NUR 2092/NUR2092 Final Exam V2 |
Health Assessment Q&A with Rationale |
Rasmussen University
1. When performing a physical assessment of the abdomen, in what order should the nurse
perform the assessment techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Palpation, Percussion, Auscultation, Inspection
Answer: A
Rationale: The abdomen is assessed in a specific sequence to avoid altering bowel sounds.
Palpation and percussion can stimulate peristalsis, which may result in false bowel sound
findings. Therefore, the nurse must inspect and then auscultate before touching the
abdomen manually.
2. Which cranial nerve is primarily responsible for the sensation of the face and the motor
function of chewing?
A. Cranial Nerve VII (Facial)
B. Cranial Nerve V (Trigeminal)
C. Cranial Nerve X (Vagus)
,D. Cranial Nerve XII (Hypoglossal)
Answer: B
Rationale: Cranial Nerve V, the trigeminal nerve, has both sensory and motor components.
It provides sensory information from the face and oversees the muscles involved in
mastication. Testing this nerve involves checking light touch on the face and assessing the
strength of the masseter muscle.
3. A nurse is assessing a patient’s peripheral pulses and notes that the pulse is ‘weak and
thready.’ How should this be documented on a 0 to 4+ scale?
A. 2+
B. 1+
C. 3+
D. 4+
Answer: B
Rationale: The standard scale for grading peripheral pulses ranges from 0 to 4+. A score of
1+ indicates a weak, thready, or diminished pulse that is easy to obliterate. A score of 2+ is
considered a normal, brisk pulse, while higher numbers indicate bounding pulses.
4. Where is Erb’s point located on the chest wall for cardiac auscultation?
A. Second right intercostal space
B. Third left intercostal space
, C. Second left intercostal space
D. Fifth left intercostal space at the midclavicular line
Answer: B
Rationale: Erb’s point is situated at the third intercostal space on the left sternal border. It
is a significant location because it is where S1 and S2 sounds can be heard equally. This site
is often used to listen for murmurs originating from the aortic or pulmonic valves.
5. The nurse is assessing a patient for tactile fremitus. Which part of the hand is most
sensitive to vibrations?
A. The ulnar surface or palmar base of the hand
B. The dorsal surface (back) of the hand
C. The fingertips
D. The thumb
Answer: A
Rationale: The ulnar surface of the hand or the base of the fingers (metacarpophalangeal
joints) is the most sensitive to vibrations. When assessing tactile fremitus, the nurse asks
the patient to repeat phrases like ‘ninety-nine’ while feeling for symmetrical vibrations.
Increased fremitus may indicate lung consolidation, such as in pneumonia.
Health Assessment Q&A with Rationale |
Rasmussen University
1. When performing a physical assessment of the abdomen, in what order should the nurse
perform the assessment techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Palpation, Percussion, Auscultation, Inspection
Answer: A
Rationale: The abdomen is assessed in a specific sequence to avoid altering bowel sounds.
Palpation and percussion can stimulate peristalsis, which may result in false bowel sound
findings. Therefore, the nurse must inspect and then auscultate before touching the
abdomen manually.
2. Which cranial nerve is primarily responsible for the sensation of the face and the motor
function of chewing?
A. Cranial Nerve VII (Facial)
B. Cranial Nerve V (Trigeminal)
C. Cranial Nerve X (Vagus)
,D. Cranial Nerve XII (Hypoglossal)
Answer: B
Rationale: Cranial Nerve V, the trigeminal nerve, has both sensory and motor components.
It provides sensory information from the face and oversees the muscles involved in
mastication. Testing this nerve involves checking light touch on the face and assessing the
strength of the masseter muscle.
3. A nurse is assessing a patient’s peripheral pulses and notes that the pulse is ‘weak and
thready.’ How should this be documented on a 0 to 4+ scale?
A. 2+
B. 1+
C. 3+
D. 4+
Answer: B
Rationale: The standard scale for grading peripheral pulses ranges from 0 to 4+. A score of
1+ indicates a weak, thready, or diminished pulse that is easy to obliterate. A score of 2+ is
considered a normal, brisk pulse, while higher numbers indicate bounding pulses.
4. Where is Erb’s point located on the chest wall for cardiac auscultation?
A. Second right intercostal space
B. Third left intercostal space
, C. Second left intercostal space
D. Fifth left intercostal space at the midclavicular line
Answer: B
Rationale: Erb’s point is situated at the third intercostal space on the left sternal border. It
is a significant location because it is where S1 and S2 sounds can be heard equally. This site
is often used to listen for murmurs originating from the aortic or pulmonic valves.
5. The nurse is assessing a patient for tactile fremitus. Which part of the hand is most
sensitive to vibrations?
A. The ulnar surface or palmar base of the hand
B. The dorsal surface (back) of the hand
C. The fingertips
D. The thumb
Answer: A
Rationale: The ulnar surface of the hand or the base of the fingers (metacarpophalangeal
joints) is the most sensitive to vibrations. When assessing tactile fremitus, the nurse asks
the patient to repeat phrases like ‘ninety-nine’ while feeling for symmetrical vibrations.
Increased fremitus may indicate lung consolidation, such as in pneumonia.
