NR304/NR 304 Final Exam V2 | Health Assessment
II Q&A with Rationale | Chamberlain University
1. During an abdominal assessment, in which order should the nurse perform the
examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Palpation, Percussion, Auscultation, Inspection
C. Auscultation, Inspection, Percussion, Palpation
D. Inspection, Auscultation, Percussion, Palpation
Correct Answer: D
Explanation: The standard sequence for an abdominal assessment is inspection, followed
by auscultation, percussion, and then palpation. This order is critical because percussion
and palpation can stimulate bowel activity and alter the frequency of bowel sounds. By
auscultating before physically manipulating the abdomen, the nurse obtains a more
accurate representation of the patient’s baseline bowel function.
2. When percussing the abdomen, the nurse expects to hear which sound over most of the
abdominal area?
A. Resonance
B. Tympany
C. Dullness
,D. Hyperresonance
Correct Answer: B
Explanation: Tympany is the predominant sound heard during percussion of the abdomen
because of the presence of air in the stomach and intestines. Dullness is typically noted
over solid organs like the liver or spleen, or over a distended bladder. Hyperresonance is
usually associated with gaseous distension or hyperinflated lungs, whereas resonance is a
normal lung sound.
3. The nurse is assessing for Murphy’s sign. Which condition is associated with a positive
result?
A. Appendicitis
B. Cholecystitis
C. Splenomegaly
D. Ascites
Correct Answer: B
Explanation: A positive Murphy’s sign occurs when a patient experiences sharp pain and
abruptly stops inspiration while the nurse palpates the lower liver border. This finding is
highly suggestive of inflammation of the gallbladder, known as cholecystitis. It is distinct
from assessments for appendicitis, which often involve Rebound tenderness or the Psoas
sign.
, 4. Which cranial nerve is responsible for visual acuity?
A. Cranial Nerve I
B. Cranial Nerve II
C. Cranial Nerve III
D. Cranial Nerve IV
Correct Answer: B
Explanation: Cranial Nerve II, also known as the Optic nerve, is responsible for
transmitting visual information from the retina to the brain. Assessment of this nerve
typically involves using a Snellen chart for distance vision or a Jaeger card for near vision.
The other nerves listed are responsible for smell (CN I) and various eye movements (CN III
and IV).
5. To assess the trigeminal nerve (CN V), which action should the nurse ask the patient to
perform?
A. Clench the teeth
B. Shrug the shoulders
C. Stick out the tongue
D. Smile and puff out the cheeks
Correct Answer: A
II Q&A with Rationale | Chamberlain University
1. During an abdominal assessment, in which order should the nurse perform the
examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Palpation, Percussion, Auscultation, Inspection
C. Auscultation, Inspection, Percussion, Palpation
D. Inspection, Auscultation, Percussion, Palpation
Correct Answer: D
Explanation: The standard sequence for an abdominal assessment is inspection, followed
by auscultation, percussion, and then palpation. This order is critical because percussion
and palpation can stimulate bowel activity and alter the frequency of bowel sounds. By
auscultating before physically manipulating the abdomen, the nurse obtains a more
accurate representation of the patient’s baseline bowel function.
2. When percussing the abdomen, the nurse expects to hear which sound over most of the
abdominal area?
A. Resonance
B. Tympany
C. Dullness
,D. Hyperresonance
Correct Answer: B
Explanation: Tympany is the predominant sound heard during percussion of the abdomen
because of the presence of air in the stomach and intestines. Dullness is typically noted
over solid organs like the liver or spleen, or over a distended bladder. Hyperresonance is
usually associated with gaseous distension or hyperinflated lungs, whereas resonance is a
normal lung sound.
3. The nurse is assessing for Murphy’s sign. Which condition is associated with a positive
result?
A. Appendicitis
B. Cholecystitis
C. Splenomegaly
D. Ascites
Correct Answer: B
Explanation: A positive Murphy’s sign occurs when a patient experiences sharp pain and
abruptly stops inspiration while the nurse palpates the lower liver border. This finding is
highly suggestive of inflammation of the gallbladder, known as cholecystitis. It is distinct
from assessments for appendicitis, which often involve Rebound tenderness or the Psoas
sign.
, 4. Which cranial nerve is responsible for visual acuity?
A. Cranial Nerve I
B. Cranial Nerve II
C. Cranial Nerve III
D. Cranial Nerve IV
Correct Answer: B
Explanation: Cranial Nerve II, also known as the Optic nerve, is responsible for
transmitting visual information from the retina to the brain. Assessment of this nerve
typically involves using a Snellen chart for distance vision or a Jaeger card for near vision.
The other nerves listed are responsible for smell (CN I) and various eye movements (CN III
and IV).
5. To assess the trigeminal nerve (CN V), which action should the nurse ask the patient to
perform?
A. Clench the teeth
B. Shrug the shoulders
C. Stick out the tongue
D. Smile and puff out the cheeks
Correct Answer: A
