NUR 3270/NUR3270 Final Exam V1 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing a patient’s lungs, the nurse hears a low-pitched, snoring sound that clears
with coughing. Which sound is the nurse identifying?
A. Wheezes
B. Pleural friction rub
C. Crackles
D. Rhonchi
Correct Answer: D
Expert Explanation: Rhonchi are low-pitched, continuous sounds caused by secretions in
the larger airways. They often resemble snoring and characteristically clear or change after
a patient coughs. This differentiates them from wheezes, which are high-pitched and
musical.
2. While performing a physical examination on an adult patient, which sequence should the
nurse follow for an abdominal assessment?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Palpation, Percussion, Auscultation, Inspection
,D. Auscultation, Inspection, Palpation, Percussion
Correct Answer: B
Expert Explanation: For the abdomen, auscultation is performed before percussion and
palpation to avoid stimulating bowel sounds. This ensures the nurse hears the natural state
of bowel activity without manual interference. Following this specific order is a standard
nursing practice in comprehensive health assessment.
3. A patient presents with a ‘swishing’ sound heard over the carotid artery. What is the
correct term for this finding?
A. Thrill
B. Gallop
C. Murmur
D. Bruit
Correct Answer: D
Expert Explanation: A bruit is a blowing or swishing sound heard over an artery caused
by turbulent blood flow. This often indicates narrowing of the vessel or atherosclerotic
plaque buildup. Nurses should use the bell of the stethoscope to detect these low-pitched
vascular sounds.
4. Which cranial nerve is the nurse assessing when asking a patient to shrug their shoulders
against resistance?
A. Cranial Nerve VII (Facial)
, B. Cranial Nerve XI (Spinal Accessory)
C. Cranial Nerve X (Vagus)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: B
Expert Explanation: Cranial Nerve XI, the spinal accessory nerve, controls the trapezius
and sternocleidomastoid muscles. Asking the patient to shrug against resistance or turn
their head against pressure tests the strength of these muscles. Dysfunction in this nerve
would result in weakness or inability to perform these movements.
5. When testing the pupillary light reflex, the nurse observes that both pupils constrict when
light is shone into the right eye. What is the term for the constriction of the left pupil?
A. Direct response
B. Convergence
C. Accommodation
D. Consensual response
Correct Answer: D
Expert Explanation: The consensual response occurs when the opposite pupil constricts
simultaneously with the eye receiving the light stimulus. This indicates that the reflex arc
and optic/oculomotor pathways are functioning correctly on both sides. A lack of this
response can indicate neurological impairment or damage to the midbrain.
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing a patient’s lungs, the nurse hears a low-pitched, snoring sound that clears
with coughing. Which sound is the nurse identifying?
A. Wheezes
B. Pleural friction rub
C. Crackles
D. Rhonchi
Correct Answer: D
Expert Explanation: Rhonchi are low-pitched, continuous sounds caused by secretions in
the larger airways. They often resemble snoring and characteristically clear or change after
a patient coughs. This differentiates them from wheezes, which are high-pitched and
musical.
2. While performing a physical examination on an adult patient, which sequence should the
nurse follow for an abdominal assessment?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Palpation, Percussion, Auscultation, Inspection
,D. Auscultation, Inspection, Palpation, Percussion
Correct Answer: B
Expert Explanation: For the abdomen, auscultation is performed before percussion and
palpation to avoid stimulating bowel sounds. This ensures the nurse hears the natural state
of bowel activity without manual interference. Following this specific order is a standard
nursing practice in comprehensive health assessment.
3. A patient presents with a ‘swishing’ sound heard over the carotid artery. What is the
correct term for this finding?
A. Thrill
B. Gallop
C. Murmur
D. Bruit
Correct Answer: D
Expert Explanation: A bruit is a blowing or swishing sound heard over an artery caused
by turbulent blood flow. This often indicates narrowing of the vessel or atherosclerotic
plaque buildup. Nurses should use the bell of the stethoscope to detect these low-pitched
vascular sounds.
4. Which cranial nerve is the nurse assessing when asking a patient to shrug their shoulders
against resistance?
A. Cranial Nerve VII (Facial)
, B. Cranial Nerve XI (Spinal Accessory)
C. Cranial Nerve X (Vagus)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: B
Expert Explanation: Cranial Nerve XI, the spinal accessory nerve, controls the trapezius
and sternocleidomastoid muscles. Asking the patient to shrug against resistance or turn
their head against pressure tests the strength of these muscles. Dysfunction in this nerve
would result in weakness or inability to perform these movements.
5. When testing the pupillary light reflex, the nurse observes that both pupils constrict when
light is shone into the right eye. What is the term for the constriction of the left pupil?
A. Direct response
B. Convergence
C. Accommodation
D. Consensual response
Correct Answer: D
Expert Explanation: The consensual response occurs when the opposite pupil constricts
simultaneously with the eye receiving the light stimulus. This indicates that the reflex arc
and optic/oculomotor pathways are functioning correctly on both sides. A lack of this
response can indicate neurological impairment or damage to the midbrain.
