NR304/NR 304 Final Exam V3 | Health
Assessment II Q&A with Rationale |
Chamberlain University
1. When assessing the abdomen, which sequence should the nurse follow to ensure accurate
findings?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: A
Rationale: The correct sequence for abdominal assessment is inspection, auscultation,
percussion, and palpation. This specific order is used because percussion and palpation can
increase peristalsis, which would provide false interpretations of bowel sounds. By
auscultating before touching the abdomen, the nurse obtains the most accurate
representation of bowel activity.
2. The nurse is performing a respiratory assessment and notes a low-pitched, snoring sound
that clears with coughing. How should this sound be documented?
A. Wheezes
B. Crackles
,C. Rhonchi
D. Pleural friction rub
Correct Answer: C
Rationale: Rhonchi are low-pitched, continuous sounds caused by secretions in the larger
airways and often clear or change after the patient coughs. In contrast, wheezes are high-
pitched and whistling, while crackles are discontinuous popping sounds. Identifying this
distinction is critical for determining appropriate interventions like airway clearance
techniques.
3. To assess the function of Cranial Nerve VII (Facial), what should the nurse ask the patient to
do?
A. Shrug the shoulders against resistance
B. Stick out the tongue and move it side to side
C. Smile, frown, and puff out the cheeks
D. Follow a penlight through the six cardinal fields of gaze
Correct Answer: C
Rationale: Cranial Nerve VII, the facial nerve, is responsible for the muscles of facial
expression. Asking the patient to smile, frown, and puff out the cheeks allows the nurse to
assess for symmetry and motor strength. Weakness or asymmetry could indicate a
neurological issue such as Bell’s palsy or a stroke.
, 4. Where is the best anatomical location to auscultate the mitral valve area?
A. Second intercostal space, right sternal border
B. Second intercostal space, left sternal border
C. Fourth intercostal space, left sternal border
D. Fifth intercostal space, left midclavicular line
Correct Answer: D
Rationale: The mitral valve area, also known as the apex of the heart, is located at the fifth
intercostal space at the left midclavicular line. This site is optimal for hearing S1 and is
where the apical pulse is measured. Proper placement ensures the nurse can accurately
identify murmurs or rhythm irregularities associated with the mitral valve.
5. During a musculoskeletal exam, the nurse asks the patient to move their arm away from
the midline of the body. What is this movement called?
A. Adduction
B. Abduction
C. Flexion
D. Extension
Correct Answer: B
Rationale: Abduction is the movement of a limb or other part away from the midline of the
body or from another part. Adduction is the opposite, moving the limb toward the midline.
Assessment II Q&A with Rationale |
Chamberlain University
1. When assessing the abdomen, which sequence should the nurse follow to ensure accurate
findings?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: A
Rationale: The correct sequence for abdominal assessment is inspection, auscultation,
percussion, and palpation. This specific order is used because percussion and palpation can
increase peristalsis, which would provide false interpretations of bowel sounds. By
auscultating before touching the abdomen, the nurse obtains the most accurate
representation of bowel activity.
2. The nurse is performing a respiratory assessment and notes a low-pitched, snoring sound
that clears with coughing. How should this sound be documented?
A. Wheezes
B. Crackles
,C. Rhonchi
D. Pleural friction rub
Correct Answer: C
Rationale: Rhonchi are low-pitched, continuous sounds caused by secretions in the larger
airways and often clear or change after the patient coughs. In contrast, wheezes are high-
pitched and whistling, while crackles are discontinuous popping sounds. Identifying this
distinction is critical for determining appropriate interventions like airway clearance
techniques.
3. To assess the function of Cranial Nerve VII (Facial), what should the nurse ask the patient to
do?
A. Shrug the shoulders against resistance
B. Stick out the tongue and move it side to side
C. Smile, frown, and puff out the cheeks
D. Follow a penlight through the six cardinal fields of gaze
Correct Answer: C
Rationale: Cranial Nerve VII, the facial nerve, is responsible for the muscles of facial
expression. Asking the patient to smile, frown, and puff out the cheeks allows the nurse to
assess for symmetry and motor strength. Weakness or asymmetry could indicate a
neurological issue such as Bell’s palsy or a stroke.
, 4. Where is the best anatomical location to auscultate the mitral valve area?
A. Second intercostal space, right sternal border
B. Second intercostal space, left sternal border
C. Fourth intercostal space, left sternal border
D. Fifth intercostal space, left midclavicular line
Correct Answer: D
Rationale: The mitral valve area, also known as the apex of the heart, is located at the fifth
intercostal space at the left midclavicular line. This site is optimal for hearing S1 and is
where the apical pulse is measured. Proper placement ensures the nurse can accurately
identify murmurs or rhythm irregularities associated with the mitral valve.
5. During a musculoskeletal exam, the nurse asks the patient to move their arm away from
the midline of the body. What is this movement called?
A. Adduction
B. Abduction
C. Flexion
D. Extension
Correct Answer: B
Rationale: Abduction is the movement of a limb or other part away from the midline of the
body or from another part. Adduction is the opposite, moving the limb toward the midline.
