Page |1
NU 136 EXAM 2 HEALTH ASSESSMENT ACTUAL EXAM [
QUESTION 1- 200] AND ANSWERS UPDATED 2026/2027|
100% VERIFIED|DETAILED RATIONALES –PASS
GUARANTEED A+ GRADED |INSTANT DOWNLOAD
Introduction:
Welcome to the comprehensive practice material for the NU 136 Exam 2 Health Assessment.
This resource is meticulously designed to support nursing students in mastering critical physical
examination and health history collection techniques. This practice set covers fundamental body
systems and advanced assessment methodologies, focusing on clinical reasoning, systematic data
gathering, and holistic patient evaluation. Preparing for NU 136 is crucial for developing the
foundational clinical competencies required to bridge theoretical knowledge with safe, bedside
nursing practice. By engaging with these original, scenario-based questions, candidates will
sharpen their ability to differentiate normal findings from abnormal pathological deviations,
recognize subtle clinical cues, and prioritize urgent health concerns. This material aligns strictly
with contemporary nursing education standards and official course objectives, ensuring that
learners build both confidence and accuracy. Detailed rationales accompany each question to
reinforce underlying physiological principles and clinical guidelines, empowering students to
achieve top-tier academic success and deliver exceptional patient-centered care.
Core Domains Covered:
1. HEENT (Head, Eyes, Ears, Nose, and Throat) Assessment: Evaluating cranial nerve function,
visual acuity, external and internal ocular structures, otoscopic landmarks, and oral cavity
integrity.
2. Respiratory System Assessment: Inspecting thoracic configuration, palpating tactile fremitus,
auscultating breath sounds, and identifying adventitious findings.
3. Cardiovascular System Assessment: Locating anatomical landmarks for auscultation,
identifying heart sounds, grading peripheral pulses, and assessing vascular perfusion.
4. Abdominal and Gastrointestinal Assessment: Performing the correct sequence of inspection,
auscultation, percussion, and palpation, and recognizing peritoneal irritation signs.
5. Neuromuscular and Musculoskeletal Assessment: Testing deep tendon reflexes, evaluating
muscle strength grading, assessing range of motion, and checking cerebellar coordination.
6. Integumentary, Lymphatic, and Breast Assessment: Evaluating skin lesions, skin turgor,
peripheral lymph node chains, and performing clinical breast examination techniques.
7. Mental Status and Psychosocial Assessment: Assessing cognitive function, mood, affect, level
of consciousness, and psychosocial well-being using standardized screening tools.
Questions Section
Question 1: A nursing student is performing an otoscopic examination on an adult patient. Which
technique is correct for straightening the ear canal during this procedure?
A) Pull the pinna straight down and back.
,Page |2
B) C) Pull the pinna up and back.
C) Pull the pinna straight out and forward.
D) Do not manipulate the pinna to prevent patient discomfort.
Rationale: The correct answer is C because, in adult patients, the ear canal is naturally curved
upward and backward. Pulling the pinna up and back straightens the S-shaped canal to provide
a clear view of the tympanic membrane. Option A is incorrect because pulling the pinna down
and back is the correct technique for infants and children under three years of age due to the
shorter, flatter Eustachian tube and canal. Options B and D are incorrect because they do not
align with anatomical guidelines for visualizing the adult tympanic membrane.
Question 2: While auscultating the breath sounds of a healthy adult, the nurse hears soft, low-
pitched sounds where inspiration is longer than expiration over most of the peripheral lung
fields. How should the nurse document these sounds?
A) Bronchial breath sounds
B) Bronchovesicular breath sounds
C) D) Vesicular breath sounds
D) Tracheal breath sounds
Rationale: The correct answer is D because vesicular breath sounds are soft, low-pitched,
rustling sounds heard over most peripheral lung fields where inspiration is longer than
expiration. Option A is incorrect because bronchial sounds are loud, high-pitched, and heard
primarily over the trachea with expiration lasting longer than inspiration. Option B is incorrect
because bronchovesicular sounds are moderate in pitch and intensity and heard over major
bronchi. Option D accurately matches vesicular characteristics.
Question 3: During a cardiovascular assessment, the nurse feels a distinct, palpable vibration
over the second intercostal space at the right sternal border. What does this physical finding
indicate?
