NR-304 Health Assessment II — Final 2 Exam
Questions And Correct Answers {Verified
Answers} Plus Rationales 2025/2026 Q&A /
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1. Which of the following is the best initial technique to assess for pleural effusion?
A. Auscultation for crackles
B. Palpation for tactile fremitus
C. Inspection for cyanosis
D. Percussion for dullness
B. Palpation for tactile fremitus
Rationale: Tactile fremitus decreases over areas of pleural effusion because fluid
dampens transmitted vibrations; percussion will also be dull, but tactile fremitus is
an early, sensitive bedside technique.
2. A nurse detects a new S3 heart sound in a 68-year-old patient. This finding most
strongly suggests:
A. Aortic stenosis
B. Heart failure or volume overload
C. Hypertrophic cardiomyopathy
D. Pericarditis
B. Heart failure or volume overload
Rationale: An S3 (ventricular gallop) in older adults typically indicates increased
volume in the ventricle and is associated with heart failure; S4 is associated with
decreased ventricular compliance.
3. The correct sequence for abdominal examination is:
A. Inspection, palpation, percussion, auscultation
B. Inspection, auscultation, percussion, palpation
C. Auscultation, inspection, percussion, palpation
D. Palpation, auscultation, inspection, percussion
B. Inspection, auscultation, percussion, palpation
Rationale: Auscultation is performed before percussion and palpation to avoid
altering bowel sounds; inspection always first.
4. A patient has a bruit over the abdominal aorta. This finding most likely indicates:
A. Normal venous hum
B. Aortic aneurysm or turbulent blood flow
C. Peritonitis
, D. Pancreatitis
B. Aortic aneurysm or turbulent blood flow
Rationale: A bruit over the aorta suggests turbulent arterial flow, which can be
seen with aneurysms or severe atherosclerotic disease.
5. During neurological testing, the Romberg sign is positive when:
A. The patient has loss of position sense with eyes open
B. The patient sways or falls with eyes closed, indicating proprioceptive or vestibular
dysfunction
C. The patient cannot perform rapid alternating movements
D. Deep tendon reflexes are absent
B. The patient sways or falls with eyes closed, indicating proprioceptive or
vestibular dysfunction
Rationale: A positive Romberg indicates impaired proprioception or vestibular
dysfunction when visual input is removed.
6. Which reflex is normal in a 6-month-old infant but abnormal in an adult?
A. Plantar (Babinski) reflex with dorsiflexion of the great toe
B. Biceps reflex
C. Triceps reflex
D. Patellar reflex
A. Plantar (Babinski) reflex with dorsiflexion of the great toe
Rationale: Upgoing Babinski response is normal in infants up to about 1 year due to
incomplete myelination; in adults it indicates an upper motor neuron lesion.
7. When assessing jugular venous pressure (JVP), the best patient position is:
A. Supine, head flat
B. Upright at 90 degrees
C. Reclined at 30–45 degrees with head turned slightly away
D. On left side with head elevated 60 degrees
C. Reclined at 30–45 degrees with head turned slightly away
Rationale: This position allows optimal visualization of the jugular venous pulsation
to estimate central venous pressure.
8. A patient presents with inspiratory wheezes and prolonged expiratory phase. This
pattern is most characteristic of:
A. Bronchitis
B. Asthma or obstructive disease
C. Pulmonary edema
D. Pleural effusion
B. Asthma or obstructive disease
Rationale: Wheezes and prolonged expiration are classic for airway obstruction as
in asthma or COPD.
, 9. The most reliable indicator of hypoxia in a chronic COPD patient is:
A. Pulse oximetry reading of SpO2
B. Respiratory rate alone
C. Subjective dyspnea report
D. Hemoglobin level
A. Pulse oximetry reading of SpO2
Rationale: Pulse oximetry gives an immediate measure of oxygen saturation; in
chronic COPD ABG may be needed for CO2 but SpO2 is the bedside measure for
hypoxia.
10. While auscultating lungs, bronchial breath sounds heard over peripheral lung fields
suggest:
A. Normal lungs
B. Consolidation such as pneumonia
C. Pleural effusion
D. Emphysema
B. Consolidation such as pneumonia
Rationale: Bronchial breath sounds in peripheral areas indicate airless lung
transmitting tracheal sounds through consolidated tissue.
11. On abdominal exam, shifting dullness indicates:
A. Ascites
B. Mass in the colon
C. Small bowel obstruction
D. Renal enlargement
A. Ascites
Rationale: Shifting dullness occurs when free fluid moves with gravity, changing
percussion notes when the patient is rolled.
12. Which skin lesion description best fits a macule?
A. Elevated, solid lesion >1 cm
B. Flat, nonpalpable change in skin color <1 cm
C. Fluid-filled blister
D. Flat, nonpalpable change in skin color >1 cm
B. Flat, nonpalpable change in skin color <1 cm
Rationale: Macules are flat and <1 cm; patches are >1 cm.
13. In assessing cranial nerve VII (facial), which action would you ask the patient to
perform?
