NUR 2092/NUR2092 Exam 2 V3 | Health
Assessment Q&A with Rationale |
Rasmussen University
1. When auscultating the heart, where is the S1 sound heard loudest?
A. At the apex of the heart
B. At the second right intercostal space
C. At the base of the heart
D. At the second left intercostal space
Correct Answer: A
Expert Explanation: The S1 heart sound is caused by the closure of the AV valves (mitral
and tricuspid). It is heard loudest at the apex of the heart, which is the bottom portion. This
sound marks the beginning of systole and is usually lower in pitch than S2.
2. Which anatomical location is most appropriate to palpate the apical pulse?
A. Fourth intercostal space, midaxillary line
B. Fifth intercostal space, left midclavicular line
C. Second intercostal space, right sternal border
D. Third intercostal space, left sternal border
Correct Answer: B
,Expert Explanation: The apical pulse, or point of maximal impulse (PMI), is located at the
fifth intercostal space at the left midclavicular line. This location allows for direct
assessment of the left ventricle’s pulsation. It is a standard landmark used for assessing
heart rate and rhythm in a physical exam.
3. When assessing a patient’s lungs, the nurse hears high-pitched, musical sounds primarily
during expiration. How should this be documented?
A. Crackles
B. Wheezes
C. Pleural friction rub
D. Stridor
Correct Answer: B
Expert Explanation: Wheezes are continuous, high-pitched musical sounds produced by
air flowing through narrowed airways. They are most commonly heard during expiration
but can also occur during inspiration. This finding is frequent in patients with asthma or
chronic obstructive pulmonary disease.
4. Where is the ‘Tail of Spence’ located, which is a frequent site for breast tumors?
A. Lower inner quadrant
B. Upper outer quadrant
C. Lower outer quadrant
, D. Upper inner quadrant
Correct Answer: B
Expert Explanation: The Tail of Spence is a projection of breast tissue that extends into
the axilla (armpit). It is located in the upper outer quadrant of the breast. Statistics show
that the highest percentage of breast tumors are found in this specific region.
5. During a breast examination, the nurse notes ‘peau d’orange’ skin. This finding is
suggestive of:
A. Lymphatic obstruction or edema
B. Fibroadenoma
C. Normal aging
D. Bacterial infection
Correct Answer: A
Expert Explanation: Peau d’orange refers to skin that appears thickened and pitted,
resembling the skin of an orange. This condition is caused by lymphatic obstruction, which
leads to edema of the breast tissue. It is often a clinical sign of inflammatory breast cancer
or advanced malignancy.
6. What is the normal expected finding when percussing healthy lung tissue in an adult?
A. Dullness
B. Tympany
Assessment Q&A with Rationale |
Rasmussen University
1. When auscultating the heart, where is the S1 sound heard loudest?
A. At the apex of the heart
B. At the second right intercostal space
C. At the base of the heart
D. At the second left intercostal space
Correct Answer: A
Expert Explanation: The S1 heart sound is caused by the closure of the AV valves (mitral
and tricuspid). It is heard loudest at the apex of the heart, which is the bottom portion. This
sound marks the beginning of systole and is usually lower in pitch than S2.
2. Which anatomical location is most appropriate to palpate the apical pulse?
A. Fourth intercostal space, midaxillary line
B. Fifth intercostal space, left midclavicular line
C. Second intercostal space, right sternal border
D. Third intercostal space, left sternal border
Correct Answer: B
,Expert Explanation: The apical pulse, or point of maximal impulse (PMI), is located at the
fifth intercostal space at the left midclavicular line. This location allows for direct
assessment of the left ventricle’s pulsation. It is a standard landmark used for assessing
heart rate and rhythm in a physical exam.
3. When assessing a patient’s lungs, the nurse hears high-pitched, musical sounds primarily
during expiration. How should this be documented?
A. Crackles
B. Wheezes
C. Pleural friction rub
D. Stridor
Correct Answer: B
Expert Explanation: Wheezes are continuous, high-pitched musical sounds produced by
air flowing through narrowed airways. They are most commonly heard during expiration
but can also occur during inspiration. This finding is frequent in patients with asthma or
chronic obstructive pulmonary disease.
4. Where is the ‘Tail of Spence’ located, which is a frequent site for breast tumors?
A. Lower inner quadrant
B. Upper outer quadrant
C. Lower outer quadrant
, D. Upper inner quadrant
Correct Answer: B
Expert Explanation: The Tail of Spence is a projection of breast tissue that extends into
the axilla (armpit). It is located in the upper outer quadrant of the breast. Statistics show
that the highest percentage of breast tumors are found in this specific region.
5. During a breast examination, the nurse notes ‘peau d’orange’ skin. This finding is
suggestive of:
A. Lymphatic obstruction or edema
B. Fibroadenoma
C. Normal aging
D. Bacterial infection
Correct Answer: A
Expert Explanation: Peau d’orange refers to skin that appears thickened and pitted,
resembling the skin of an orange. This condition is caused by lymphatic obstruction, which
leads to edema of the breast tissue. It is often a clinical sign of inflammatory breast cancer
or advanced malignancy.
6. What is the normal expected finding when percussing healthy lung tissue in an adult?
A. Dullness
B. Tympany
