NR304/NR 304 Final Exam V1 | Health Assessment
II Q&A with Rationale | Chamberlain University
1. During a neurological assessment, the nurse asks the patient to smile, frown, and puff out
their cheeks. Which cranial nerve is being evaluated?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve VII (Facial)
C. Cranial Nerve X (Vagus)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: B
Explanation: Cranial Nerve VII, the facial nerve, is responsible for motor movements of the
face such as smiling and frowning. Testing for symmetry during these maneuvers helps
identify potential nerve damage or paralysis, such as Bell’s palsy. Cranial Nerve V involves
facial sensation and mastication, while CN X and XII involve the throat and tongue
movements respectively.
2. A nurse is performing an abdominal assessment. In which order should the physical
examination techniques be performed?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
,D. Percussion, Palpation, Auscultation, Inspection
Correct Answer: A
Explanation: The correct sequence for an abdominal assessment is inspection,
auscultation, percussion, and then palpation. Auscultation is performed before percussion
and palpation because manual manipulation of the abdomen can stimulate peristalsis and
alter the frequency of bowel sounds. This specific order ensures that the nurse obtains the
most accurate data regarding the patient’s gastrointestinal function.
3. The nurse is assessing a patient’s deep tendon reflexes and notes a very brisk, hyperactive
response with clonus. How should this be documented?
A. 1+
B. 2+
C. 3+
D. 4+
Correct Answer: D
Explanation: A reflex score of 4+ indicates a very brisk, hyperactive response that is often
associated with disease and may include clonus. A score of 2+ is considered normal or
average, while 1+ is diminished. Documentation of these findings is critical for identifying
upper motor neuron lesions or electrolyte imbalances.
, 4. Which anatomical landmark is used to locate the second intercostal space to begin
auscultating heart sounds?
A. Angle of Louis (Sternal Angle)
B. Xiphoid process
C. Suprasternal notch
D. Costal margin
Correct Answer: A
Explanation: The Angle of Louis, or the sternal angle, is the articulation of the manubrium
and the body of the sternum and is continuous with the second rib. By palpating this
landmark, the nurse can easily identify the second intercostal space on either side of the
sternum. This serves as the starting point for cardiac auscultation, specifically for the aortic
and pulmonic areas.
5. The nurse is assessing a patient for a potential pneumothorax. Which finding during
percussion of the affected side would the nurse expect?
A. Resonance
B. Dullness
C. Hyperresonance
D. Tympany
Correct Answer: C
II Q&A with Rationale | Chamberlain University
1. During a neurological assessment, the nurse asks the patient to smile, frown, and puff out
their cheeks. Which cranial nerve is being evaluated?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve VII (Facial)
C. Cranial Nerve X (Vagus)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: B
Explanation: Cranial Nerve VII, the facial nerve, is responsible for motor movements of the
face such as smiling and frowning. Testing for symmetry during these maneuvers helps
identify potential nerve damage or paralysis, such as Bell’s palsy. Cranial Nerve V involves
facial sensation and mastication, while CN X and XII involve the throat and tongue
movements respectively.
2. A nurse is performing an abdominal assessment. In which order should the physical
examination techniques be performed?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
,D. Percussion, Palpation, Auscultation, Inspection
Correct Answer: A
Explanation: The correct sequence for an abdominal assessment is inspection,
auscultation, percussion, and then palpation. Auscultation is performed before percussion
and palpation because manual manipulation of the abdomen can stimulate peristalsis and
alter the frequency of bowel sounds. This specific order ensures that the nurse obtains the
most accurate data regarding the patient’s gastrointestinal function.
3. The nurse is assessing a patient’s deep tendon reflexes and notes a very brisk, hyperactive
response with clonus. How should this be documented?
A. 1+
B. 2+
C. 3+
D. 4+
Correct Answer: D
Explanation: A reflex score of 4+ indicates a very brisk, hyperactive response that is often
associated with disease and may include clonus. A score of 2+ is considered normal or
average, while 1+ is diminished. Documentation of these findings is critical for identifying
upper motor neuron lesions or electrolyte imbalances.
, 4. Which anatomical landmark is used to locate the second intercostal space to begin
auscultating heart sounds?
A. Angle of Louis (Sternal Angle)
B. Xiphoid process
C. Suprasternal notch
D. Costal margin
Correct Answer: A
Explanation: The Angle of Louis, or the sternal angle, is the articulation of the manubrium
and the body of the sternum and is continuous with the second rib. By palpating this
landmark, the nurse can easily identify the second intercostal space on either side of the
sternum. This serves as the starting point for cardiac auscultation, specifically for the aortic
and pulmonic areas.
5. The nurse is assessing a patient for a potential pneumothorax. Which finding during
percussion of the affected side would the nurse expect?
A. Resonance
B. Dullness
C. Hyperresonance
D. Tympany
Correct Answer: C