A. Shrug shoulders
B. Puff out cheeks and smile
C. Stick out tongue
D. Say "ah" while observing palate
Questions And Correct Answers {Verified
Answers} Plus Rationales 2025/2026 Q&A /
Instant Download Pdf
1. Which of the following is the best initial technique to assess for pleural effusion?
A. Auscultation for crackles
B. Palpation for tactile fremitus
C. Inspection for cyanosis
D. Percussion for dullness
B. Palpation for tactile fremitus
Rationale: Tactile fremitus decreases over areas of pleural effusion because fluid
dampens transmitted vibrations; percussion will also be dull, but tactile fremitus is
an early, sensitive bedside technique.
2. A nurse detects a new S3 heart sound in a 68-year-old patient. This finding most
strongly suggests:
A. Aortic stenosis
B. Heart failure or volume overload
C. Hypertrophic cardiomyopathy
D. Pericarditis
B. Heart failure or volume overload
Rationale: An S3 (ventricular gallop) in older adults typically indicates increased
volume in the ventricle and is associated with heart failure; S4 is associated with
decreased ventricular compliance.
3. The correct sequence for abdominal examination is:
A. Inspection, palpation, percussion, auscultation
B. Inspection, auscultation, percussion, palpation
C. Auscultation, inspection, percussion, palpation
D. Palpation, auscultation, inspection, percussion
B. Inspection, auscultation, percussion, palpation
Rationale: Auscultation is performed before percussion and palpation to avoid
altering bowel sounds; inspection always first.
4. A patient has a bruit over the abdominal aorta. This finding most likely indicates:
A. Normal venous hum
B. Aortic aneurysm or turbulent blood flow
C. Peritonitis
, D. Pancreatitis
B. Aortic aneurysm or turbulent blood flow
Rationale: A bruit over the aorta suggests turbulent arterial flow, which can be
seen with aneurysms or severe atherosclerotic disease.
5. During neurological testing, the Romberg sign is positive when:
A. The patient has loss of position sense with eyes open
B. The patient sways or falls with eyes closed, indicating proprioceptive or vestibular
dysfunction
C. The patient cannot perform rapid alternating movements
D. Deep tendon reflexes are absent
B. The patient sways or falls with eyes closed, indicating proprioceptive or
vestibular dysfunction
Rationale: A positive Romberg indicates impaired proprioception or vestibular
dysfunction when visual input is removed.
6. Which reflex is normal in a 6-month-old infant but abnormal in an adult?
A. Plantar (Babinski) reflex with dorsiflexion of the great toe
B. Biceps reflex
C. Triceps reflex
D. Patellar reflex
A. Plantar (Babinski) reflex with dorsiflexion of the great toe
Rationale: Upgoing Babinski response is normal in infants up to about 1 year due to
incomplete myelination; in adults it indicates an upper motor neuron lesion.
7. When assessing jugular venous pressure (JVP), the best patient position is:
A. Supine, head flat
B. Upright at 90 degrees
C. Reclined at 30–45 degrees with head turned slightly away
D. On left side with head elevated 60 degrees
C. Reclined at 30–45 degrees with head turned slightly away
Rationale: This position allows optimal visualization of the jugular venous pulsation
to estimate central venous pressure.
8. A patient presents with inspiratory wheezes and prolonged expiratory phase. This
pattern is most characteristic of:
A. Bronchitis
B. Asthma or obstructive disease
C. Pulmonary edema
D. Pleural effusion
B. Asthma or obstructive disease
Rationale: Wheezes and prolonged expiration are classic for airway obstruction as
in asthma or COPD.
, 9. The most reliable indicator of hypoxia in a chronic COPD patient is:
A. Pulse oximetry reading of SpO2
B. Respiratory rate alone
C. Subjective dyspnea report
D. Hemoglobin level
A. Pulse oximetry reading of SpO2
Rationale: Pulse oximetry gives an immediate measure of oxygen saturation; in
chronic COPD ABG may be needed for CO2 but SpO2 is the bedside measure for
hypoxia.
10. While auscultating lungs, bronchial breath sounds heard over peripheral lung fields
suggest:
A. Normal lungs
B. Consolidation such as pneumonia
C. Pleural effusion
D. Emphysema
B. Consolidation such as pneumonia
Rationale: Bronchial breath sounds in peripheral areas indicate airless lung
transmitting tracheal sounds through consolidated tissue.
11. On abdominal exam, shifting dullness indicates:
A. Ascites
B. Mass in the colon
C. Small bowel obstruction
D. Renal enlargement
A. Ascites
Rationale: Shifting dullness occurs when free fluid moves with gravity, changing
percussion notes when the patient is rolled.
12. Which skin lesion description best fits a macule?
A. Elevated, solid lesion >1 cm
B. Flat, nonpalpable change in skin color <1 cm
C. Fluid-filled blister
D. Flat, nonpalpable change in skin color >1 cm
B. Flat, nonpalpable change in skin color <1 cm
Rationale: Macules are flat and <1 cm; patches are >1 cm.
13. In assessing cranial nerve VII (facial), which action would you ask the patient to
perform?
A. Shrug shoulders
B. Puff out cheeks and smile
C. Stick out tongue
D. Say "ah" while observing palate
