NUR 3270/NUR3270 Exam 2 V2 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing a patient’s abdomen, in what order should the nurse perform the physical
examination techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: A
Expert Explanation: The abdominal assessment follows a specific sequence of inspection,
auscultation, percussion, and then palpation. This order is essential because palpation and
percussion can stimulate peristalsis and alter bowel sounds if done before auscultation. By
auscultating first, the nurse ensures a more accurate representation of the patient’s natural
bowel activity.
2. Which heart sound is produced by the closure of the atrioventricular (AV) valves?
A. S1
B. S2
C. S3
,D. S4
Correct Answer: A
Expert Explanation: The first heart sound, S1, occurs when the mitral and tricuspid valves
close at the beginning of systole. It is usually heard loudest at the apex of the heart. This
sound signals the end of ventricular filling and the start of ventricular contraction.
3. A nurse is palpating the chest of a patient and notes a coarse, crackling sensation over the
skin surface. This finding is documented as:
A. Crepitus
B. Tactile fremitus
C. Friction rub
D. Wheezing
Correct Answer: A
Expert Explanation: Crepitus is a coarse, crackling sensation palpable over the skin
surface. It occurs when air escapes from the lung or airways and enters the subcutaneous
tissue, often after thoracic surgery or injury. This finding should be distinguished from
tactile fremitus, which is a normal vibration felt during speech.
4. The nurse is assessing a patient for a ‘barrel chest.’ This condition is characterized by which
finding?
A. An anteroposterior-to-transverse diameter ratio of 1:1
, B. An anteroposterior-to-transverse diameter ratio of 1:2
C. A sunken sternum and adjacent cartilages
D. A forward protrusion of the sternum
Correct Answer: A
Expert Explanation: A barrel chest is characterized by an equal anteroposterior-to-
transverse diameter ratio, making the chest appear round. This condition is frequently
associated with chronic obstructive pulmonary disease (COPD) due to hyperinflation of the
lungs. In healthy adults, the ratio is typically closer to 1:2.
5. Where is the best anatomical location to auscultate the mitral valve?
A. Second intercostal space, right sternal border
B. Second intercostal space, left sternal border
C. Fourth intercostal space, left sternal border
D. Fifth intercostal space, left midclavicular line
Correct Answer: D
Expert Explanation: The mitral valve is best heard at the apex of the heart, located at the
fifth intercostal space along the left midclavicular line. This site is also where the apical
pulse is measured. Auscultating at this location provides the clearest sound of mitral valve
closure during S1.
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing a patient’s abdomen, in what order should the nurse perform the physical
examination techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: A
Expert Explanation: The abdominal assessment follows a specific sequence of inspection,
auscultation, percussion, and then palpation. This order is essential because palpation and
percussion can stimulate peristalsis and alter bowel sounds if done before auscultation. By
auscultating first, the nurse ensures a more accurate representation of the patient’s natural
bowel activity.
2. Which heart sound is produced by the closure of the atrioventricular (AV) valves?
A. S1
B. S2
C. S3
,D. S4
Correct Answer: A
Expert Explanation: The first heart sound, S1, occurs when the mitral and tricuspid valves
close at the beginning of systole. It is usually heard loudest at the apex of the heart. This
sound signals the end of ventricular filling and the start of ventricular contraction.
3. A nurse is palpating the chest of a patient and notes a coarse, crackling sensation over the
skin surface. This finding is documented as:
A. Crepitus
B. Tactile fremitus
C. Friction rub
D. Wheezing
Correct Answer: A
Expert Explanation: Crepitus is a coarse, crackling sensation palpable over the skin
surface. It occurs when air escapes from the lung or airways and enters the subcutaneous
tissue, often after thoracic surgery or injury. This finding should be distinguished from
tactile fremitus, which is a normal vibration felt during speech.
4. The nurse is assessing a patient for a ‘barrel chest.’ This condition is characterized by which
finding?
A. An anteroposterior-to-transverse diameter ratio of 1:1
, B. An anteroposterior-to-transverse diameter ratio of 1:2
C. A sunken sternum and adjacent cartilages
D. A forward protrusion of the sternum
Correct Answer: A
Expert Explanation: A barrel chest is characterized by an equal anteroposterior-to-
transverse diameter ratio, making the chest appear round. This condition is frequently
associated with chronic obstructive pulmonary disease (COPD) due to hyperinflation of the
lungs. In healthy adults, the ratio is typically closer to 1:2.
5. Where is the best anatomical location to auscultate the mitral valve?
A. Second intercostal space, right sternal border
B. Second intercostal space, left sternal border
C. Fourth intercostal space, left sternal border
D. Fifth intercostal space, left midclavicular line
Correct Answer: D
Expert Explanation: The mitral valve is best heard at the apex of the heart, located at the
fifth intercostal space along the left midclavicular line. This site is also where the apical
pulse is measured. Auscultating at this location provides the clearest sound of mitral valve
closure during S1.