A) Normal closure of the aortic valve
B) C) A thrill indicating turbulent blood flow
D) A normal heaving PMI (Point of Maximal Impulse)
Rationale: The correct answer is C because a palpable vibration, known as a thrill, signifies
turbulent blood flow usually associated with significant heart murmurs or valvular stenosis.
Option A is incorrect because valve closures produce heart sounds heard via stethoscope, not
palpable vibrations on the chest wall. Option B is incorrect because thrills are abnormal
findings, not normal variants. Option D is incorrect because the PMI is typically located at the
fifth intercostal space in the midclavicular line, not the second right intercostal space.
Question 4: The nurse is preparing to assess a patient's abdomen. Which of the following is the
correct sequence for abdominal assessment techniques?
A) Inspection, Palpation, Percussion, Auscultation
B) C) Inspection, Auscultation, Percussion, Palpation
C) Auscultation, Inspection, Palpation, Percussion
D) Percussion, Palpation, Auscultation, Inspection
Rationale: The correct answer is C because auscultation must be performed before percussion
and palpation in an abdominal assessment. Palpation and percussion can alter bowel motility
,Page |3
and alter bowel sounds, leading to inaccurate diagnostic findings. Option A, B, and D fail to
follow this golden rule of abdominal assessment sequence.
Question 5: A nurse assesses a patient's deep tendon reflexes and records a score of 4+ in the
patellar tendon. How should the nurse interpret this finding?
A) Hypoactive reflex without reinforcement
B) Normal, average reflex response
C) D) Hyperactive reflex with clonus, indicating central nervous system pathology
D) Sluggish response requiring re-testing
Rationale: The correct answer is D because a 4+ reflex grade indicates a very brisk response
accompanied by clonus, which is an abnormal finding strongly suggestive of central nervous
system disease or upper motor neuron lesions. Option A is incorrect because 0 or 1+ indicates
hypoactivity. Option B is incorrect because 2+ is the normal, average response. Option C is
incorrect because hyperactive with clonus is 4+, whereas 3+ is brisker than average without
clonus.
Question 6: When assessing skin turgor in an elderly patient, the nurse pinches the skin on the
dorsal aspect of the forearm and notices it remains elevated for several seconds after release.
What is the most accurate interpretation of this finding?
A) B) Dehydration and decreased skin elasticity
B) Normal age-related physiological improvement
C) Severe localized edema and fluid overload
D) Normal capillary refill time status
Rationale: The correct answer is B because poor skin turgor (tenting) indicates loss of
interstitial fluid (dehydration) and natural loss of subcutaneous tissue elasticity associated with
aging. Option A is incorrect because it misinterprets a pathological or age-related sign as
normal improvement. Option C is incorrect because edema causes tight, shiny skin that indents
rather than tents. Option D is incorrect because capillary refill measures peripheral vascular
perfusion, not tissue turgor.
Question 7: A patient reports difficulty hearing high-frequency tones during a whispered voice
test. Which cranial nerve is primarily being evaluated during this screening?
A) Cranial Nerve II (Optic)
B) C) Cranial Nerve VIII (Vestibulocochlear)
D) Cranial Nerve V (Trigeminal)
Rationale: The correct answer is C because Cranial Nerve VIII (Vestibulocochlear nerve) is
responsible for hearing and equilibrium. Option A is incorrect because Cranial Nerve II is for
vision. Option B is incorrect because Cranial Nerve V handles facial sensation and mastication.
Option D is incorrect because hearing acuity falls strictly under CN VIII assessment.
Question 8: The nurse is performing a respiratory assessment and notes an increased
anteroposterior-to-transverse chest diameter ratio of 1:1. This finding is most commonly
associated with which chronic condition?
A) Acute lobar pneumonia
B) C) Chronic obstructive pulmonary disease (COPD)
D) Uncomplicated pleural effusion
, Page |4
Rationale: The correct answer is C because a barrel chest configuration (1:1 ratio) results from
hyperinflation of the lungs, a hallmark sign of chronic obstructive pulmonary disease such as
emphysema. Option A is incorrect because pneumonia presents with localized consolidation
findings. Option B is incorrect because pleural effusion causes localized dullness and decreased
breath sounds without barrel chest deformity. Option D is incorrect because it does not cause
chronic structural thoracic changes.
Question 9: During an eye examination, the nurse notes that the patient's pupils constrict when
shifting gaze from a distant object to a near object. What term describes this physiological
response?
