NUR 2092/NUR2092 Exam 2 V2 | Health
Assessment Q&A with Rationale |
Rasmussen University
1. When percussing the posterior thorax of a healthy adult, which sound does the nurse
expect to hear over the lung fields?
A. Hyperresonance
B. Dullness
C. Resonance
D. Tympany
Answer: C
Rationale: Resonance is the low-pitched, clear, hollow sound that predominates in healthy
lung tissue in the adult. Hyperresonance is found when too much air is present, such as in
emphysema or pneumothorax. Dullness indicates an abnormal density in the lungs, as seen
with pneumonia or pleural effusion.
2. The nurse is assessing a patient for a possible aortic aneurysm. Which assessment finding
would most likely indicate this condition?
A. Hyperactive bowel sounds in the RUQ
B. Tenderness at McBurney’s point
C. Dullness over the left upper quadrant
,D. A pulsating mass in the upper abdomen
Answer: D
Rationale: An aortic aneurysm is most commonly located in the upper abdomen just to the
left of the midline. A pulsating mass is a hallmark sign that can often be felt during light
palpation. The nurse should avoid deep palpation if an aneurysm is suspected to prevent
rupture.
3. During a cardiovascular assessment, where should the nurse palpate to find the apical
impulse?
A. Second intercostal space, right sternal border
B. Fifth intercostal space, left midclavicular line
C. Fourth intercostal space, left sternal border
D. Second intercostal space, left sternal border
Answer: B
Rationale: The apical impulse, formerly known as the point of maximal impulse (PMI), is
located at the fifth intercostal space at or inside the left midclavicular line. It represents the
pulsation of the left ventricle against the chest wall. In some patients, especially those with
thick chest walls or obesity, it may not be palpable.
4. When auscultating the abdomen, in which quadrant should the nurse begin?
A. Left Upper Quadrant (LUQ)
, B. Right Lower Quadrant (RLQ)
C. Right Upper Quadrant (RUQ)
D. Left Lower Quadrant (LLQ)
Answer: B
Rationale: The nurse should always begin auscultating the abdomen in the Right Lower
Quadrant (RLQ). This area is chosen because bowel sounds are normally always present
here at the ileocecal valve. Following a clockwise pattern ensures all four quadrants are
assessed systematically.
5. A patient has a 160-degree angle of the nail base. How should the nurse document this
finding?
A. Normal profile sign
B. Early clubbing
C. Late clubbing
D. Koilonychia
Answer: A
Rationale: A normal nail base angle is about 160 degrees. Clubbing occurs when the angle
straightens out to 180 degrees or more, often due to chronic hypoxia. Identifying this early
helps in assessing long-term respiratory or cardiovascular health.
Assessment Q&A with Rationale |
Rasmussen University
1. When percussing the posterior thorax of a healthy adult, which sound does the nurse
expect to hear over the lung fields?
A. Hyperresonance
B. Dullness
C. Resonance
D. Tympany
Answer: C
Rationale: Resonance is the low-pitched, clear, hollow sound that predominates in healthy
lung tissue in the adult. Hyperresonance is found when too much air is present, such as in
emphysema or pneumothorax. Dullness indicates an abnormal density in the lungs, as seen
with pneumonia or pleural effusion.
2. The nurse is assessing a patient for a possible aortic aneurysm. Which assessment finding
would most likely indicate this condition?
A. Hyperactive bowel sounds in the RUQ
B. Tenderness at McBurney’s point
C. Dullness over the left upper quadrant
,D. A pulsating mass in the upper abdomen
Answer: D
Rationale: An aortic aneurysm is most commonly located in the upper abdomen just to the
left of the midline. A pulsating mass is a hallmark sign that can often be felt during light
palpation. The nurse should avoid deep palpation if an aneurysm is suspected to prevent
rupture.
3. During a cardiovascular assessment, where should the nurse palpate to find the apical
impulse?
A. Second intercostal space, right sternal border
B. Fifth intercostal space, left midclavicular line
C. Fourth intercostal space, left sternal border
D. Second intercostal space, left sternal border
Answer: B
Rationale: The apical impulse, formerly known as the point of maximal impulse (PMI), is
located at the fifth intercostal space at or inside the left midclavicular line. It represents the
pulsation of the left ventricle against the chest wall. In some patients, especially those with
thick chest walls or obesity, it may not be palpable.
4. When auscultating the abdomen, in which quadrant should the nurse begin?
A. Left Upper Quadrant (LUQ)
, B. Right Lower Quadrant (RLQ)
C. Right Upper Quadrant (RUQ)
D. Left Lower Quadrant (LLQ)
Answer: B
Rationale: The nurse should always begin auscultating the abdomen in the Right Lower
Quadrant (RLQ). This area is chosen because bowel sounds are normally always present
here at the ileocecal valve. Following a clockwise pattern ensures all four quadrants are
assessed systematically.
5. A patient has a 160-degree angle of the nail base. How should the nurse document this
finding?
A. Normal profile sign
B. Early clubbing
C. Late clubbing
D. Koilonychia
Answer: A
Rationale: A normal nail base angle is about 160 degrees. Clubbing occurs when the angle
straightens out to 180 degrees or more, often due to chronic hypoxia. Identifying this early
helps in assessing long-term respiratory or cardiovascular health.
