NU 325 Exams 1–4 – Health Assessment EXAM with
Questions and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
Table of Contents
1. Foundations of Health Assessment and Communication
2. Assessment of Skin, Hair, and Nails
3. Assessment of Head, Neck, and Lymphatics
4. Cardiovascular and Peripheral Vascular Assessment
5. Respiratory and Abdominal Assessment
1. A 68-year-old patient presents with a history of hypertension. During the cardiovascular
assessment, you note a displaced point of maximal impulse (PMI) at the 6th intercostal space,
left mid-axillary line. What does this physical finding suggest?
A. Left ventricular hypertrophy
B. Right ventricular dilation
C. Pericardial effusion
D. Chronic obstructive pulmonary disease
Answer: A
CORRECT ANSWER : A
Rationale: A displaced PMI inferiorly and laterally is a hallmark physical finding of left
ventricular hypertrophy, often resulting from chronic hypertension forcing the heart to work
harder. Right ventricular dilation would typically present with a parasternal heave rather than a
displaced apical impulse. Pericardial effusion and COPD may mask or shift the impulse, but
, they do not typically cause the specific lateral/inferior displacement associated with
hypertrophy.
2. While assessing a patient's skin, you identify a 4mm lesion that is asymmetric, has irregular
borders, and exhibits variegated coloring. What is the priority nursing intervention?
A. Document the finding as a common seborrheic keratosis
B. Instruct the patient to monitor the lesion for 30 days
C. Refer the patient for a biopsy to rule out malignant melanoma
D. Apply a topical steroid to reduce potential inflammation
Answer: C
CORRECT ANSWER : C
Rationale: The ABCDE criteria (Asymmetry, Border, Color, Diameter, Evolution) suggest a high
suspicion for malignant melanoma, requiring urgent biopsy for definitive diagnosis. Seborrheic
keratoses are typically well-demarcated and uniform, making option A incorrect. Observation is
dangerous in the presence of suspicious markers, and topical steroids are inappropriate for
undiagnosed pigmented lesions.
3. During an abdominal assessment, you auscultate high-pitched, rushing bowel sounds in the right
lower quadrant, followed by periods of silence. Which clinical interpretation is most accurate?
A. Normal bowel activity
B. Early mechanical bowel obstruction
C. Paralytic ileus
D. Severe gastroenteritis
Answer: B
CORRECT ANSWER : B
Rationale: High-pitched, "tinkling" or rushing sounds indicate that the bowel is struggling to
move contents past an obstruction, which is a classic sign of early mechanical obstruction.
Normal sounds are clicks and gurgles, whereas a paralytic ileus would present with absent or
hypoactive sounds throughout. Gastroenteritis typically presents with hyperactive, continuous
sounds rather than the high-pitched, intermittent sounds described.
,4. A patient reports sharp, stabbing chest pain that worsens with deep inspiration and improves
when sitting forward. Which assessment finding would support a diagnosis of pericarditis?
A. An S3 gallop at the apex
B. A friction rub at the left sternal border
C. Distended neck veins and muffled heart sounds
D. A blowing holosystolic murmur
Answer: B
CORRECT ANSWER : B
Rationale: Pericarditis is characterized by a pericardial friction rub resulting from inflamed
layers of the pericardium rubbing together. An S3 gallop is associated with heart failure,
distended neck veins and muffled sounds indicate cardiac tamponade, and a holosystolic murmur
suggests valvular regurgitation, none of which are diagnostic of pericarditis.
5. When assessing the neck of a patient with suspected heart failure, you observe significant jugular
venous distention (JVD) even when the patient is sitting at a 45-degree angle. What is the
clinical significance of this?
A. Increased central venous pressure
B. Decreased venous return
C. Normal age-related physiological change
D. Acute carotid artery stenosis
Answer: A
CORRECT ANSWER : A
Rationale: JVD at 45 degrees indicates elevated central venous pressure, often caused by right-
sided heart failure or fluid volume overload. This is not a normal finding in healthy individuals,
and it is unrelated to carotid artery patency (stenosis), which would be assessed via auscultation
for bruits.
6. You are performing a respiratory assessment on a patient with chronic bronchitis. Which
findings are most likely during percussion and auscultation?
A. Hyperresonance and fine crackles
, B. Dullness and wheezing
C. Resonance and friction rubs
D. Dullness and diminished breath sounds
Answer: B
CORRECT ANSWER : B
Rationale: Chronic bronchitis involves mucus production and airway inflammation, leading to
areas of atelectasis or consolidation which present as dullness on percussion, and wheezing due
to narrowed airways. Hyperresonance is associated with emphysema (air trapping), not
bronchitis. Friction rubs are pleural, and diminished sounds are more typical of pleural effusion
or pneumothorax.
7. A patient presents with a history of "claudication." During the peripheral vascular assessment,
what findings would you expect to document?
A. Warm, edematous lower extremities with brown pigmentation
B. Diminished pedal pulses and thin, shiny skin with hair loss
C. Pitting edema that worsens throughout the day
D. Palpable cords along the saphenous veins
Answer: B
CORRECT ANSWER : B
Rationale: Claudication is a symptom of peripheral artery disease (PAD), which manifests as
restricted blood flow leading to diminished pulses, thin skin, and hair loss. Options A and C
describe venous insufficiency, and option D describes superficial thrombophlebitis.
8. Which assessment technique is most effective for detecting a diaphragmatic excursion of less
than 3 cm?