A) Direct light reflex
B) C) Accommodation
D) Consensual pupillary response
Rationale: The correct answer is C because accommodation refers to the adaptation of the eye
for near vision, demonstrated by pupillary constriction and convergence when focusing on a
close target. Option A is incorrect because the direct light reflex involves constriction when a
light shines directly into the eye. Option B is incorrect because consensual response refers to
constriction of the opposite pupil when light is shone into one eye. Option D is incorrect because
accommodation specifically addresses distance-to-near focus transitions.
Question 10: Which assessment technique is best for evaluating tactile fremitus on the posterior
thorax?
A) Percussing lightly with a pleximeter finger
B) C) Using the ulnar surface of the hands to feel for vibrations while the patient speaks
D) Placing the bell of the stethoscope over lung fields
Rationale: The correct answer is C because tactile fremitus is best detected by using the ulnar
edge of the hands or the base of the fingers to palpate symmetrical vibrations transmitted
through the bronchopulmonary system when the patient repeats words like ninety-nine. Option A
is incorrect because percussion evaluates tissue density, not vibrations. Option B is incorrect
because auscultation uses a stethoscope, not palpatory touch. Option D is incorrect because
tactile fremitus is a palpatory, not auscultatory, maneuver.
Question 11: A nurse is assessing a patient with right upper quadrant abdominal pain. Which
sign, when positive, strongly suggests acute cholecystitis during deep palpation?
A) McBurney point tenderness
B) C) Murphy sign
D) Rovsing sign
Rationale: The correct answer is C because Murphy sign (inspiratory arrest during deep
palpation of the right upper quadrant under the liver margin) indicates acute inflammation of the
gallbladder. Option A is incorrect because McBurney point tenderness is associated with acute
appendicitis. Option B is incorrect because Rovsing sign indicates referred rebound tenderness
in appendicitis. Option D is incorrect because it tests lower quadrant pathology.
Question 12: Which cranial nerve is tested when the nurse asks a patient to smile, frown, and
puff out their cheeks?
A) Cranial Nerve V (Trigeminal)
B) C) Cranial Nerve VII (Facial)
NU 136 EXAM 2 HEALTH ASSESSMENT ACTUAL EXAM [
QUESTION 1- 200] AND ANSWERS UPDATED 2026/2027|
100% VERIFIED|DETAILED RATIONALES –PASS
GUARANTEED A+ GRADED |INSTANT DOWNLOAD
Introduction:
Welcome to the comprehensive practice material for the NU 136 Exam 2 Health Assessment.
This resource is meticulously designed to support nursing students in mastering critical physical
examination and health history collection techniques. This practice set covers fundamental body
systems and advanced assessment methodologies, focusing on clinical reasoning, systematic data
gathering, and holistic patient evaluation. Preparing for NU 136 is crucial for developing the
foundational clinical competencies required to bridge theoretical knowledge with safe, bedside
nursing practice. By engaging with these original, scenario-based questions, candidates will
sharpen their ability to differentiate normal findings from abnormal pathological deviations,
recognize subtle clinical cues, and prioritize urgent health concerns. This material aligns strictly
with contemporary nursing education standards and official course objectives, ensuring that
learners build both confidence and accuracy. Detailed rationales accompany each question to
reinforce underlying physiological principles and clinical guidelines, empowering students to
achieve top-tier academic success and deliver exceptional patient-centered care.
Core Domains Covered:
1. HEENT (Head, Eyes, Ears, Nose, and Throat) Assessment: Evaluating cranial nerve function,
visual acuity, external and internal ocular structures, otoscopic landmarks, and oral cavity
integrity.
2. Respiratory System Assessment: Inspecting thoracic configuration, palpating tactile fremitus,
auscultating breath sounds, and identifying adventitious findings.
3. Cardiovascular System Assessment: Locating anatomical landmarks for auscultation,
identifying heart sounds, grading peripheral pulses, and assessing vascular perfusion.
4. Abdominal and Gastrointestinal Assessment: Performing the correct sequence of inspection,
auscultation, percussion, and palpation, and recognizing peritoneal irritation signs.
5. Neuromuscular and Musculoskeletal Assessment: Testing deep tendon reflexes, evaluating
muscle strength grading, assessing range of motion, and checking cerebellar coordination.
