBurney’s point is located two-thirds of the distance from the
umbilicus to the anterior superior iliac spine. Rebound tenderness in this specific area is a
classic clinical indicator of acute appendicitis. The examiner must assess for other signs like
the Psoas or Obturator signs to confirm the diagnosis.
3. When performing a respiratory assessment, the nurse notes increased tactile fremitus over
the right lower lobe. This finding is consistent with:
A. Pneumothorax
B. Pleural effusion
C. Emphysema
D. Lobar pneumonia
Correct Answer: D
Expert Explanation: Tactile fremitus increases when the lung tissue becomes
consolidated, such as in lobar pneumonia. Solid tissue conducts sound vibrations more
efficiently than air-filled tissue. Conversely, conditions that trap air or put fluid in the
pleural space, like pneumothorax or effusion, will decrease fremitus.
4. A 55-year-old patient reports difficulty seeing objects up close, requiring them to hold
reading material at arm’s length. What is this condition called?
A. Myopia
, B. Presbyopia
C. Hyperopia
D. Astigmatism
Correct Answer: B
Expert Explanation: Presbyopia is the age-related loss of lens elasticity, which impairs the
eye’s ability to focus on near objects. This condition typically begins in the mid-40s and
progresses as the lens becomes stiffer. It is a normal part of aging and is usually corrected
with reading glasses or bifocals.
5. Which cranial nerve is being assessed when the nurse asks the patient to shrug their
shoulders against resistance?
A. Cranial Nerve XI
B. Cranial Nerve X
C. Cranial Nerve IX
D. Cranial Nerve XII
Correct Answer: A
Expert Explanation: Cranial Nerve XI, the Spinal Accessory nerve, innervates the trapezius
and sternocleidomastoid muscles. To test this nerve, the nurse assesses the strength of
shoulder shrugging and head turning against resistance. Asymmetry or weakness may
indicate nerve damage or muscle pathology.
