NRS 420 Final Exam V1 | NRS 420 Health
Assessment | Actual Q&A with Rationale (NRS420
Final Exam) | Grand Canyon University
1. When conducting a general survey on a patient, which of the following elements should
the nurse include? (Select All That Apply)
A. Physical appearance and hygiene
B. Body structure and posture
C. Mobility and gait
D. Deep tendon reflexes
E. Mental status and behavior
F. Bowel sounds and abdominal contour
Correct Answer: A, B, C, E
Explanation: The general survey is a study of the whole person, covering the general
health state and any obvious physical characteristics. It includes physical appearance, body
structure, mobility, and behavior to provide an overall impression of the patient. Deep
tendon reflexes and bowel sounds are specific components of a regional physical
examination rather than the initial general survey.
,2. A nurse is auscultating the heart sounds of a 50-year-old patient. Where is the S2 sound
heard loudest?
A. At the apex of the heart using the bell
B. At the base of the heart using the diaphragm
C. At the left lower sternal border using the diaphragm
D. At the fifth intercostal space, midclavicular line
Correct Answer: B
Explanation: The S2 heart sound, which represents the closure of the semilunar valves, is
loudest at the base of the heart. The nurse should use the diaphragm of the stethoscope to
best capture these high-pitched sounds. In contrast, S1 is loudest at the apex,
corresponding to the closure of the atrioventricular valves.
3. During a respiratory assessment, the nurse notes a ‘palpable vibration transmitted through
the chest wall.’ How should the nurse document this finding?
A. Tactile fremitus
B. Adventitious sounds
C. Crepitus
D. Resonance
Correct Answer: A
, Explanation: Tactile fremitus is the vibration felt by the nurse’s hand on the patient’s chest
wall while the patient speaks. It is generated from the larynx and transmitted through the
patent bronchi and lung parenchyma to the chest wall. Factors such as lung consolidation
can increase this vibration, while air or fluid in the pleural space can decrease it.
4. In what order should the nurse perform the physical assessment of the abdomen?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: B
Explanation: The sequence for abdominal assessment is inspection followed by
auscultation, percussion, and finally palpation. This specific order is necessary because
percussion and palpation can increase peristalsis, which would result in false
interpretations of bowel sounds. By auscultating first, the nurse ensures the bowel sounds
are heard in their natural state.
5. The nurse is testing a patient’s visual accommodation. Which of the following observations
indicates a normal finding?
A. Pupillary dilation and convergence of the axes of the eyes
B. Pupillary constriction and divergence of the axes of the eyes
C. Pupillary dilation and divergence of the axes of the eyes
Assessment | Actual Q&A with Rationale (NRS420
Final Exam) | Grand Canyon University
1. When conducting a general survey on a patient, which of the following elements should
the nurse include? (Select All That Apply)
A. Physical appearance and hygiene
B. Body structure and posture
C. Mobility and gait
D. Deep tendon reflexes
E. Mental status and behavior
F. Bowel sounds and abdominal contour
Correct Answer: A, B, C, E
Explanation: The general survey is a study of the whole person, covering the general
health state and any obvious physical characteristics. It includes physical appearance, body
structure, mobility, and behavior to provide an overall impression of the patient. Deep
tendon reflexes and bowel sounds are specific components of a regional physical
examination rather than the initial general survey.
,2. A nurse is auscultating the heart sounds of a 50-year-old patient. Where is the S2 sound
heard loudest?
A. At the apex of the heart using the bell
B. At the base of the heart using the diaphragm
C. At the left lower sternal border using the diaphragm
D. At the fifth intercostal space, midclavicular line
Correct Answer: B
Explanation: The S2 heart sound, which represents the closure of the semilunar valves, is
loudest at the base of the heart. The nurse should use the diaphragm of the stethoscope to
best capture these high-pitched sounds. In contrast, S1 is loudest at the apex,
corresponding to the closure of the atrioventricular valves.
3. During a respiratory assessment, the nurse notes a ‘palpable vibration transmitted through
the chest wall.’ How should the nurse document this finding?
A. Tactile fremitus
B. Adventitious sounds
C. Crepitus
D. Resonance
Correct Answer: A
, Explanation: Tactile fremitus is the vibration felt by the nurse’s hand on the patient’s chest
wall while the patient speaks. It is generated from the larynx and transmitted through the
patent bronchi and lung parenchyma to the chest wall. Factors such as lung consolidation
can increase this vibration, while air or fluid in the pleural space can decrease it.
4. In what order should the nurse perform the physical assessment of the abdomen?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: B
Explanation: The sequence for abdominal assessment is inspection followed by
auscultation, percussion, and finally palpation. This specific order is necessary because
percussion and palpation can increase peristalsis, which would result in false
interpretations of bowel sounds. By auscultating first, the nurse ensures the bowel sounds
are heard in their natural state.
5. The nurse is testing a patient’s visual accommodation. Which of the following observations
indicates a normal finding?
A. Pupillary dilation and convergence of the axes of the eyes
B. Pupillary constriction and divergence of the axes of the eyes
C. Pupillary dilation and divergence of the axes of the eyes