A. Light palpation of the chest wall
B. Percussion along the scapular line during inspiration and expiration
C. Auscultation of breath sounds at the base of the lungs
D. Inspection of the chest wall for symmetry
Questions and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
Table of Contents
1. Foundations of Health Assessment and Communication
2. Assessment of Skin, Hair, and Nails
3. Assessment of Head, Neck, and Lymphatics
4. Cardiovascular and Peripheral Vascular Assessment
5. Respiratory and Abdominal Assessment
1. A 68-year-old patient presents with a history of hypertension. During the cardiovascular
assessment, you note a displaced point of maximal impulse (PMI) at the 6th intercostal space,
left mid-axillary line. What does this physical finding suggest?
A. Left ventricular hypertrophy
B. Right ventricular dilation
C. Pericardial effusion
D. Chronic obstructive pulmonary disease
Answer: A
CORRECT ANSWER : A
Rationale: A displaced PMI inferiorly and laterally is a hallmark physical finding of left
ventricular hypertrophy, often resulting from chronic hypertension forcing the heart to work
harder. Right ventricular dilation would typically present with a parasternal heave rather than a
displaced apical impulse. Pericardial effusion and COPD may mask or shift the impulse, but
, they do not typically cause the specific lateral/inferior displacement associated with
hypertrophy.
2. While assessing a patient's skin, you identify a 4mm lesion that is asymmetric, has irregular
borders, and exhibits variegated coloring. What is the priority nursing intervention?
A. Document the finding as a common seborrheic keratosis
B. Instruct the patient to monitor the lesion for 30 days
C. Refer the patient for a biopsy to rule out malignant melanoma
D. Apply a topical steroid to reduce potential inflammation
Answer: C
CORRECT ANSWER : C
Rationale: The ABCDE criteria (Asymmetry, Border, Color, Diameter, Evolution) suggest a high
suspicion for malignant melanoma, requiring urgent biopsy for definitive diagnosis. Seborrheic
keratoses are typically well-demarcated and uniform, making option A incorrect. Observation is
dangerous in the presence of suspicious markers, and topical steroids are inappropriate for
undiagnosed pigmented lesions.
3. During an abdominal assessment, you auscultate high-pitched, rushing bowel sounds in the right
lower quadrant, followed by periods of silence. Which clinical interpretation is most accurate?
A. Normal bowel activity
B. Early mechanical bowel obstruction
C. Paralytic ileus
D. Severe gastroenteritis
Answer: B
CORRECT ANSWER : B
Rationale: High-pitched, "tinkling" or rushing sounds indicate that the bowel is struggling to
move contents past an obstruction, which is a classic sign of early mechanical obstruction.
Normal sounds are clicks and gurgles, whereas a paralytic ileus would present with absent or
hypoactive sounds throughout. Gastroenteritis typically presents with hyperactive, continuous
sounds rather than the high-pitched, intermittent sounds described.
,4. A patient reports sharp, stabbing chest pain that worsens with deep inspiration and improves
when sitting forward. Which assessment finding would support a diagnosis of pericarditis?
A. An S3 gallop at the apex
B. A friction rub at the left sternal border
C. Distended neck veins and muffled heart sounds
D. A blowing holosystolic murmur
Answer: B
CORRECT ANSWER : B
Rationale: Pericarditis is characterized by a pericardial friction rub resulting from inflamed
layers of the pericardium rubbing together. An S3 gallop is associated with heart failure,
distended neck veins and muffled sounds indicate cardiac tamponade, and a holosystolic murmur
suggests valvular regurgitation, none of which are diagnostic of pericarditis.
5. When assessing the neck of a patient with suspected heart failure, you observe significant jugular
venous distention (JVD) even when the patient is sitting at a 45-degree angle. What is the
clinical significance of this?
A. Increased central venous pressure
B. Decreased venous return
C. Normal age-related physiological change
D. Acute carotid artery stenosis
Answer: A
CORRECT ANSWER : A
Rationale: JVD at 45 degrees indicates elevated central venous pressure, often caused by right-
sided heart failure or fluid volume overload. This is not a normal finding in healthy individuals,
and it is unrelated to carotid artery patency (stenosis), which would be assessed via auscultation
for bruits.
6. You are performing a respiratory assessment on a patient with chronic bronchitis. Which
findings are most likely during percussion and auscultation?
A. Hyperresonance and fine crackles
, B. Dullness and wheezing
C. Resonance and friction rubs
D. Dullness and diminished breath sounds
Answer: B
CORRECT ANSWER : B
Rationale: Chronic bronchitis involves mucus production and airway inflammation, leading to
areas of atelectasis or consolidation which present as dullness on percussion, and wheezing due
to narrowed airways. Hyperresonance is associated with emphysema (air trapping), not
bronchitis. Friction rubs are pleural, and diminished sounds are more typical of pleural effusion
or pneumothorax.
7. A patient presents with a history of "claudication." During the peripheral vascular assessment,
what findings would you expect to document?
A. Warm, edematous lower extremities with brown pigmentation
B. Diminished pedal pulses and thin, shiny skin with hair loss
C. Pitting edema that worsens throughout the day
D. Palpable cords along the saphenous veins
Answer: B
CORRECT ANSWER : B
Rationale: Claudication is a symptom of peripheral artery disease (PAD), which manifests as
restricted blood flow leading to diminished pulses, thin skin, and hair loss. Options A and C
describe venous insufficiency, and option D describes superficial thrombophlebitis.
8. Which assessment technique is most effective for detecting a diaphragmatic excursion of less
than 3 cm?
A. Light palpation of the chest wall
B. Percussion along the scapular line during inspiration and expiration
C. Auscultation of breath sounds at the base of the lungs
D. Inspection of the chest wall for symmetry
