NUR 2092/NUR2092 Exam 2 V3 | Health
Assessment Q&A with Rationale |
Rasmussen University
1. When assessing a patient’s lungs, the nurse hears soft, low-pitched sounds over the
peripheral lung fields where inspiration is longer than expiration. How should the nurse
document these sounds?
A. Vesicular sounds
B. Bronchovesicular sounds
C. Bronchial sounds
D. Adventitious sounds
Answer: A
Rationale: Vesicular breath sounds are normal findings over the peripheral lung fields.
They are characterized by a soft, rustling quality where the inspiratory phase lasts longer
than the expiratory phase. If these sounds were heard over the trachea, they would be
considered abnormal or misplaced.
2. The nurse is performing a cardiac assessment and identifies the S1 heart sound. Where is
this sound usually heard the 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 sternal border
Answer: A
Rationale: The S1 heart sound corresponds to the closure of the atrioventricular valves,
which include the mitral and tricuspid valves. It is typically heard loudest at the apex of the
heart, which is located at the fifth intercostal space at the left midclavicular line. This sound
marks the beginning of systole and coincides with the carotid artery pulse.
3. During an abdominal assessment, in which order should the nurse perform the physical
examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Answer: B
Rationale: The standard order for abdominal assessment is inspection followed by
auscultation, percussion, and palpation. Auscultation is performed second to prevent
physical manipulation from altering bowel sounds. If the nurse palpated first, it could
create false bowel sounds or obscure the actual frequency of peristalsis.
, 4. A patient presents with a lateral curvature of the thoracic and lumbar spine. The nurse
recognizes this condition as:
A. Kyphosis
B. Lordosis
C. Ankylosis
D. Scoliosis
Answer: D
Rationale: Scoliosis is defined as a lateral S-shaped curvature of the spinal column. This
condition is most commonly screened for in school-age children and adolescents during
their growth spurts. Severe cases may require bracing or surgical intervention to prevent
respiratory or cardiovascular complications.
5. When assessing the carotid arteries, what is the correct technique for auscultation?
A. Use the bell of the stethoscope and ask the patient to hold their breath.
B. Use the diaphragm of the stethoscope and ask the patient to breathe deeply.
C. Apply heavy pressure with the diaphragm of the stethoscope.
D. Auscultate both sides simultaneously to compare sounds.
E.
Answer: A
Assessment Q&A with Rationale |
Rasmussen University
1. When assessing a patient’s lungs, the nurse hears soft, low-pitched sounds over the
peripheral lung fields where inspiration is longer than expiration. How should the nurse
document these sounds?
A. Vesicular sounds
B. Bronchovesicular sounds
C. Bronchial sounds
D. Adventitious sounds
Answer: A
Rationale: Vesicular breath sounds are normal findings over the peripheral lung fields.
They are characterized by a soft, rustling quality where the inspiratory phase lasts longer
than the expiratory phase. If these sounds were heard over the trachea, they would be
considered abnormal or misplaced.
2. The nurse is performing a cardiac assessment and identifies the S1 heart sound. Where is
this sound usually heard the 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 sternal border
Answer: A
Rationale: The S1 heart sound corresponds to the closure of the atrioventricular valves,
which include the mitral and tricuspid valves. It is typically heard loudest at the apex of the
heart, which is located at the fifth intercostal space at the left midclavicular line. This sound
marks the beginning of systole and coincides with the carotid artery pulse.
3. During an abdominal assessment, in which order should the nurse perform the physical
examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Answer: B
Rationale: The standard order for abdominal assessment is inspection followed by
auscultation, percussion, and palpation. Auscultation is performed second to prevent
physical manipulation from altering bowel sounds. If the nurse palpated first, it could
create false bowel sounds or obscure the actual frequency of peristalsis.
, 4. A patient presents with a lateral curvature of the thoracic and lumbar spine. The nurse
recognizes this condition as:
A. Kyphosis
B. Lordosis
C. Ankylosis
D. Scoliosis
Answer: D
Rationale: Scoliosis is defined as a lateral S-shaped curvature of the spinal column. This
condition is most commonly screened for in school-age children and adolescents during
their growth spurts. Severe cases may require bracing or surgical intervention to prevent
respiratory or cardiovascular complications.
5. When assessing the carotid arteries, what is the correct technique for auscultation?
A. Use the bell of the stethoscope and ask the patient to hold their breath.
B. Use the diaphragm of the stethoscope and ask the patient to breathe deeply.
C. Apply heavy pressure with the diaphragm of the stethoscope.
D. Auscultate both sides simultaneously to compare sounds.
E.
Answer: A