6. Integumentary, Lymphatic, and Breast Assessment: Evaluating skin lesions, skin turgor,
peripheral lymph node chains, and performing clinical breast examination techniques.
7. Mental Status and Psychosocial Assessment: Assessing cognitive function, mood, affect, level
of consciousness, and psychosocial well-being using standardized screening tools.
Questions Section
Question 1: A nursing student is performing an otoscopic examination on an adult patient. Which
technique is correct for straightening the ear canal during this procedure?
A) Pull the pinna straight down and back.
,Page |2
B) C) Pull the pinna up and back.
C) Pull the pinna straight out and forward.
D) Do not manipulate the pinna to prevent patient discomfort.
Rationale: The correct answer is C because, in adult patients, the ear canal is naturally curved
upward and backward. Pulling the pinna up and back straightens the S-shaped canal to provide
a clear view of the tympanic membrane. Option A is incorrect because pulling the pinna down
and back is the correct technique for infants and children under three years of age due to the
shorter, flatter Eustachian tube and canal. Options B and D are incorrect because they do not
align with anatomical guidelines for visualizing the adult tympanic membrane.
Question 2: While auscultating the breath sounds of a healthy adult, the nurse hears soft, low-
pitched sounds where inspiration is longer than expiration over most of the peripheral lung
fields. How should the nurse document these sounds?
A) Bronchial breath sounds
B) Bronchovesicular breath sounds
C) D) Vesicular breath sounds
D) Tracheal breath sounds
Rationale: The correct answer is D because vesicular breath sounds are soft, low-pitched,
rustling sounds heard over most peripheral lung fields where inspiration is longer than
expiration. Option A is incorrect because bronchial sounds are loud, high-pitched, and heard
primarily over the trachea with expiration lasting longer than inspiration. Option B is incorrect
because bronchovesicular sounds are moderate in pitch and intensity and heard over major
bronchi. Option D accurately matches vesicular characteristics.
Question 3: During a cardiovascular assessment, the nurse feels a distinct, palpable vibration
over the second intercostal space at the right sternal border. What does this physical finding
indicate?
A) Normal closure of the aortic valve
B) C) A thrill indicating turbulent blood flow
D) A normal heaving PMI (Point of Maximal Impulse)
Rationale: The correct answer is C because a palpable vibration, known as a thrill, signifies
turbulent blood flow usually associated with significant heart murmurs or valvular stenosis.
Option A is incorrect because valve closures produce heart sounds heard via stethoscope, not
palpable vibrations on the chest wall. Option B is incorrect because thrills are abnormal
findings, not normal variants. Option D is incorrect because the PMI is typically located at the
fifth intercostal space in the midclavicular line, not the second right intercostal space.
Question 4: The nurse is preparing to assess a patient's abdomen. Which of the following is the
correct sequence for abdominal assessment techniques?
A) Inspection, Palpation, Percussion, Auscultation
B) C) Inspection, Auscultation, Percussion, Palpation
C) Auscultation, Inspection, Palpation, Percussion
D) Percussion, Palpation, Auscultation, Inspection
Rationale: The correct answer is C because auscultation must be performed before percussion
and palpation in an abdominal assessment. Palpation and percussion can alter bowel motility
,Page |3
and alter bowel sounds, leading to inaccurate diagnostic findings. Option A, B, and D fail to
follow this golden rule of abdominal assessment sequence.
Question 5: A nurse assesses a patient's deep tendon reflexes and records a score of 4+ in the
patellar tendon. How should the nurse interpret this finding?
A) Hypoactive reflex without reinforcement
B) Normal, average reflex response
C) D) Hyperactive reflex with clonus, indicating central nervous system pathology
D) Sluggish response requiring re-testing
Rationale: The correct answer is D because a 4+ reflex grade indicates a very brisk response
accompanied by clonus, which is an abnormal finding strongly suggestive of central nervous
system disease or upper motor neuron lesions. Option A is incorrect because 0 or 1+ indicates
hypoactivity. Option B is incorrect because 2+ is the normal, average response. Option C is
incorrect because hyperactive with clonus is 4+, whereas 3+ is brisker than average without
clonus.
Question 6: When assessing skin turgor in an elderly patient, the nurse pinches the skin on the
dorsal aspect of the forearm and notices it remains elevated for several seconds after release.
