NUR 245 | NUR245 Exam 2: Health Assessment And
Promotion - MCPHS Updated and Latest Questions
and Correct Answers with Rationale
1. When assessing an older adult, the nurse auscultates an S3 heart sound at the apex. What
is the most likely clinical significance of this finding?
A. It is a normal finding in patients over the age of 65.
B. It indicates a ventricular gallop often associated with heart failure.
C. It represents the closure of the semilunar valves during diastole.
D. It is an atrial gallop suggesting decreased ventricular compliance.
Correct Answer: B
Rationale: An S3 heart sound is known as a ventricular gallop and occurs early in diastole
during rapid ventricular filling. While normal in children and athletes, it often indicates
fluid overload or heart failure in older adults. The nurse should prioritize assessing for
pulmonary congestion and peripheral edema if this sound is present. Using the bell of the
stethoscope at the apex helps in identifying this low-pitched sound. Early detection is vital
for initiating interventions that reduce cardiac workload and maintain patient safety.
2. In which order should the nurse perform an abdominal assessment for a patient reporting
pain?
A. Inspection, Palpation, Percussion, Auscultation
B. Palpation, Percussion, Auscultation, Inspection
C. Auscultation, Inspection, Palpation, Percussion
D. Inspection, Auscultation, Percussion, Palpation
Correct Answer: D
Rationale: The abdominal assessment sequence is unique because percussion and
palpation can stimulate peristalsis and alter bowel sounds. The nurse begins with
inspection to observe the contour, symmetry, and skin condition of the abdomen.
Auscultation follows immediately to ensure the bowel sounds recorded are truly
representative of the patient’s resting state. Percussion and palpation are performed last to
assess organ size and check for masses or tenderness. This systematic approach ensures
assessment accuracy and prevents the creation of false-positive diagnostic data.
3. The nurse is assessing a patient’s extraocular movements and notes that the eyes do not
move together smoothly. Which cranial nerves are responsible for these movements?
A. CN II, III, and IV
B. CN I, II, and III
,C. CN V, VII, and IX
D. CN III, IV, and VI
Correct Answer: D
Rationale: Cranial nerves III (Oculomotor), IV (Trochlear), and VI (Abducens) work in
coordination to control the muscles of the eye. The nurse evaluates these nerves by asking
the patient to follow an object through the six cardinal positions of gaze. Lack of
coordination or nystagmus can indicate neurological impairment or increased intracranial
pressure. Safety is a priority during this test to ensure the patient does not become dizzy or
lose their balance. Documenting these findings provides a baseline for the patient’s
neurological health and helps identify early signs of brainstem dysfunction.
4. A nurse hears high-pitched, popping, non-musical sounds during inspiration that do not
clear with coughing. How should these sounds be documented?
A. Crackles
B. Rhonchi
C. Wheezes
D. Stridor
Correct Answer: A
Rationale: Crackles, formerly known as rales, are discontinuous sounds caused by the
sudden opening of small airways or fluid in the alveoli. Fine crackles are typically high-
pitched and heard during inspiration, indicating conditions like pneumonia or heart failure.
Unlike rhonchi, crackles are usually not cleared by a patient’s cough. The nurse must
monitor the patient’s oxygen saturation and work of breathing when crackles are present.
Identifying these sounds early is essential for preventing the progression of respiratory
distress and ensuring timely medical treatment.
5. When assessing for jugular venous distention (JVD), at what angle should the head of the
bed be positioned?
A. Flat (0 degrees)
B. 30 to 45 degrees
C. 30 to 45 degrees
D. 15 degrees
B. 90 degrees (High-Fowler’s)
Correct Answer: C
Rationale: To accurately assess jugular venous distention, the patient should be in a semi-
Fowler’s position at a 30 to 45-degree angle. This position allows the nurse to visualize the
, pulsation of the internal jugular vein relative to the sternal angle. Distention above 3
centimeters is considered abnormal and suggests increased central venous pressure. High
central venous pressure is a key clinical indicator of right-sided heart failure or fluid
overload. Proper positioning is crucial to avoid false measurements that could occur if the
patient is too flat or too upright.
6. A nurse finds that a patient’s radial pulse is very weak and easily obliterated with light
pressure. What grade should the nurse assign to this pulse?
A. 0
B. 1+
C. 2+
D. 3+
Correct Answer: B
Rationale: A 1+ pulse grade signifies a weak, thready pulse that is difficult to palpate and
easily extinguished. This finding can indicate decreased cardiac output, peripheral arterial
disease, or dehydration. The nurse should compare this finding bilaterally and assess the
patient’s skin temperature and capillary refill. If pulses are absent (0), a Doppler device
should be used immediately to confirm blood flow. Accurate pulse grading is a fundamental
component of the cardiovascular assessment used to monitor circulatory health and
patient safety.
7. While assessing the abdomen, the nurse pushes down slowly and deeply in an area away
from the reported pain and then releases quickly. The patient winces in pain. What does this
indicate?
A. Murphy’s sign
B. CVA tenderness
C. Psoas sign
D. Rebound tenderness (Blumberg’s sign)
Correct Answer: D
Rationale: Rebound tenderness, or Blumberg’s sign, is a clinical indicator of peritoneal
inflammation often associated with appendicitis. The pain occurs when the displaced
peritoneum snaps back into place after pressure is released. The nurse should perform this
test at the end of the abdominal examination to minimize patient discomfort. It is
important to palpate in a site away from the painful area to confirm the generalized nature
of the irritation. Detecting rebound tenderness is a critical finding that necessitates
immediate communication with the surgical team.
