NUR 2092/NUR2092 Final Exam V1 |
Health Assessment Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a client’s heart sounds and notes a low-pitched vibration heard in early
diastole at the apex. How should the nurse document this finding?
A. S3 heart sound
B. S2 heart sound
C. S1 heart sound
D. S4 heart sound
Answer: A
Rationale: The S3 heart sound occurs during the rapid filling phase of the ventricles in
early diastole. It is often referred to as a ventricular gallop and is best heard with the bell of
the stethoscope at the apex. This sound can be a normal finding in children or athletes but
may indicate fluid overload in older adults.
2. When assessing the abdomen, which sequence of physical examination techniques should
the nurse follow?
A. Inspection, Palpation, Percussion, Auscultation
B. Percussion, Auscultation, Inspection, Palpation
C. Auscultation, Inspection, Palpation, Percussion
,D. Inspection, Auscultation, Percussion, Palpation
Answer: D
Rationale: In abdominal assessment, auscultation is performed immediately after
inspection to avoid altering bowel sounds. Palpation and percussion can stimulate
peristalsis, leading to inaccurate findings if done before listening. This specific order
ensures the most reliable assessment of the gastrointestinal system.
3. A nurse is testing a patient’s cranial nerves. When the patient is asked to shrug their
shoulders against resistance, which nerve is being evaluated?
A. Cranial Nerve VII (Facial)
B. Cranial Nerve XI (Spinal Accessory)
C. Cranial Nerve IX (Glossopharyngeal)
D. Cranial Nerve XII (Hypoglossal)
Answer: B
Rationale: Cranial Nerve XI, the Spinal Accessory nerve, controls the trapezius and
sternocleidomastoid muscles. Testing shoulder shrugging and neck rotation against
resistance assesses the motor function of this nerve. Weakness or asymmetry during this
test could indicate nerve damage or muscle pathology.
4. During an eye examination using the Snellen chart, a patient’s vision is recorded as 20/50.
What does this measurement indicate?
A. The patient can see at 50 feet what a person with normal vision sees at 20 feet.
, B. The patient has 50% vision in both eyes compared to a standard baseline.
C. The patient needs to stand 50 feet away to see the line clearly.
D. The patient can see at 20 feet what a person with normal vision sees at 50 feet.
Answer: D
Rationale: The first number in a Snellen fraction represents the distance the patient is
standing from the chart, which is typically 20 feet. The second number represents the
distance at which a person with normal vision could read that same line. Therefore, 20/50
means the patient’s distance vision is poorer than normal.
5. While assessing a client’s respiratory system, the nurse notes a high-pitched, musical sound
heard primarily during expiration. This is most likely:
A. Wheezes
B. Crackles
C. Pleural friction rub
D. Stridor
Answer: A
Rationale: Wheezes are continuous, musical lung sounds caused 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 prominent during the expiratory phase.
Health Assessment Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a client’s heart sounds and notes a low-pitched vibration heard in early
diastole at the apex. How should the nurse document this finding?
A. S3 heart sound
B. S2 heart sound
C. S1 heart sound
D. S4 heart sound
Answer: A
Rationale: The S3 heart sound occurs during the rapid filling phase of the ventricles in
early diastole. It is often referred to as a ventricular gallop and is best heard with the bell of
the stethoscope at the apex. This sound can be a normal finding in children or athletes but
may indicate fluid overload in older adults.
2. When assessing the abdomen, which sequence of physical examination techniques should
the nurse follow?
A. Inspection, Palpation, Percussion, Auscultation
B. Percussion, Auscultation, Inspection, Palpation
C. Auscultation, Inspection, Palpation, Percussion
,D. Inspection, Auscultation, Percussion, Palpation
Answer: D
Rationale: In abdominal assessment, auscultation is performed immediately after
inspection to avoid altering bowel sounds. Palpation and percussion can stimulate
peristalsis, leading to inaccurate findings if done before listening. This specific order
ensures the most reliable assessment of the gastrointestinal system.
3. A nurse is testing a patient’s cranial nerves. When the patient is asked to shrug their
shoulders against resistance, which nerve is being evaluated?
A. Cranial Nerve VII (Facial)
B. Cranial Nerve XI (Spinal Accessory)
C. Cranial Nerve IX (Glossopharyngeal)
D. Cranial Nerve XII (Hypoglossal)
Answer: B
Rationale: Cranial Nerve XI, the Spinal Accessory nerve, controls the trapezius and
sternocleidomastoid muscles. Testing shoulder shrugging and neck rotation against
resistance assesses the motor function of this nerve. Weakness or asymmetry during this
test could indicate nerve damage or muscle pathology.
4. During an eye examination using the Snellen chart, a patient’s vision is recorded as 20/50.
What does this measurement indicate?
A. The patient can see at 50 feet what a person with normal vision sees at 20 feet.
, B. The patient has 50% vision in both eyes compared to a standard baseline.
C. The patient needs to stand 50 feet away to see the line clearly.
D. The patient can see at 20 feet what a person with normal vision sees at 50 feet.
Answer: D
Rationale: The first number in a Snellen fraction represents the distance the patient is
standing from the chart, which is typically 20 feet. The second number represents the
distance at which a person with normal vision could read that same line. Therefore, 20/50
means the patient’s distance vision is poorer than normal.
5. While assessing a client’s respiratory system, the nurse notes a high-pitched, musical sound
heard primarily during expiration. This is most likely:
A. Wheezes
B. Crackles
C. Pleural friction rub
D. Stridor
Answer: A
Rationale: Wheezes are continuous, musical lung sounds caused 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 prominent during the expiratory phase.