What is the most accurate interpretation of this finding?
A) B) Dehydration and decreased skin elasticity
B) Normal age-related physiological improvement
C) Severe localized edema and fluid overload
D) Normal capillary refill time status
Rationale: The correct answer is B because poor skin turgor (tenting) indicates loss of
interstitial fluid (dehydration) and natural loss of subcutaneous tissue elasticity associated with
aging. Option A is incorrect because it misinterprets a pathological or age-related sign as
normal improvement. Option C is incorrect because edema causes tight, shiny skin that indents
rather than tents. Option D is incorrect because capillary refill measures peripheral vascular
perfusion, not tissue turgor.
Question 7: A patient reports difficulty hearing high-frequency tones during a whispered voice
test. Which cranial nerve is primarily being evaluated during this screening?
A) Cranial Nerve II (Optic)
B) C) Cranial Nerve VIII (Vestibulocochlear)
D) Cranial Nerve V (Trigeminal)
Rationale: The correct answer is C because Cranial Nerve VIII (Vestibulocochlear nerve) is
responsible for hearing and equilibrium. Option A is incorrect because Cranial Nerve II is for
vision. Option B is incorrect because Cranial Nerve V handles facial sensation and mastication.
Option D is incorrect because hearing acuity falls strictly under CN VIII assessment.
Question 8: The nurse is performing a respiratory assessment and notes an increased
anteroposterior-to-transverse chest diameter ratio of 1:1. This finding is most commonly
associated with which chronic condition?
A) Acute lobar pneumonia
B) C) Chronic obstructive pulmonary disease (COPD)
D) Uncomplicated pleural effusion
, Page |4
Rationale: The correct answer is C because a barrel chest configuration (1:1 ratio) results from
hyperinflation of the lungs, a hallmark sign of chronic obstructive pulmonary disease such as
emphysema. Option A is incorrect because pneumonia presents with localized consolidation
findings. Option B is incorrect because pleural effusion causes localized dullness and decreased
breath sounds without barrel chest deformity. Option D is incorrect because it does not cause
chronic structural thoracic changes.
Question 9: During an eye examination, the nurse notes that the patient's pupils constrict when
shifting gaze from a distant object to a near object. What term describes this physiological
response?
A) Direct light reflex
B) C) Accommodation
D) Consensual pupillary response
Rationale: The correct answer is C because accommodation refers to the adaptation of the eye
for near vision, demonstrated by pupillary constriction and convergence when focusing on a
close target. Option A is incorrect because the direct light reflex involves constriction when a
light shines directly into the eye. Option B is incorrect because consensual response refers to
constriction of the opposite pupil when light is shone into one eye. Option D is incorrect because
accommodation specifically addresses distance-to-near focus transitions.
Question 10: Which assessment technique is best for evaluating tactile fremitus on the posterior
thorax?
A) Percussing lightly with a pleximeter finger
B) C) Using the ulnar surface of the hands to feel for vibrations while the patient speaks
D) Placing the bell of the stethoscope over lung fields
Rationale: The correct answer is C because tactile fremitus is best detected by using the ulnar
edge of the hands or the base of the fingers to palpate symmetrical vibrations transmitted
through the bronchopulmonary system when the patient repeats words like ninety-nine. Option A
is incorrect because percussion evaluates tissue density, not vibrations. Option B is incorrect
because auscultation uses a stethoscope, not palpatory touch. Option D is incorrect because
tactile fremitus is a palpatory, not auscultatory, maneuver.
Question 11: A nurse is assessing a patient with right upper quadrant abdominal pain. Which
sign, when positive, strongly suggests acute cholecystitis during deep palpation?
A) McBurney point tenderness
B) C) Murphy sign
D) Rovsing sign
Rationale: The correct answer is C because Murphy sign (inspiratory arrest during deep
palpation of the right upper quadrant under the liver margin) indicates acute inflammation of the
gallbladder. Option A is incorrect because McBurney point tenderness is associated with acute
appendicitis. Option B is incorrect because Rovsing sign indicates referred rebound tenderness
in appendicitis. Option D is incorrect because it tests lower quadrant pathology.
Question 12: Which cranial nerve is tested when the nurse asks a patient to smile, frown, and
puff out their cheeks?
A) Cranial Nerve V (Trigeminal)
B) C) Cranial Nerve VII (Facial)
