NRS 420 Exam 2 V3 | NRS 420 Health Assessment |
Actual Q&A with Rationale (NRS420 Exam 2) |
Grand Canyon University
1. A nurse is performing a respiratory assessment on a client with a history of chronic
obstructive pulmonary disease (COPD). Which of the following findings would the nurse
expect to observe? (Select All That Apply)
A. Anteroposterior-to-transverse diameter ratio of 1:1
B. Use of accessory muscles during respiration
C. Hyperresonance upon percussion of the lung fields
D. Pursed-lip breathing during expiration
E. Presence of stridor on inspiration
Correct Answer: A, B, C, D
Explanation: Patients with COPD often develop a barrel chest, resulting in an equal AP-to-
transverse diameter. They frequently utilize accessory muscles and pursed-lip breathing to
assist with air trapping and impaired gas exchange. Hyperresonance is common due to air
trapping, whereas stridor indicates upper airway obstruction and is not standard for COPD.
2. When auscultating the heart, the nurse understands that the S1 heart sound is caused by
the closure of which valves?
A. Aortic and Pulmonic
,B. Mitral and Tricuspid
C. Aortic and Mitral
D. Tricuspid and Pulmonic
Correct Answer: B
Explanation: The first heart sound, S1, is produced by the closure of the atrioventricular
valves, which are the mitral and tricuspid valves. This sound marks the beginning of systole
and is usually loudest at the apex. Understanding the mechanical events of the cardiac cycle
is essential for differentiating normal from abnormal sounds.
3. The nurse is preparing to assess a client’s abdomen. What is the correct sequence for
performing this physical examination?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: C
Explanation: The abdominal assessment must follow a specific sequence to prevent false
findings. Auscultation is performed before percussion and palpation because manual
manipulation of the bowel can increase peristalsis and alter bowel sounds. Adhering to this
standard ensures the accuracy of the clinical data collected.
, 4. A nurse is assessing a client for possible carotid artery stenosis. Which technique should
the nurse use to check for a bruit?
A. Palpate both carotid arteries simultaneously to compare strength.
B. Auscultate using the diaphragm of the stethoscope while the patient breathes deeply.
C. Auscultate using the bell of the stethoscope while the patient holds their breath.
D. Use the pads of the fingers to percuss over the carotid bifurcation.
Correct Answer: C
Explanation: A bruit is a blowing or swishing sound indicating turbulent blood flow, best
heard with the bell of the stethoscope. The patient is asked to hold their breath so that
respiratory sounds do not interfere with the auscultation. Palpating both carotids
simultaneously is dangerous as it can compromise cerebral blood flow.
5. While assessing a client’s lower extremities, the nurse notes that a 2 mm indentation
disappears rapidly after pressure is applied. How should the nurse document this finding?
A. 4+ edema
B. 2+ edema
C. 3+ edema
D. 1+ edema
Correct Answer: D
Actual Q&A with Rationale (NRS420 Exam 2) |
Grand Canyon University
1. A nurse is performing a respiratory assessment on a client with a history of chronic
obstructive pulmonary disease (COPD). Which of the following findings would the nurse
expect to observe? (Select All That Apply)
A. Anteroposterior-to-transverse diameter ratio of 1:1
B. Use of accessory muscles during respiration
C. Hyperresonance upon percussion of the lung fields
D. Pursed-lip breathing during expiration
E. Presence of stridor on inspiration
Correct Answer: A, B, C, D
Explanation: Patients with COPD often develop a barrel chest, resulting in an equal AP-to-
transverse diameter. They frequently utilize accessory muscles and pursed-lip breathing to
assist with air trapping and impaired gas exchange. Hyperresonance is common due to air
trapping, whereas stridor indicates upper airway obstruction and is not standard for COPD.
2. When auscultating the heart, the nurse understands that the S1 heart sound is caused by
the closure of which valves?
A. Aortic and Pulmonic
,B. Mitral and Tricuspid
C. Aortic and Mitral
D. Tricuspid and Pulmonic
Correct Answer: B
Explanation: The first heart sound, S1, is produced by the closure of the atrioventricular
valves, which are the mitral and tricuspid valves. This sound marks the beginning of systole
and is usually loudest at the apex. Understanding the mechanical events of the cardiac cycle
is essential for differentiating normal from abnormal sounds.
3. The nurse is preparing to assess a client’s abdomen. What is the correct sequence for
performing this physical examination?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: C
Explanation: The abdominal assessment must follow a specific sequence to prevent false
findings. Auscultation is performed before percussion and palpation because manual
manipulation of the bowel can increase peristalsis and alter bowel sounds. Adhering to this
standard ensures the accuracy of the clinical data collected.
, 4. A nurse is assessing a client for possible carotid artery stenosis. Which technique should
the nurse use to check for a bruit?
A. Palpate both carotid arteries simultaneously to compare strength.
B. Auscultate using the diaphragm of the stethoscope while the patient breathes deeply.
C. Auscultate using the bell of the stethoscope while the patient holds their breath.
D. Use the pads of the fingers to percuss over the carotid bifurcation.
Correct Answer: C
Explanation: A bruit is a blowing or swishing sound indicating turbulent blood flow, best
heard with the bell of the stethoscope. The patient is asked to hold their breath so that
respiratory sounds do not interfere with the auscultation. Palpating both carotids
simultaneously is dangerous as it can compromise cerebral blood flow.
5. While assessing a client’s lower extremities, the nurse notes that a 2 mm indentation
disappears rapidly after pressure is applied. How should the nurse document this finding?
A. 4+ edema
B. 2+ edema
C. 3+ edema
D. 1+ edema
Correct Answer: D
