NSG 3160 HEALTH ASSESSMENT -
EXAM 2 COMPREHENSIVE QUESTIONS
AND ANSWERS
1. During a respiratory assessment, the nurse notes a coarse, low-pitched, snoring sound that
clears significantly after the patient coughs. How should this finding be documented?
A. Fine crackles
B. Pleural friction rub
C. Rhonchi (Sonorous wheeze)
D. Rhonchi (Sibilant wheeze)
Answer: C
Conceptual Explanation: Sonorous wheezes (rhonchi) are low-pitched, snoring sounds
caused by airflow obstruction in larger airways, often by mucus, and typically clear with
coughing.
2. When auscultating the heart, the nurse identifies a blowing, swooshing sound heard best
at the left 2nd intercostal space. Which valve area is being assessed?
A. Aortic
B. Tricuspid
,C. Pulmonic
D. Mitral
Answer: C
Conceptual Explanation: The pulmonic valve area is located at the second left intercostal
space at the sternal border.
3. A patient presents with sharp, stabbing chest pain that increases with deep inspiration and
decreases when sitting forward. What is the most likely cause?
A. Myocardial infarction
B. Pericarditis
C. Angina pectoris
D. Heart failure
Answer: B
Conceptual Explanation: Pericarditis typically causes chest pain that is pleuritic (worse
with breathing) and relieved by sitting up and leaning forward.
4. Which physical examination finding is most characteristic of chronic arterial insufficiency in
the lower extremities?
A. Painless ulcers on the medial malleolus
B. Brownish discoloration of the skin
C. Thin, shiny skin with loss of hair
, D. Pitting edema 3+
Answer: C
Conceptual Explanation: Chronic arterial insufficiency leads to trophic changes like thin,
shiny, atrophic skin, hair loss on the legs, and thickened nails due to poor oxygenation.
5. During an abdominal assessment, why is auscultation performed before percussion and
palpation?
A. To allow the patient to relax before more invasive maneuvers.
B. To identify areas of tenderness first.
C. To prevent distortion of bowel sounds by mechanical stimulation.
D. To ensure the bladder is empty before palpating.
Answer: C
Conceptual Explanation: Palpation and percussion can stimulate peristalsis, resulting in
false-positive hyperactive bowel sounds if performed before auscultation.
6. A nurse is assessing a 70-year-old patient and notes a high-pitched, scratchy sound during
both systole and diastole while the patient holds their breath. This indicates:
A. S3 and S4 gallops
B. A pleural friction rub
C. A Grade III murmur
D. A pericardial friction rub
EXAM 2 COMPREHENSIVE QUESTIONS
AND ANSWERS
1. During a respiratory assessment, the nurse notes a coarse, low-pitched, snoring sound that
clears significantly after the patient coughs. How should this finding be documented?
A. Fine crackles
B. Pleural friction rub
C. Rhonchi (Sonorous wheeze)
D. Rhonchi (Sibilant wheeze)
Answer: C
Conceptual Explanation: Sonorous wheezes (rhonchi) are low-pitched, snoring sounds
caused by airflow obstruction in larger airways, often by mucus, and typically clear with
coughing.
2. When auscultating the heart, the nurse identifies a blowing, swooshing sound heard best
at the left 2nd intercostal space. Which valve area is being assessed?
A. Aortic
B. Tricuspid
,C. Pulmonic
D. Mitral
Answer: C
Conceptual Explanation: The pulmonic valve area is located at the second left intercostal
space at the sternal border.
3. A patient presents with sharp, stabbing chest pain that increases with deep inspiration and
decreases when sitting forward. What is the most likely cause?
A. Myocardial infarction
B. Pericarditis
C. Angina pectoris
D. Heart failure
Answer: B
Conceptual Explanation: Pericarditis typically causes chest pain that is pleuritic (worse
with breathing) and relieved by sitting up and leaning forward.
4. Which physical examination finding is most characteristic of chronic arterial insufficiency in
the lower extremities?
A. Painless ulcers on the medial malleolus
B. Brownish discoloration of the skin
C. Thin, shiny skin with loss of hair
, D. Pitting edema 3+
Answer: C
Conceptual Explanation: Chronic arterial insufficiency leads to trophic changes like thin,
shiny, atrophic skin, hair loss on the legs, and thickened nails due to poor oxygenation.
5. During an abdominal assessment, why is auscultation performed before percussion and
palpation?
A. To allow the patient to relax before more invasive maneuvers.
B. To identify areas of tenderness first.
C. To prevent distortion of bowel sounds by mechanical stimulation.
D. To ensure the bladder is empty before palpating.
Answer: C
Conceptual Explanation: Palpation and percussion can stimulate peristalsis, resulting in
false-positive hyperactive bowel sounds if performed before auscultation.
6. A nurse is assessing a 70-year-old patient and notes a high-pitched, scratchy sound during
both systole and diastole while the patient holds their breath. This indicates:
A. S3 and S4 gallops
B. A pleural friction rub
C. A Grade III murmur
D. A pericardial friction rub
