**The Health Assessment and Physical
Examination Final: Comprehensive
Techniques for Nursing Practice**
1. A nurse is preparing to perform a physical assessment on an adult client. Which action should the
nurse take first?
A. Palpate the abdomen.
B. Auscultate breath sounds.
C. Obtain a health history.
D. Inspect the skin.
💫RATIONALE✔️✔️: The health history (subjective data) is always obtained first. It guides the physical
examination and identifies areas of focus. The physical exam sequence is inspection, palpation,
percussion, auscultation (except for abdomen).
💫ANSWER✔️✔️: C. Obtain a health history.
---
2. During a cardiac assessment, the nurse places the stethoscope at the second intercostal space, right
sternal border. Which heart valve is best heard at this location?
A. Aortic
B. Pulmonic
C. Tricuspid
D. Mitral
💫RATIONALE✔️✔️: The aortic valve is best heard at the second intercostal space, right sternal border
(aortic area).
💫ANSWER✔️✔️: A. Aortic
,---
3. A nurse is assessing a client’s jugular veins. The client is positioned supine with the head of the bed at
30 degrees. The nurse notes jugular vein distension (JVD) to the angle of the jaw. This finding suggests:
A. Hypovolemia
B. Right-sided heart failure
C. Dehydration
D. Pneumothorax
💫RATIONALE✔️✔️: JVD above the level of the clavicle when the head of the bed is elevated 30-45
degrees indicates elevated central venous pressure, most commonly from right-sided heart failure or
fluid overload.
💫ANSWER✔️✔️: B. Right-sided heart failure
---
4. A nurse is performing a respiratory assessment. Which finding indicates normal breathing?
A. Respiratory rate of 28 breaths/min
B. Use of accessory muscles
C. Symmetrical chest expansion
D. Nasal flaring
💫RATIONALE✔️✔️: Symmetrical chest expansion is normal. Tachypnea (>20), accessory muscle use,
and nasal flaring indicate respiratory distress.
💫ANSWER✔️✔️: C. Symmetrical chest expansion
---
5. During an abdominal assessment, the nurse should perform auscultation before palpation because:
A. Palpation can increase bowel sounds
B. Palpation can decrease bowel sounds
C. Palpation can alter the frequency of bowel sounds
D. Palpation is not part of the abdominal exam
💫RATIONALE✔️✔️: Palpation can stimulate peristalsis and alter (increase) bowel sounds, so
auscultation should be performed first after inspection.
, 💫ANSWER✔️✔️: C. Palpation can alter the frequency of bowel sounds
---
6. A nurse is assessing a client’s pupillary response. Both pupils constrict when light is shone into the
right eye. This is documented as:
A. Direct reflex present, consensual reflex present
B. Direct reflex present, consensual reflex absent
C. Direct reflex absent, consensual reflex present
D. Direct reflex absent, consensual reflex absent
💫RATIONALE✔️✔️: Direct reflex: right eye constricts when light is shone in right eye → present.
Consensual reflex: left eye constricts when light is shone in right eye → present.
💫ANSWER✔️✔️: A. Direct reflex present, consensual reflex present
---
7. A nurse is assessing a client’s cranial nerve VII (facial). Which action should the nurse ask the client to
perform?
A. Smile, frown, and raise the eyebrows
B. Stick out the tongue and move it side to side
C. Shrug the shoulders against resistance
D. Follow a finger with the eyes
💫RATIONALE✔️✔️: Cranial nerve VII (facial) controls facial expressions. Asking the client to smile,
frown, puff out cheeks, and raise eyebrows tests motor function.
💫ANSWER✔️✔️: A. Smile, frown, and raise the eyebrows
---
8. During a neurological assessment, the nurse asks the client to stand with feet together and eyes
closed. The client sways and loses balance. This is a positive:
A. Babinski sign
B. Romberg test
C. Kernig’s sign
, D. Brudzinski’s sign
💫RATIONALE✔️✔️: Romberg test assesses proprioception and vestibular function. Loss of balance with
eyes closed (swaying) indicates a positive Romberg sign.
💫ANSWER✔️✔️: B. Romberg test
---
9. A nurse is assessing a client’s breath sounds. Which sound is heard over the trachea and is loud, high-
pitched, with a longer expiratory phase?
A. Vesicular
B. Bronchovesicular
C. Bronchial (tracheal)
D. Crackles
💫RATIONALE✔️✔️: Bronchial (tracheal) breath sounds are loud, high-pitched, and have a longer
expiratory phase. They are heard over the trachea and are normal only there.
💫ANSWER✔️✔️: C. Bronchial (tracheal)
---
10. A nurse auscultates breath sounds that are soft, low-pitched, and heard over most of the lung fields.
These are:
A. Vesicular sounds
B. Bronchovesicular sounds
C. Bronchial sounds
D. Adventitious sounds
💫RATIONALE✔️✔️: Vesicular breath sounds are soft, low-pitched, with a shorter expiratory phase, and
are heard over most peripheral lung fields. They are normal.
💫ANSWER✔️✔️: A. Vesicular sounds
---
11. A nurse is assessing a client’s abdomen. Which finding indicates a normal abdominal aorta?
A. A palpable, pulsatile mass in the epigastrium
Examination Final: Comprehensive
Techniques for Nursing Practice**
1. A nurse is preparing to perform a physical assessment on an adult client. Which action should the
nurse take first?
