NUR 6001/NUR6001 Exam 3 V2 | Advanced
Health Assessment Q&A with Rationale |
William Paterson University
1. Which heart sound is also known as a ventricular gallop and occurs early in diastole during
the rapid filling phase of the ventricle?
A. S1
B. S4
C. S3
D. S2
Answer: C
Rationale: The S3 heart sound occurs during the early part of diastole when blood flows
rapidly into the ventricle. It is often described as a ventricular gallop because of its cadence.
While normal in children and athletes, in older adults it frequently indicates fluid volume
overload or heart failure.
2. When assessing for tactile fremitus, the nurse should expect to find increased vibrations in
which clinical condition?
A. Pneumothorax
B. Pneumonia with consolidation
C. Pleural effusion
,D. Asthma
Answer: B
Rationale: Consolidation in the lung tissue, such as that seen in pneumonia, provides a
solid medium that conducts sound vibrations better than air. Therefore, tactile fremitus is
increased over areas of consolidated lung. Conditions like pneumothorax or pleural
effusion create a barrier between the lung and the chest wall, resulting in decreased or
absent fremitus.
3. A positive Murphy’s sign is most indicative of which of the following inflammatory
conditions?
A. Acute appendicitis
B. Diverticulitis
C. Acute pancreatitis
D. Acute cholecystitis
Answer: D
Rationale: Murphy’s sign is tested by asking the patient to inhale while the examiner
applies pressure under the right costal margin. If the patient experiences a sudden stop in
inspiration due to pain, the test is positive. This finding is highly specific for gallbladder
inflammation or acute cholecystitis.
, 4. Which cranial nerve is being assessed when a nurse asks the patient to puff out their
cheeks and show their teeth?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve VII (Facial)
C. Cranial Nerve IX (Glossopharyngeal)
D. Cranial Nerve XII (Hypoglossal)
Answer: B
Rationale: Cranial Nerve VII, the facial nerve, controls the muscles of facial expression. By
asking the patient to smile, frown, or puff out their cheeks, the examiner evaluates the
motor function of this nerve. Asymmetry in these movements may suggest nerve damage
or a neurological event like a stroke.
5. What is the standard distance a patient should stand from the Snellen eye chart to assess
distant visual acuity?
A. 20 feet
B. 15 feet
C. 10 feet
D. 25 feet
Answer: A
Health Assessment Q&A with Rationale |
William Paterson University
1. Which heart sound is also known as a ventricular gallop and occurs early in diastole during
the rapid filling phase of the ventricle?
A. S1
B. S4
C. S3
D. S2
Answer: C
Rationale: The S3 heart sound occurs during the early part of diastole when blood flows
rapidly into the ventricle. It is often described as a ventricular gallop because of its cadence.
While normal in children and athletes, in older adults it frequently indicates fluid volume
overload or heart failure.
2. When assessing for tactile fremitus, the nurse should expect to find increased vibrations in
which clinical condition?
A. Pneumothorax
B. Pneumonia with consolidation
C. Pleural effusion
,D. Asthma
Answer: B
Rationale: Consolidation in the lung tissue, such as that seen in pneumonia, provides a
solid medium that conducts sound vibrations better than air. Therefore, tactile fremitus is
increased over areas of consolidated lung. Conditions like pneumothorax or pleural
effusion create a barrier between the lung and the chest wall, resulting in decreased or
absent fremitus.
3. A positive Murphy’s sign is most indicative of which of the following inflammatory
conditions?
A. Acute appendicitis
B. Diverticulitis
C. Acute pancreatitis
D. Acute cholecystitis
Answer: D
Rationale: Murphy’s sign is tested by asking the patient to inhale while the examiner
applies pressure under the right costal margin. If the patient experiences a sudden stop in
inspiration due to pain, the test is positive. This finding is highly specific for gallbladder
inflammation or acute cholecystitis.
, 4. Which cranial nerve is being assessed when a nurse asks the patient to puff out their
cheeks and show their teeth?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve VII (Facial)
C. Cranial Nerve IX (Glossopharyngeal)
D. Cranial Nerve XII (Hypoglossal)
Answer: B
Rationale: Cranial Nerve VII, the facial nerve, controls the muscles of facial expression. By
asking the patient to smile, frown, or puff out their cheeks, the examiner evaluates the
motor function of this nerve. Asymmetry in these movements may suggest nerve damage
or a neurological event like a stroke.
5. What is the standard distance a patient should stand from the Snellen eye chart to assess
distant visual acuity?
A. 20 feet
B. 15 feet
C. 10 feet
D. 25 feet
Answer: A
