NUR 2092/NUR2092 Exam 2 V2 | 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 base of the heart
C. Over the aortic area
D. At the second left intercostal space
Correct Answer: A
Expert Explanation: The S1 heart sound corresponds to the closure of the atrioventricular
valves. It is heard most clearly at the apex of the heart, which is located at the fifth
intercostal space. This sound marks the beginning of systole and is often synchronous with
the carotid pulse.
2. 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 and low-pitched sounds heard over
most of the lungs. They feature a longer inspiratory phase than the expiratory phase. These
are considered normal findings in a healthy adult when assessed in the periphery.
3. A nurse is assessing a patient for pitting edema and notes a deep indentation that remains
for a short time. This is documented as:
A. 1+
B. 2+
C. 3+
D. 4+
Correct Answer: C
Expert Explanation: 3+ edema is characterized by a deep pit that remains for a short time
and the leg looks swollen. The scale typically ranges from 1+ (mild) to 4+ (very deep).
Accurate documentation is essential for monitoring changes in fluid status over time.
4. Which area is the ‘Tail of Spence’ located in during a breast examination?
A. Lower inner quadrant
B. Upper inner quadrant
C. Lower outer quadrant
D. Upper outer quadrant
, Correct Answer: D
Expert Explanation: The Tail of Spence is the superior lateral corner of breast tissue that
extends into the axilla. It is located in the upper outer quadrant, which is the most frequent
site for breast tumors. Nurses must ensure they palpate this specific area thoroughly
during a clinical breast exam.
5. A patient presents with a ‘barrel chest.’ What is the expected ratio of the anteroposterior
(AP) diameter to the transverse diameter?
A. 1:1
B. 2:1
C. 1:2
D. 3:2
Correct Answer: A
Expert Explanation: A barrel chest occurs when the AP diameter is equal to the transverse
diameter, resulting in a 1:1 ratio. This condition is often seen in patients with chronic
obstructive pulmonary disease (COPD) due to hyperinflation of the lungs. In a healthy
adult, the normal ratio should be approximately 1:2.
6. What is the primary purpose of the Allen test?
A. To evaluate collateral circulation in the hand
B. To check for deep vein thrombosis
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 base of the heart
C. Over the aortic area
D. At the second left intercostal space
Correct Answer: A
Expert Explanation: The S1 heart sound corresponds to the closure of the atrioventricular
valves. It is heard most clearly at the apex of the heart, which is located at the fifth
intercostal space. This sound marks the beginning of systole and is often synchronous with
the carotid pulse.
2. 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 and low-pitched sounds heard over
most of the lungs. They feature a longer inspiratory phase than the expiratory phase. These
are considered normal findings in a healthy adult when assessed in the periphery.
3. A nurse is assessing a patient for pitting edema and notes a deep indentation that remains
for a short time. This is documented as:
A. 1+
B. 2+
C. 3+
D. 4+
Correct Answer: C
Expert Explanation: 3+ edema is characterized by a deep pit that remains for a short time
and the leg looks swollen. The scale typically ranges from 1+ (mild) to 4+ (very deep).
Accurate documentation is essential for monitoring changes in fluid status over time.
4. Which area is the ‘Tail of Spence’ located in during a breast examination?
A. Lower inner quadrant
B. Upper inner quadrant
C. Lower outer quadrant
D. Upper outer quadrant
, Correct Answer: D
Expert Explanation: The Tail of Spence is the superior lateral corner of breast tissue that
extends into the axilla. It is located in the upper outer quadrant, which is the most frequent
site for breast tumors. Nurses must ensure they palpate this specific area thoroughly
during a clinical breast exam.
5. A patient presents with a ‘barrel chest.’ What is the expected ratio of the anteroposterior
(AP) diameter to the transverse diameter?
A. 1:1
B. 2:1
C. 1:2
D. 3:2
Correct Answer: A
Expert Explanation: A barrel chest occurs when the AP diameter is equal to the transverse
diameter, resulting in a 1:1 ratio. This condition is often seen in patients with chronic
obstructive pulmonary disease (COPD) due to hyperinflation of the lungs. In a healthy
adult, the normal ratio should be approximately 1:2.
6. What is the primary purpose of the Allen test?
A. To evaluate collateral circulation in the hand
B. To check for deep vein thrombosis