A. Palpate the abdomen.
B. Auscultate breath sounds.
C. Obtain a health history.
D. Inspect the skin.
💫RATIONALE✔️✔️: The health history (subjective data) is always obtained first. It guides the physical
examination and identifies areas of focus. The physical exam sequence is inspection, palpation,
percussion, auscultation (except for abdomen).
💫ANSWER✔️✔️: C. Obtain a health history.
---
2. During a cardiac assessment, the nurse places the stethoscope at the second intercostal space, right
sternal border. Which heart valve is best heard at this location?
A. Aortic
B. Pulmonic
C. Tricuspid
D. Mitral
💫RATIONALE✔️✔️: The aortic valve is best heard at the second intercostal space, right sternal border
(aortic area).
💫ANSWER✔️✔️: A. Aortic
,---
3. A nurse is assessing a client’s jugular veins. The client is positioned supine with the head of the bed at
30 degrees. The nurse notes jugular vein distension (JVD) to the angle of the jaw. This finding suggests:
A. Hypovolemia
B. Right-sided heart failure
C. Dehydration
D. Pneumothorax
💫RATIONALE✔️✔️: JVD above the level of the clavicle when the head of the bed is elevated 30-45
degrees indicates elevated central venous pressure, most commonly from right-sided heart failure or
fluid overload.
💫ANSWER✔️✔️: B. Right-sided heart failure
---
4. A nurse is performing a respiratory assessment. Which finding indicates normal breathing?
A. Respiratory rate of 28 breaths/min
B. Use of accessory muscles
C. Symmetrical chest expansion
D. Nasal flaring
💫RATIONALE✔️✔️: Symmetrical chest expansion is normal. Tachypnea (>20), accessory muscle use,
and nasal flaring indicate respiratory distress.
💫ANSWER✔️✔️: C. Symmetrical chest expansion
---
5. During an abdominal assessment, the nurse should perform auscultation before palpation because:
A. Palpation can increase bowel sounds
B. Palpation can decrease bowel sounds
C. Palpation can alter the frequency of bowel sounds
D. Palpation is not part of the abdominal exam
💫RATIONALE✔️✔️: Palpation can stimulate peristalsis and alter (increase) bowel sounds, so
auscultation should be performed first after inspection.
, 💫ANSWER✔️✔️: C. Palpation can alter the frequency of bowel sounds
---
6. A nurse is assessing a client’s pupillary response. Both pupils constrict when light is shone into the
right eye. This is documented as:
A. Direct reflex present, consensual reflex present
B. Direct reflex present, consensual reflex absent
C. Direct reflex absent, consensual reflex present
D. Direct reflex absent, consensual reflex absent
💫RATIONALE✔️✔️: Direct reflex: right eye constricts when light is shone in right eye → present.
Consensual reflex: left eye constricts when light is shone in right eye → present.
💫ANSWER✔️✔️: A. Direct reflex present, consensual reflex present
---
7. A nurse is assessing a client’s cranial nerve VII (facial). Which action should the nurse ask the client to
perform?
A. Smile, frown, and raise the eyebrows
B. Stick out the tongue and move it side to side
C. Shrug the shoulders against resistance
D. Follow a finger with the eyes
💫RATIONALE✔️✔️: Cranial nerve VII (facial) controls facial expressions. Asking the client to smile,
frown, puff out cheeks, and raise eyebrows tests motor function.
💫ANSWER✔️✔️: A. Smile, frown, and raise the eyebrows
---
8. During a neurological assessment, the nurse asks the client to stand with feet together and eyes
closed. The client sways and loses balance. This is a positive:
A. Babinski sign
B. Romberg test
C. Kernig’s sign
, D. Brudzinski’s sign
💫RATIONALE✔️✔️: Romberg test assesses proprioception and vestibular function. Loss of balance with
eyes closed (swaying) indicates a positive Romberg sign.
💫ANSWER✔️✔️: B. Romberg test
---
9. A nurse is assessing a client’s breath sounds. Which sound is heard over the trachea and is loud, high-
pitched, with a longer expiratory phase?
A. Vesicular
B. Bronchovesicular
C. Bronchial (tracheal)
D. Crackles
💫RATIONALE✔️✔️: Bronchial (tracheal) breath sounds are loud, high-pitched, and have a longer
expiratory phase. They are heard over the trachea and are normal only there.
💫ANSWER✔️✔️: C. Bronchial (tracheal)
---
10. A nurse auscultates breath sounds that are soft, low-pitched, and heard over most of the lung fields.
These are:
A. Vesicular sounds
B. Bronchovesicular sounds
C. Bronchial sounds
D. Adventitious sounds
💫RATIONALE✔️✔️: Vesicular breath sounds are soft, low-pitched, with a shorter expiratory phase, and
are heard over most peripheral lung fields. They are normal.
💫ANSWER✔️✔️: A. Vesicular sounds
---
11. A nurse is assessing a client’s abdomen. Which finding indicates a normal abdominal aorta?
A. A palpable, pulsatile mass in the epigastrium
