NR304/NR 304 Final Exam V2 | Health
Assessment II Q&A with Rationale |
Chamberlain University
1. When conducting a physical examination of the abdomen, in which order should the nurse
perform the assessment techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: C
Rationale: This sequence is critical because palpation and percussion can stimulate
peristalsis, which would lead to an inaccurate interpretation of bowel sounds. By
auscultating immediately after inspection, the nurse ensures the bowel sounds are heard in
their natural state. This standard protocol is a fundamental component of the NR304
abdominal assessment curriculum.
2. A nurse is assessing a patient for possible cholecystitis. Which specific physical exam
technique should be utilized?
A. Rovsing sign
B. Iliopsoas muscle test
,C. Murphy sign
D. Blumberg sign
Correct Answer: C
Rationale: Murphy sign is specifically used to identify inflammation of the gallbladder,
known as cholecystitis. The nurse asks the patient to take a deep breath while applying
pressure under the right costal margin; a positive sign is when the patient abruptly stops
inhaling due to pain. Rovsing and Iliopsoas tests are more commonly associated with
appendicitis assessments.
3. The nurse is evaluating the patellar reflex and notes it is very brisk with a few beats of
clonus. How should this be documented using the standard scale?
A. 1+
B. 4+
C. 3+
D. 2+
Correct Answer: B
Rationale: A 4+ reflex is defined as being very brisk, hyperactive, and often associated with
clonus, which indicates potential upper motor neuron disease. The 2+ grade is considered a
normal or average response for a healthy adult. Proper grading of deep tendon reflexes is
essential for neurological monitoring in the clinical setting.
, 4. During a musculoskeletal assessment, the nurse asks the patient to move their arm away
from the midline of the body. This movement is known as:
A. Adduction
B. Extension
C. Flexion
D. Abduction
Correct Answer: D
Rationale: Abduction refers to the movement of a limb or other part away from the
midline of the body or from another part. Conversely, adduction is the movement toward
the midline, essentially ‘adding’ it back to the body. Understanding these anatomical terms
is vital for accurately documenting range of motion during health assessments.
5. Which cranial nerve is the nurse assessing when asking the patient to shrug their shoulders
against resistance?
A. Cranial Nerve IX
B. Cranial Nerve X
C. Cranial Nerve XI
D. Cranial Nerve XII
Correct Answer: C
Assessment II Q&A with Rationale |
Chamberlain University
1. When conducting a physical examination of the abdomen, in which order should the nurse
perform the assessment techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: C
Rationale: This sequence is critical because palpation and percussion can stimulate
peristalsis, which would lead to an inaccurate interpretation of bowel sounds. By
auscultating immediately after inspection, the nurse ensures the bowel sounds are heard in
their natural state. This standard protocol is a fundamental component of the NR304
abdominal assessment curriculum.
2. A nurse is assessing a patient for possible cholecystitis. Which specific physical exam
technique should be utilized?
A. Rovsing sign
B. Iliopsoas muscle test
,C. Murphy sign
D. Blumberg sign
Correct Answer: C
Rationale: Murphy sign is specifically used to identify inflammation of the gallbladder,
known as cholecystitis. The nurse asks the patient to take a deep breath while applying
pressure under the right costal margin; a positive sign is when the patient abruptly stops
inhaling due to pain. Rovsing and Iliopsoas tests are more commonly associated with
appendicitis assessments.
3. The nurse is evaluating the patellar reflex and notes it is very brisk with a few beats of
clonus. How should this be documented using the standard scale?
A. 1+
B. 4+
C. 3+
D. 2+
Correct Answer: B
Rationale: A 4+ reflex is defined as being very brisk, hyperactive, and often associated with
clonus, which indicates potential upper motor neuron disease. The 2+ grade is considered a
normal or average response for a healthy adult. Proper grading of deep tendon reflexes is
essential for neurological monitoring in the clinical setting.
, 4. During a musculoskeletal assessment, the nurse asks the patient to move their arm away
from the midline of the body. This movement is known as:
A. Adduction
B. Extension
C. Flexion
D. Abduction
Correct Answer: D
Rationale: Abduction refers to the movement of a limb or other part away from the
midline of the body or from another part. Conversely, adduction is the movement toward
the midline, essentially ‘adding’ it back to the body. Understanding these anatomical terms
is vital for accurately documenting range of motion during health assessments.
5. Which cranial nerve is the nurse assessing when asking the patient to shrug their shoulders
against resistance?
A. Cranial Nerve IX
B. Cranial Nerve X
C. Cranial Nerve XI
D. Cranial Nerve XII
Correct Answer: C