Promotion - MCPHS Updated and Latest Questions
and Correct Answers with Rationale
1. When assessing an older adult, the nurse auscultates an S3 heart sound at the apex. What
is the most likely clinical significance of this finding?
A. It is a normal finding in patients over the age of 65.
B. It indicates a ventricular gallop often associated with heart failure.
C. It represents the closure of the semilunar valves during diastole.
D. It is an atrial gallop suggesting decreased ventricular compliance.
Correct Answer: B
Rationale: An S3 heart sound is known as a ventricular gallop and occurs early in diastole
during rapid ventricular filling. While normal in children and athletes, it often indicates
fluid overload or heart failure in older adults. The nurse should prioritize assessing for
pulmonary congestion and peripheral edema if this sound is present. Using the bell of the
stethoscope at the apex helps in identifying this low-pitched sound. Early detection is vital
for initiating interventions that reduce cardiac workload and maintain patient safety.
2. In which order should the nurse perform an abdominal assessment for a patient reporting
pain?
A. Inspection, Palpation, Percussion, Auscultation
B. Palpation, Percussion, Auscultation, Inspection
C. Auscultation, Inspection, Palpation, Percussion
D. Inspection, Auscultation, Percussion, Palpation
Correct Answer: D
Rationale: The abdominal assessment sequence is unique because percussion and
palpation can stimulate peristalsis and alter bowel sounds. The nurse begins with
inspection to observe the contour, symmetry, and skin condition of the abdomen.
Auscultation follows immediately to ensure the bowel sounds recorded are truly
representative of the patient’s resting state. Percussion and palpation are performed last to
assess organ size and check for masses or tenderness. This systematic approach ensures
assessment accuracy and prevents the creation of false-positive diagnostic data.
3. The nurse is assessing a patient’s extraocular movements and notes that the eyes do not
move together smoothly. Which cranial nerves are responsible for these movements?
A. CN II, III, and IV
B. CN I, II, and III
,C. CN V, VII, and IX
D. CN III, IV, and VI
Correct Answer: D
Rationale: Cranial nerves III (Oculomotor), IV (Trochlear), and VI (Abducens) work in
coordination to control the muscles of the eye. The nurse evaluates these nerves by asking
the patient to follow an object through the six cardinal positions of gaze. Lack of
coordination or nystagmus can indicate neurological impairment or increased intracranial
pressure. Safety is a priority during this test to ensure the patient does not become dizzy or
lose their balance. Documenting these findings provides a baseline for the patient’s
neurological health and helps identify early signs of brainstem dysfunction.
4. A nurse hears high-pitched, popping, non-musical sounds during inspiration that do not
clear with coughing. How should these sounds be documented?
A. Crackles
B. Rhonchi
C. Wheezes
D. Stridor
Correct Answer: A
Rationale: Crackles, formerly known as rales, are discontinuous sounds caused by the
sudden opening of small airways or fluid in the alveoli. Fine crackles are typically high-
pitched and heard during inspiration, indicating conditions like pneumonia or heart failure.
Unlike rhonchi, crackles are usually not cleared by a patient’s cough. The nurse must
monitor the patient’s oxygen saturation and work of breathing when crackles are present.
Identifying these sounds early is essential for preventing the progression of respiratory
distress and ensuring timely medical treatment.
5. When assessing for jugular venous distention (JVD), at what angle should the head of the
bed be positioned?
A. Flat (0 degrees)
B. 30 to 45 degrees
C. 30 to 45 degrees
D. 15 degrees
B. 90 degrees (High-Fowler’s)
Correct Answer: C
Rationale: To accurately assess jugular venous distention, the patient should be in a semi-
Fowler’s position at a 30 to 45-degree angle. This position allows the nurse to visualize the
, pulsation of the internal jugular vein relative to the sternal angle. Distention above 3
centimeters is considered abnormal and suggests increased central venous pressure. High
central venous pressure is a key clinical indicator of right-sided heart failure or fluid
overload. Proper positioning is crucial to avoid false measurements that could occur if the
patient is too flat or too upright.
6. A nurse finds that a patient’s radial pulse is very weak and easily obliterated with light
pressure. What grade should the nurse assign to this pulse?
A. 0
B. 1+
C. 2+
D. 3+
Correct Answer: B
Rationale: A 1+ pulse grade signifies a weak, thready pulse that is difficult to palpate and
easily extinguished. This finding can indicate decreased cardiac output, peripheral arterial
disease, or dehydration. The nurse should compare this finding bilaterally and assess the
patient’s skin temperature and capillary refill. If pulses are absent (0), a Doppler device
should be used immediately to confirm blood flow. Accurate pulse grading is a fundamental
component of the cardiovascular assessment used to monitor circulatory health and
patient safety.
7. While assessing the abdomen, the nurse pushes down slowly and deeply in an area away
from the reported pain and then releases quickly. The patient winces in pain. What does this
indicate?
A. Murphy’s sign
B. CVA tenderness
C. Psoas sign
D. Rebound tenderness (Blumberg’s sign)
Correct Answer: D
Rationale: Rebound tenderness, or Blumberg’s sign, is a clinical indicator of peritoneal
inflammation often associated with appendicitis. The pain occurs when the displaced
peritoneum snaps back into place after pressure is released. The nurse should perform this
test at the end of the abdominal examination to minimize patient discomfort. It is
important to palpate in a site away from the painful area to confirm the generalized nature
of the irritation. Detecting rebound tenderness is a critical finding that necessitates
immediate communication with the surgical team.
