NUR 3270/NUR3270 Exam 3 V2 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. A nurse is auscultating the heart of a patient and identifies the first heart sound (S1).
Which event is responsible for the production of S1?
A. Closure of the semilunar valves
B. Opening of the mitral and tricuspid valves
C. Closure of the atrioventricular valves
D. Blood hitting the wall of the ventricles
Correct Answer: C
Expert Explanation: The S1 heart sound, often described as ‘lub,’ is produced by the
closure of the mitral and tricuspid valves. This event signals the beginning of systole and
the contraction of the ventricles. It is usually heard loudest at the apex of the heart.
2. When assessing a patient’s lungs, the nurse notes increased tactile fremitus over the right
lower lobe. This finding is most consistent with which condition?
A. Pneumothorax
B. Pneumonia with consolidation
C. Pleural effusion
,D. Asthma
Correct Answer: B
Expert Explanation: Increased tactile fremitus occurs when there is consolidation in the
lung tissue, such as in pneumonia. Solid or fluid-filled tissue conducts sound vibrations
more effectively than air-filled tissue. Conversely, conditions like pneumothorax or pleural
effusion would decrease fremitus by creating a barrier to sound.
3. During a peripheral vascular assessment, the nurse finds that a patient’s pedal pulses are
weak but palpable. How should this pulse be graded?
A. 1+
B. 2+
C. 3+
D. 4+
Correct Answer: A
Expert Explanation: A grade of 1+ indicates a weak, thready pulse that may be difficult to
palpate. A normal pulse is graded as 2+, while 3+ is full/bounding and 4+ is often used for
exceptionally strong or abnormal bounding pulses. Accurately grading pulses is essential
for monitoring perfusion in the extremities.
4. A nurse is assessing a patient for jugular venous distention (JVD). At what angle should the
head of the bed be positioned for the most accurate measurement?
A. Flat (0 degrees)
, B. 15 to 30 degrees
C. 30 to 45 degrees
D. 90 degrees
Correct Answer: C
Expert Explanation: JVD is typically assessed with the patient reclining at a 30 to 45-
degree angle. This position allows for the visualization of the internal jugular vein
pulsations relative to the sternal angle. Distention at or above this level can indicate heart
failure or increased central venous pressure.
5. When performing a breast examination on a female patient, the nurse identifies a lesion
that is firm, fixed, and has irregular borders. Where is the most common site for breast
tumors?
A. Upper inner quadrant
B. Lower outer quadrant
C. Upper outer quadrant
D. Lower inner quadrant
Correct Answer: C
Expert Explanation: The upper outer quadrant, which includes the Tail of Spence
extending into the axilla, is the most common site for breast cancer. Over 50% of breast
Health Assessment Q&A with Rationale |
William Paterson University
1. A nurse is auscultating the heart of a patient and identifies the first heart sound (S1).
Which event is responsible for the production of S1?
A. Closure of the semilunar valves
B. Opening of the mitral and tricuspid valves
C. Closure of the atrioventricular valves
D. Blood hitting the wall of the ventricles
Correct Answer: C
Expert Explanation: The S1 heart sound, often described as ‘lub,’ is produced by the
closure of the mitral and tricuspid valves. This event signals the beginning of systole and
the contraction of the ventricles. It is usually heard loudest at the apex of the heart.
2. When assessing a patient’s lungs, the nurse notes increased tactile fremitus over the right
lower lobe. This finding is most consistent with which condition?
A. Pneumothorax
B. Pneumonia with consolidation
C. Pleural effusion
,D. Asthma
Correct Answer: B
Expert Explanation: Increased tactile fremitus occurs when there is consolidation in the
lung tissue, such as in pneumonia. Solid or fluid-filled tissue conducts sound vibrations
more effectively than air-filled tissue. Conversely, conditions like pneumothorax or pleural
effusion would decrease fremitus by creating a barrier to sound.
3. During a peripheral vascular assessment, the nurse finds that a patient’s pedal pulses are
weak but palpable. How should this pulse be graded?
A. 1+
B. 2+
C. 3+
D. 4+
Correct Answer: A
Expert Explanation: A grade of 1+ indicates a weak, thready pulse that may be difficult to
palpate. A normal pulse is graded as 2+, while 3+ is full/bounding and 4+ is often used for
exceptionally strong or abnormal bounding pulses. Accurately grading pulses is essential
for monitoring perfusion in the extremities.
4. A nurse is assessing a patient for jugular venous distention (JVD). At what angle should the
head of the bed be positioned for the most accurate measurement?
A. Flat (0 degrees)
, B. 15 to 30 degrees
C. 30 to 45 degrees
D. 90 degrees
Correct Answer: C
Expert Explanation: JVD is typically assessed with the patient reclining at a 30 to 45-
degree angle. This position allows for the visualization of the internal jugular vein
pulsations relative to the sternal angle. Distention at or above this level can indicate heart
failure or increased central venous pressure.
5. When performing a breast examination on a female patient, the nurse identifies a lesion
that is firm, fixed, and has irregular borders. Where is the most common site for breast
tumors?
A. Upper inner quadrant
B. Lower outer quadrant
C. Upper outer quadrant
D. Lower inner quadrant
Correct Answer: C
Expert Explanation: The upper outer quadrant, which includes the Tail of Spence
extending into the axilla, is the most common site for breast cancer. Over 50% of breast
