NUR 3270/NUR3270 Final Exam V2 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing the heart, where is the S1 sound heard most loudly?
A. At the base of the heart
B. In the second left intercostal space
C. Over the aortic area
D. At the apex of the heart
Correct Answer: D
Expert Explanation: The S1 heart sound signifies the closure of the mitral and tricuspid
valves at the start of systole. It is loudest at the apex of the heart, which is located at the
fifth intercostal space, midclavicular line. This location allows for better transmission of the
sound created by the auriculoventricular valves.
2. In the ABCDE rule for skin cancer assessment, what does the ‘E’ stand for?
A. Evolving
B. Erythema
C. Elevation
D. Exudate
,Correct Answer: A
Expert Explanation: The ABCDE mnemonic is essential for screening moles and lesions for
potential melanoma. The letter E stands for Evolving, which refers to any change in size,
shape, or color over time. Continuous monitoring of evolving lesions is critical for early
detection of skin cancer.
3. What is the correct order for performing an abdominal assessment?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Percussion, Palpation, Auscultation
C. Inspection, Auscultation, Percussion, Palpation
D. Auscultation, Inspection, Palpation, Percussion
Correct Answer: C
Expert Explanation: The abdominal assessment follows a specific order to ensure bowel
sounds are not artificially altered. Auscultation is performed immediately after inspection
because percussion and palpation can increase peristalsis. This specific sequence provides
the most accurate clinical data regarding the patient’s bowel activity.
4. Which breath sound is considered normal when heard over the majority of the peripheral
lung fields?
A. Bronchial
B. Bronchovesicular
, C. Vesicular
D. Adventitious
Correct Answer: C
Expert Explanation: Vesicular breath sounds are soft, low-pitched sounds heard over the
majority of the lung tissue. They are characterized by an inspiratory phase that is longer
than the expiratory phase. Hearing these sounds in the periphery indicates normal aeration
of the lung segments.
5. When assessing for tactile fremitus, the nurse expects to find increased vibrations over
areas of:
A. Pneumothorax
B. Emphysema
C. Pleural effusion
D. Consolidation (e.g., Pneumonia)
Correct Answer: D
Expert Explanation: Tactile fremitus is a palpable vibration transmitted through the chest
wall during speech. Increased fremitus occurs when there is consolidation, such as in
pneumonia, which acts as a better conductor for sound vibrations. Conversely, conditions
like pneumothorax or pleural effusion decrease or absent fremitus because they block
sound transmission.
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing the heart, where is the S1 sound heard most loudly?
A. At the base of the heart
B. In the second left intercostal space
C. Over the aortic area
D. At the apex of the heart
Correct Answer: D
Expert Explanation: The S1 heart sound signifies the closure of the mitral and tricuspid
valves at the start of systole. It is loudest at the apex of the heart, which is located at the
fifth intercostal space, midclavicular line. This location allows for better transmission of the
sound created by the auriculoventricular valves.
2. In the ABCDE rule for skin cancer assessment, what does the ‘E’ stand for?
A. Evolving
B. Erythema
C. Elevation
D. Exudate
,Correct Answer: A
Expert Explanation: The ABCDE mnemonic is essential for screening moles and lesions for
potential melanoma. The letter E stands for Evolving, which refers to any change in size,
shape, or color over time. Continuous monitoring of evolving lesions is critical for early
detection of skin cancer.
3. What is the correct order for performing an abdominal assessment?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Percussion, Palpation, Auscultation
C. Inspection, Auscultation, Percussion, Palpation
D. Auscultation, Inspection, Palpation, Percussion
Correct Answer: C
Expert Explanation: The abdominal assessment follows a specific order to ensure bowel
sounds are not artificially altered. Auscultation is performed immediately after inspection
because percussion and palpation can increase peristalsis. This specific sequence provides
the most accurate clinical data regarding the patient’s bowel activity.
4. Which breath sound is considered normal when heard over the majority of the peripheral
lung fields?
A. Bronchial
B. Bronchovesicular
, C. Vesicular
D. Adventitious
Correct Answer: C
Expert Explanation: Vesicular breath sounds are soft, low-pitched sounds heard over the
majority of the lung tissue. They are characterized by an inspiratory phase that is longer
than the expiratory phase. Hearing these sounds in the periphery indicates normal aeration
of the lung segments.
5. When assessing for tactile fremitus, the nurse expects to find increased vibrations over
areas of:
A. Pneumothorax
B. Emphysema
C. Pleural effusion
D. Consolidation (e.g., Pneumonia)
Correct Answer: D
Expert Explanation: Tactile fremitus is a palpable vibration transmitted through the chest
wall during speech. Increased fremitus occurs when there is consolidation, such as in
pneumonia, which acts as a better conductor for sound vibrations. Conversely, conditions
like pneumothorax or pleural effusion decrease or absent fremitus because they block
sound transmission.
