NUR 2092/NUR2092 Final Exam V3 |
Health Assessment Q&A with Rationale |
Rasmussen University
1. When auscultating the heart, the nurse knows that the S1 sound is loudest at which
location?
A. Second right intercostal space
B. Apex of the heart
C. Base of the heart
D. Second left intercostal space
Answer: B
Rationale: The S1 heart sound, often described as ‘lub,’ signifies the closure of the
atrioventricular valves. It is heard most clearly and loudly at the apex of the heart, 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.
2. A nurse is performing a physical assessment on a client and notes a positive Phalen test.
This finding is suggestive of which condition?
A. Carpal tunnel syndrome
B. Rheumatoid arthritis
C. Osteoarthritis
,D. Gouty arthritis
Answer: A
Rationale: The Phalen test is used to evaluate the presence of carpal tunnel syndrome by
compressing the median nerve. A positive result occurs when the patient experiences
numbness or tingling after holding the wrists in a flexed position for 60 seconds. This
maneuver increases pressure within the carpal tunnel, eliciting symptoms in affected
individuals.
3. During an abdominal assessment, in which order should the nurse perform the following
techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Answer: A
Rationale: The correct sequence for abdominal assessment is inspection, auscultation,
percussion, and then palpation. Percussion and palpation are done last because they can
stimulate bowel activity and alter the bowel sounds heard during auscultation. Following
this sequence ensures the most accurate assessment of the patient’s gastrointestinal status.
, 4. When assessing a client’s lung sounds, the nurse hears high-pitched, musical sounds
primarily during expiration. How should the nurse document this finding?
A. Crackles
B. Pleural friction rub
C. Wheezes
D. Stridor
Answer: C
Rationale: Wheezes are continuous, high-pitched musical sounds produced by air flowing
through narrowed or obstructed airways. They are commonly associated with conditions
like asthma or chronic obstructive pulmonary disease. While they can occur during
inspiration, they are most frequently heard during the expiratory phase of respiration.
5. The nurse is assessing the cranial nerves and asks the patient to smile, frown, and puff out
their cheeks. Which cranial nerve is being tested?
A. Cranial Nerve VII (Facial)
B. Cranial Nerve V (Trigeminal)
C. Cranial Nerve VIII (Acoustic)
D. Cranial Nerve X (Vagus)
Answer: A
Health Assessment Q&A with Rationale |
Rasmussen University
1. When auscultating the heart, the nurse knows that the S1 sound is loudest at which
location?
A. Second right intercostal space
B. Apex of the heart
C. Base of the heart
D. Second left intercostal space
Answer: B
Rationale: The S1 heart sound, often described as ‘lub,’ signifies the closure of the
atrioventricular valves. It is heard most clearly and loudly at the apex of the heart, 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.
2. A nurse is performing a physical assessment on a client and notes a positive Phalen test.
This finding is suggestive of which condition?
A. Carpal tunnel syndrome
B. Rheumatoid arthritis
C. Osteoarthritis
,D. Gouty arthritis
Answer: A
Rationale: The Phalen test is used to evaluate the presence of carpal tunnel syndrome by
compressing the median nerve. A positive result occurs when the patient experiences
numbness or tingling after holding the wrists in a flexed position for 60 seconds. This
maneuver increases pressure within the carpal tunnel, eliciting symptoms in affected
individuals.
3. During an abdominal assessment, in which order should the nurse perform the following
techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Answer: A
Rationale: The correct sequence for abdominal assessment is inspection, auscultation,
percussion, and then palpation. Percussion and palpation are done last because they can
stimulate bowel activity and alter the bowel sounds heard during auscultation. Following
this sequence ensures the most accurate assessment of the patient’s gastrointestinal status.
, 4. When assessing a client’s lung sounds, the nurse hears high-pitched, musical sounds
primarily during expiration. How should the nurse document this finding?
A. Crackles
B. Pleural friction rub
C. Wheezes
D. Stridor
Answer: C
Rationale: Wheezes are continuous, high-pitched musical sounds produced by air flowing
through narrowed or obstructed airways. They are commonly associated with conditions
like asthma or chronic obstructive pulmonary disease. While they can occur during
inspiration, they are most frequently heard during the expiratory phase of respiration.
5. The nurse is assessing the cranial nerves and asks the patient to smile, frown, and puff out
their cheeks. Which cranial nerve is being tested?
A. Cranial Nerve VII (Facial)
B. Cranial Nerve V (Trigeminal)
C. Cranial Nerve VIII (Acoustic)
D. Cranial Nerve X (Vagus)
Answer: A
