NSG3160 HEALTH ASSESSMENT EXAM 3 COMPLETE QUESTIONS WITH CORRECT ANSWERS AND RATIONALE 2026/2027

NSG3160 HEALTH ASSESSMENT EXAM 3 COMPLETE QUESTIONS WITH CORRECT ANSWERS AND RATIONALE 1. A nurse assesses a patient’s jugular venous pressure (JVP). The patient is positioned supine with the head of bed at 30 degrees. The nurse sees pulsations 4 cm above the sternal angle. What is the most appropriate interpretation? A. Normal finding B. Elevated JVP C. Low JVP D. Inconsistent with patient position Correct Answer: B Rationale: Normal JVP is ≤3 cm above the sternal angle. 4 cm suggests elevated right atrial pressure (e.g., heart failure, fluid overload). ________________________________________ 2. During a cardiovascular assessment, the nurse palpates the chest wall and feels a vibration over the aortic area during systole. This finding is documented as: A. Heave B. Thrill C. Lift D. Bruit Correct Answer: B Rationale: A thrill is a palpable vibration indicating turbulent blood flow. Heaves/lifts are sustained impulses from ventricular hypertrophy. Bruits are audible vascular sounds. ________________________________________ 3. A patient reports chest pain that is worse when lying flat and improves when sitting up and leaning forward. This presentation is most suggestive of: A. Myocardial infarction B. Pericarditis C. Aortic dissection D. Pulmonary embolism Correct Answer: B Rationale: Pericarditis classically causes pleuritic chest pain that worsens supine and improves with sitting/leaning forward. ________________________________________ 4. The nurse auscultates a high-pitched, blowing sound immediately after S2 at the left sternal border. This is most likely: A. Mitral stenosis B. Aortic regurgitation C. Mitral regurgitation D. Pulmonic stenosis Correct Answer: B Rationale: Aortic regurgitation causes an early diastolic decrescendo murmur best heard at left sternal border (Erb’s point). ________________________________________ 5. When auscultating lung sounds, the nurse hears continuous, high-pitched sounds primarily during expiration in a patient with asthma. These are: A. Fine crackles B. Coarse crackles C. Wheezes D. Stridor Correct Answer: C Rationale: Wheezes are continuous, musical, high-pitched sounds from narrowed airways (e.g., asthma, COPD). Stridor is upper airway. ________________________________________ 6. A patient has decreased breath sounds at the left lower lobe, dullness to percussion, and tactile fremitus is increased. These findings suggest: A. Pneumothorax B. Pleural effusion C. Lobar pneumonia D. Emphysema Correct Answer: C Rationale: Lobar pneumonia causes consolidation → increased fremitus, dullness, bronchial breath sounds. Effusion decreases fremitus. ________________________________________ 7. The nurse palpates the abdomen and feels a firm, nodular edge 3 cm below the right costal margin. This most likely indicates: A. Normal liver B. Hepatomegaly C. Palpable kidney D. Fecal mass Correct Answer: B Rationale: Normal liver edge may be palpable but is soft and smooth. A firm, nodular, enlarged liver suggests hepatomegaly (e.g., cirrhosis, tumor). ________________________________________ 8. While testing deep tendon reflexes, the nurse notes that the patient’s patellar reflex is absent despite reinforcement. This is documented as: A. 1+ B. 2+ C. 0 D. 3+ Correct Answer: C *Rationale: Reflex grading: 0 = absent, 1+ = hypoactive, 2+ = normal, 3+ = brisk, 4+ = hyperactive with clonus.* ________________________________________ 9. A patient presents with sudden onset of severe, tearing chest pain radiating to the back. Blood pressure is 160/90 in right arm and 100/70 in left arm. Most likely cause: A. Acute myocardial infarction B. Aortic dissection C. Pulmonary embolism D. Pericarditis