NUR 245 | NUR245 Final Exam: Health Assessment
And Promotion - MCPHS Updated and Latest
Questions and Correct Answers with Rationale
1. During a physical examination, the nurse notes a patient has a blowing, swishing sound
when auscultating the carotid artery. How should the nurse document this finding?
A. Normal carotid pulse
B. A thrill
C. A bruit
D. S3 heart sound
Correct Answer: C
Rationale: A bruit is a blowing or swishing sound heard through a stethoscope when blood
flows through a narrowed or partially obstructed artery. This finding is significant because
it suggests the presence of atherosclerotic narrowing, which increases the risk of stroke.
The nurse should use the bell of the stethoscope to detect these low-pitched vascular
sounds effectively. Palpating a thrill is the tactile equivalent, but the sound itself is
specifically termed a bruit. Immediate documentation and reporting are necessary to
initiate further cardiovascular diagnostic testing.
2. When assessing a patient’s abdomen, in which order should the nurse perform the
assessment techniques?
A. Inspection, palpation, percussion, auscultation
B. Auscultation, inspection, percussion, palpation
C. Inspection, auscultation, percussion, palpation
D. Palpation, percussion, auscultation, inspection
Correct Answer: C
Rationale: The correct order for abdominal assessment is inspection, auscultation,
percussion, and then palpation. Auscultation is performed before percussion and palpation
because manual manipulation of the abdomen can alter bowel sounds. Inspection allows
the nurse to observe for symmetry, lesions, or pulsations without interference. Following
inspection, listening to all four quadrants ensures an accurate representation of bowel
activity. This sequence is a standard nursing competency to ensure physical exam findings
are not artificially induced.
3. A nurse is teaching a patient about the ABCDE rule for skin cancer self-examination. What
does the ‘D’ represent in this mnemonic?
A. Depth of the lesion
,B. Density of the tissue
C. Diameter greater than 6mm
D. Discoloration of the border
Correct Answer: C
Rationale: In the ABCDE mnemonic for assessing melanoma, the ‘D’ stands for diameter,
specifically noting if it is larger than 6mm. Early detection of changes in the size of a mole is
critical for improving skin cancer outcomes. Other components include Asymmetry, Border
irregularity, Color variation, and Evolving characteristics. Educating patients on these
criteria empowers them to seek medical advice for suspicious lesions promptly. This
simple tool is a fundamental aspect of secondary prevention and health promotion in
nursing.
4. A 70-year-old patient presents with a cough and shortness of breath. Which finding during
percussion of the lungs would suggest the presence of fluid or a solid mass?
A. Dullness
B. Hyperresonance
C. Resonance
D. Tympany
Correct Answer: A
Rationale: Dullness is the sound heard during percussion over dense tissue such as a solid
organ or a collection of fluid. In the context of lung assessment, this may indicate
pneumonia, pleural effusion, or a tumor. Normal lung tissue should produce a resonant
sound, which is clear and long-lasting. Hyperresonance is typically associated with trapped
air, such as in emphysema or pneumothorax. Recognizing these distinct sounds allows the
nurse to hypothesize potential underlying pathologies before confirming with imaging.
5. The nurse is performing a neurological assessment and asks the patient to smile, frown,
and puff out their cheeks. Which cranial nerve is being tested?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve IX (Glossopharyngeal)
C. Cranial Nerve VII (Facial)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: C
Rationale: Cranial Nerve VII, the facial nerve, is responsible for controlling the muscles of
facial expression. By asking the patient to perform these actions, the nurse evaluates for
symmetry and muscle strength on both sides of the face. Asymmetry could indicate a
, condition such as Bell’s palsy or a stroke affecting the motor pathways. This assessment is a
vital part of a comprehensive neurological exam to determine functional integrity. Testing
CN VII helps the nurse differentiate between peripheral and central nervous system
lesions.
6. A nurse is assessing a patient’s deep tendon reflexes and finds them to be very brisk with
clonus. What numerical score should the nurse assign?
A. 4+
B. 2+
C. 3+
D. 1+
Correct Answer: A
Rationale: A score of 4+ on the deep tendon reflex scale indicates a very brisk response,
often associated with clonus. Normal reflexes are typically graded as 2+, representing an
average or expected response. Hyperactive reflexes suggest upper motor neuron disease or
electrolyte imbalances like hypocalcemia. The nurse must compare findings bilaterally to
ensure consistency across the patient’s neurological system. Accurate grading is essential
for tracking changes in the patient’s neurological status over time.
7. Which assessment finding would be most indicative of chronic hypoxia in a patient with
COPD?
A. Cyanosis of the lips
B. Use of accessory muscles
C. Pursed-lip breathing
D. Clubbing of the fingernails
Correct Answer: D
Rationale: Clubbing of the fingernails is a sign of long-term oxygen deprivation and is
characterized by a straightening of the nail angle to 180 degrees or more. While cyanosis
indicates acute desaturation, clubbing reflects a chronic adaptive change in peripheral
tissues. This finding is common in respiratory conditions such as COPD or cystic fibrosis
where gas exchange is chronically impaired. The nurse should assess the profile of the
fingers to detect early signs of clubbing. Recognizing this physical marker provides insight
into the patient’s long-standing physiological compensation mechanisms.
