NSG 3160 EXAM 2 - HEALTH
ASSESSMENT ADVANCED TOPICS.
QUESTIONS AND ANSWERS
1. During the assessment of a client’s respiratory system, the nurse notes a low-pitched,
snoring sound that clears with coughing. How should the nurse document this finding?
A. Sibilant wheezes
B. Sonorous rhonchi
C. Pleural friction rub
D. Coarse crackles
Answer: B
Conceptual Explanation: Sonorous rhonchi are low-pitched, continuous snoring sounds
caused by secretions in large airways and often clear with coughing, unlike crackles or
wheezes.
2. When auscultating the heart, the nurse identifies a split S2 sound. In which location is this
sound most likely to be heard?
A. Mitral area
,B. Tricuspid area
C. Aortic area
D. Pulmonic area
Answer: D
Conceptual Explanation: A split S2 is best heard over the pulmonic valve area (second left
intercostal space) because it relates to the closure of the aortic and pulmonic valves.
3. Which physical assessment technique is performed first when assessing the abdomen?
A. Palpation
B. Inspection
C. Auscultation
D. Percussion
Answer: B
Conceptual Explanation: The order for abdominal assessment is Inspection, Auscultation,
Percussion, and Palpation to avoid altering bowel sounds.
4. A nurse is assessing a client for deep vein thrombosis (DVT). Which finding would be most
suggestive of this condition?
A. Bilateral pedal edema
B. Diminished dorsalis pedis pulses
, C. Unilateral calf warmth and swelling
D. Brownish discoloration of the lower legs
Answer: C
Conceptual Explanation: Unilateral warmth, swelling, and redness are classic signs of
DVT, whereas bilateral edema often suggests heart failure.
5. A client presents with ‘barrel chest.’ This clinical finding is most commonly associated with
which underlying pathophysiology?
A. Fluid accumulation in the pleural space
B. Acute lobar pneumonia
C. Chronic hyperinflation of the lungs
D. Collapse of the alveoli
Answer: C
Conceptual Explanation: Barrel chest is characterized by an increased anteroposterior-to-
transverse diameter, typically caused by chronic air trapping in COPD.
6. While palpating the precordium, the nurse feels a sustained forceful thrusting of the
ventricle during systole. This should be documented as a:
A. Thrill
B. Heave or lift
C. Pulse deficit
ASSESSMENT ADVANCED TOPICS.
QUESTIONS AND ANSWERS
1. During the assessment of a client’s respiratory system, the nurse notes a low-pitched,
snoring sound that clears with coughing. How should the nurse document this finding?
A. Sibilant wheezes
B. Sonorous rhonchi
C. Pleural friction rub
D. Coarse crackles
Answer: B
Conceptual Explanation: Sonorous rhonchi are low-pitched, continuous snoring sounds
caused by secretions in large airways and often clear with coughing, unlike crackles or
wheezes.
2. When auscultating the heart, the nurse identifies a split S2 sound. In which location is this
sound most likely to be heard?
A. Mitral area
,B. Tricuspid area
C. Aortic area
D. Pulmonic area
Answer: D
Conceptual Explanation: A split S2 is best heard over the pulmonic valve area (second left
intercostal space) because it relates to the closure of the aortic and pulmonic valves.
3. Which physical assessment technique is performed first when assessing the abdomen?
A. Palpation
B. Inspection
C. Auscultation
D. Percussion
Answer: B
Conceptual Explanation: The order for abdominal assessment is Inspection, Auscultation,
Percussion, and Palpation to avoid altering bowel sounds.
4. A nurse is assessing a client for deep vein thrombosis (DVT). Which finding would be most
suggestive of this condition?
A. Bilateral pedal edema
B. Diminished dorsalis pedis pulses
, C. Unilateral calf warmth and swelling
D. Brownish discoloration of the lower legs
Answer: C
Conceptual Explanation: Unilateral warmth, swelling, and redness are classic signs of
DVT, whereas bilateral edema often suggests heart failure.
5. A client presents with ‘barrel chest.’ This clinical finding is most commonly associated with
which underlying pathophysiology?
A. Fluid accumulation in the pleural space
B. Acute lobar pneumonia
C. Chronic hyperinflation of the lungs
D. Collapse of the alveoli
Answer: C
Conceptual Explanation: Barrel chest is characterized by an increased anteroposterior-to-
transverse diameter, typically caused by chronic air trapping in COPD.
6. While palpating the precordium, the nurse feels a sustained forceful thrusting of the
ventricle during systole. This should be documented as a:
A. Thrill
B. Heave or lift
C. Pulse deficit
