UT Arlington NURS 3320 Holistic Health Assessment Exam 2 (pdf) |
2026/2027 | Health Assessment Q&A | Nursing
1. When performing a cardiovascular assessment, the nurse auscultates the
heart sounds. Which of the following correctly describes the location and
cause of the S1 heart sound?
A) Closure of the semilunar valves at the end of systole
B) Closure of the atrioventricular (AV) valves at the beginning of systole
C) Rapid ventricular filling during diastole
D) Atrial contraction just before systole
Correct Answer: Closure of the atrioventricular (AV) valves at the beginning
of systole
Rationale: The S1 heart sound ("lub") is produced by the closure of the
atrioventricular (mitral and tricuspid) valves at the beginning of ventricular
systole. S2 ("dub") is the closure of the semilunar (aortic and pulmonic)
valves at the end of systole.
2. A nurse is assessing a patient's jugular venous pressure (JVP). The patient
is positioned supine with the head of the bed elevated 30-45 degrees. The
nurse observes the jugular venous pulsation 4 cm above the sternal angle.
This finding indicates:
A) Normal JVP
B) Elevated JVP suggestive of right-sided heart failure
C) Elevated JVP suggestive of left-sided heart failure
D) Decreased JVP suggestive of hypovolemia
Correct Answer: Elevated JVP suggestive of right-sided heart failure
,Rationale: Normal JVP is typically less than 3-4 cm above the sternal angle.
An elevated JVP (>4 cm) suggests increased central venous pressure, which
is commonly seen in right-sided heart failure, fluid overload, or cardiac
tamponade.
3. The nurse is assessing a patient's carotid arteries. Which of the following
is the correct sequence for assessing the carotid artery?
A) Palpate both carotid arteries simultaneously, then auscultate for bruits
B) Auscultate for bruits, then palpate gently one side at a time
C) Palpate one side, then the other, then auscultate for bruits
D) Auscultate for bruits, then palpate both sides simultaneously
Correct Answer: Auscultate for bruits, then palpate gently one side at a time
Rationale: The carotid artery should be auscultated for bruits before
palpation to avoid compression and alteration of blood flow. Palpation should
be done gently, and both sides should never be palpated simultaneously to
prevent compromising cerebral blood flow.
4. A patient presents with chest pain that is relieved by rest and worsened
with exertion. The nurse suspects this is due to:
A) Pericarditis
B) Stable angina
C) Unstable angina
D) Myocardial infarction
Correct Answer: Stable angina
Rationale: Stable angina is characterized by chest pain or discomfort that
occurs with physical exertion or emotional stress and is relieved by rest or
,nitroglycerin. Unstable angina occurs at rest or with minimal exertion and is
not relieved by rest.
5. A nurse auscultates a patient's heart and hears a high-pitched, blowing
sound best heard with the diaphragm at the apex. This is most likely:
A) An S3 gallop
B) A murmur of mitral stenosis
C) A murmur of mitral regurgitation
D) A pericardial friction rub
Correct Answer: A murmur of mitral regurgitation
Rationale: Mitral regurgitation produces a high-pitched, blowing, holosystolic
murmur best heard at the apex (fifth intercostal space, midclavicular line)
with the diaphragm. Mitral stenosis produces a low-pitched, rumbling
diastolic murmur heard with the bell.
6. A patient reports a history of intermittent claudication. The nurse
understands that this symptom is most commonly associated with:
A) Venous insufficiency
B) Peripheral arterial disease
C) Deep vein thrombosis
D) Lymphedema
Correct Answer: Peripheral arterial disease
Rationale: Intermittent claudication is a cramping pain in the calf or thigh
that occurs with exercise and is relieved by rest. It is a classic symptom of
peripheral arterial disease (PAD) caused by atherosclerosis.
, 7. Which of the following assessment findings is most consistent with chronic
arterial insufficiency?
A) Warm, edematous extremities with brownish discoloration
B) Pallor with elevation, dependent rubor, and thick, shiny nails
C) Bilateral, pitting edema with normal skin color
D) Superficial, dilated, tortuous veins
Correct Answer: Pallor with elevation, dependent rubor, and thick, shiny nails
Rationale: Chronic arterial insufficiency presents with pallor of the extremity
when elevated (elevation pallor), rubor (redness) when dependent, thick,
shiny, hairless skin, and thickened nails. Venous insufficiency presents with
edema, brownish discoloration, and stasis dermatitis.
8. The nurse is assessing a patient for peripheral venous disease. Which of
the following findings would the nurse expect?
A) Thin, shiny skin with hair loss
B) Pallor on elevation of the extremity
C) Brownish discoloration and edema of the lower extremities
D) Cool, pale extremities with decreased pulses
Correct Answer: Brownish discoloration and edema of the lower extremities
Rationale: Peripheral venous disease is characterized by edema, brownish
discoloration (hemosiderin deposition) around the ankles, stasis dermatitis,
and sometimes ulceration. Arterial insufficiency presents with thin, shiny
skin, hair loss, and pallor.