8. While assessing a patient’s heart, the nurse hears a high-pitched, scratchy sound during
both systole and diastole. This is most likely:
A. An S4 gallop
B. A grade II murmur
And Promotion - MCPHS Updated and Latest
Questions and Correct Answers with Rationale
1. During a physical examination, the nurse notes a patient has a blowing, swishing sound
when auscultating the carotid artery. How should the nurse document this finding?
A. Normal carotid pulse
B. A thrill
C. A bruit
D. S3 heart sound
Correct Answer: C
Rationale: A bruit is a blowing or swishing sound heard through a stethoscope when blood
flows through a narrowed or partially obstructed artery. This finding is significant because
it suggests the presence of atherosclerotic narrowing, which increases the risk of stroke.
The nurse should use the bell of the stethoscope to detect these low-pitched vascular
sounds effectively. Palpating a thrill is the tactile equivalent, but the sound itself is
specifically termed a bruit. Immediate documentation and reporting are necessary to
initiate further cardiovascular diagnostic testing.
2. When assessing a patient’s abdomen, in which order should the nurse perform the
assessment techniques?
A. Inspection, palpation, percussion, auscultation
B. Auscultation, inspection, percussion, palpation
C. Inspection, auscultation, percussion, palpation
D. Palpation, percussion, auscultation, inspection
Correct Answer: C
Rationale: The correct order for abdominal assessment is inspection, auscultation,
percussion, and then palpation. Auscultation is performed before percussion and palpation
because manual manipulation of the abdomen can alter bowel sounds. Inspection allows
the nurse to observe for symmetry, lesions, or pulsations without interference. Following
inspection, listening to all four quadrants ensures an accurate representation of bowel
activity. This sequence is a standard nursing competency to ensure physical exam findings
are not artificially induced.
3. A nurse is teaching a patient about the ABCDE rule for skin cancer self-examination. What
does the ‘D’ represent in this mnemonic?
A. Depth of the lesion
,B. Density of the tissue
C. Diameter greater than 6mm
D. Discoloration of the border
Correct Answer: C
Rationale: In the ABCDE mnemonic for assessing melanoma, the ‘D’ stands for diameter,
specifically noting if it is larger than 6mm. Early detection of changes in the size of a mole is
critical for improving skin cancer outcomes. Other components include Asymmetry, Border
irregularity, Color variation, and Evolving characteristics. Educating patients on these
criteria empowers them to seek medical advice for suspicious lesions promptly. This
simple tool is a fundamental aspect of secondary prevention and health promotion in
nursing.
4. A 70-year-old patient presents with a cough and shortness of breath. Which finding during
percussion of the lungs would suggest the presence of fluid or a solid mass?
A. Dullness
B. Hyperresonance
C. Resonance
D. Tympany
Correct Answer: A
Rationale: Dullness is the sound heard during percussion over dense tissue such as a solid
organ or a collection of fluid. In the context of lung assessment, this may indicate
pneumonia, pleural effusion, or a tumor. Normal lung tissue should produce a resonant
sound, which is clear and long-lasting. Hyperresonance is typically associated with trapped
air, such as in emphysema or pneumothorax. Recognizing these distinct sounds allows the
nurse to hypothesize potential underlying pathologies before confirming with imaging.
5. The nurse is performing a neurological assessment and asks the patient to smile, frown,
and puff out their cheeks. Which cranial nerve is being tested?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve IX (Glossopharyngeal)
C. Cranial Nerve VII (Facial)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: C
Rationale: Cranial Nerve VII, the facial nerve, is responsible for controlling the muscles of
facial expression. By asking the patient to perform these actions, the nurse evaluates for
symmetry and muscle strength on both sides of the face. Asymmetry could indicate a
, condition such as Bell’s palsy or a stroke affecting the motor pathways. This assessment is a
vital part of a comprehensive neurological exam to determine functional integrity. Testing
CN VII helps the nurse differentiate between peripheral and central nervous system
lesions.
6. A nurse is assessing a patient’s deep tendon reflexes and finds them to be very brisk with
clonus. What numerical score should the nurse assign?
A. 4+
B. 2+
C. 3+
D. 1+
Correct Answer: A
Rationale: A score of 4+ on the deep tendon reflex scale indicates a very brisk response,
often associated with clonus. Normal reflexes are typically graded as 2+, representing an
average or expected response. Hyperactive reflexes suggest upper motor neuron disease or
electrolyte imbalances like hypocalcemia. The nurse must compare findings bilaterally to
ensure consistency across the patient’s neurological system. Accurate grading is essential
for tracking changes in the patient’s neurological status over time.
7. Which assessment finding would be most indicative of chronic hypoxia in a patient with
COPD?
A. Cyanosis of the lips
B. Use of accessory muscles
C. Pursed-lip breathing
D. Clubbing of the fingernails
Correct Answer: D
Rationale: Clubbing of the fingernails is a sign of long-term oxygen deprivation and is
characterized by a straightening of the nail angle to 180 degrees or more. While cyanosis
indicates acute desaturation, clubbing reflects a chronic adaptive change in peripheral
tissues. This finding is common in respiratory conditions such as COPD or cystic fibrosis
where gas exchange is chronically impaired. The nurse should assess the profile of the
fingers to detect early signs of clubbing. Recognizing this physical marker provides insight
into the patient’s long-standing physiological compensation mechanisms.
8. While assessing a patient’s heart, the nurse hears a high-pitched, scratchy sound during
both systole and diastole. This is most likely:
A. An S4 gallop
B. A grade II murmur