2026/2027 | Health Assessment Q&A | Nursing
1. When performing a cardiovascular assessment, the nurse auscultates the
heart sounds. Which of the following correctly describes the location and
cause of the S1 heart sound?
A) Closure of the semilunar valves at the end of systole
B) Closure of the atrioventricular (AV) valves at the beginning of systole
C) Rapid ventricular filling during diastole
D) Atrial contraction just before systole
Correct Answer: Closure of the atrioventricular (AV) valves at the beginning
of systole
Rationale: The S1 heart sound ("lub") is produced by the closure of the
atrioventricular (mitral and tricuspid) valves at the beginning of ventricular
systole. S2 ("dub") is the closure of the semilunar (aortic and pulmonic)
valves at the end of systole.
2. A nurse is assessing a patient's jugular venous pressure (JVP). The patient
is positioned supine with the head of the bed elevated 30-45 degrees. The
nurse observes the jugular venous pulsation 4 cm above the sternal angle.
This finding indicates:
A) Normal JVP
B) Elevated JVP suggestive of right-sided heart failure
C) Elevated JVP suggestive of left-sided heart failure
D) Decreased JVP suggestive of hypovolemia
Correct Answer: Elevated JVP suggestive of right-sided heart failure
,Rationale: Normal JVP is typically less than 3-4 cm above the sternal angle.
An elevated JVP (>4 cm) suggests increased central venous pressure, which
is commonly seen in right-sided heart failure, fluid overload, or cardiac
tamponade.
3. The nurse is assessing a patient's carotid arteries. Which of the following
is the correct sequence for assessing the carotid artery?
A) Palpate both carotid arteries simultaneously, then auscultate for bruits
B) Auscultate for bruits, then palpate gently one side at a time
C) Palpate one side, then the other, then auscultate for bruits
D) Auscultate for bruits, then palpate both sides simultaneously
Correct Answer: Auscultate for bruits, then palpate gently one side at a time
Rationale: The carotid artery should be auscultated for bruits before
palpation to avoid compression and alteration of blood flow. Palpation should
be done gently, and both sides should never be palpated simultaneously to
prevent compromising cerebral blood flow.
4. A patient presents with chest pain that is relieved by rest and worsened
with exertion. The nurse suspects this is due to:
A) Pericarditis
B) Stable angina
C) Unstable angina
D) Myocardial infarction
Correct Answer: Stable angina
Rationale: Stable angina is characterized by chest pain or discomfort that
occurs with physical exertion or emotional stress and is relieved by rest or
,nitroglycerin. Unstable angina occurs at rest or with minimal exertion and is
not relieved by rest.
5. A nurse auscultates a patient's heart and hears a high-pitched, blowing
sound best heard with the diaphragm at the apex. This is most likely:
A) An S3 gallop
B) A murmur of mitral stenosis
C) A murmur of mitral regurgitation
D) A pericardial friction rub
Correct Answer: A murmur of mitral regurgitation
Rationale: Mitral regurgitation produces a high-pitched, blowing, holosystolic
murmur best heard at the apex (fifth intercostal space, midclavicular line)
with the diaphragm. Mitral stenosis produces a low-pitched, rumbling
diastolic murmur heard with the bell.
6. A patient reports a history of intermittent claudication. The nurse
understands that this symptom is most commonly associated with:
A) Venous insufficiency
B) Peripheral arterial disease
C) Deep vein thrombosis
D) Lymphedema
Correct Answer: Peripheral arterial disease
Rationale: Intermittent claudication is a cramping pain in the calf or thigh
that occurs with exercise and is relieved by rest. It is a classic symptom of
peripheral arterial disease (PAD) caused by atherosclerosis.
, 7. Which of the following assessment findings is most consistent with chronic
arterial insufficiency?
A) Warm, edematous extremities with brownish discoloration
B) Pallor with elevation, dependent rubor, and thick, shiny nails
C) Bilateral, pitting edema with normal skin color
D) Superficial, dilated, tortuous veins
Correct Answer: Pallor with elevation, dependent rubor, and thick, shiny nails
Rationale: Chronic arterial insufficiency presents with pallor of the extremity
when elevated (elevation pallor), rubor (redness) when dependent, thick,
shiny, hairless skin, and thickened nails. Venous insufficiency presents with
edema, brownish discoloration, and stasis dermatitis.
8. The nurse is assessing a patient for peripheral venous disease. Which of
the following findings would the nurse expect?
A) Thin, shiny skin with hair loss
B) Pallor on elevation of the extremity
C) Brownish discoloration and edema of the lower extremities
D) Cool, pale extremities with decreased pulses
Correct Answer: Brownish discoloration and edema of the lower extremities
Rationale: Peripheral venous disease is characterized by edema, brownish
discoloration (hemosiderin deposition) around the ankles, stasis dermatitis,
and sometimes ulceration. Arterial insufficiency presents with thin, shiny
skin, hair loss, and pallor.
