NU 209 Health Assessment
Final Assessment Review
Questions & Solutions
2025
©2025
,Multiple Choice Questions (MCQs)
A 65-year-old patient presents with bilateral lower extremity swelling,
jugular vein distention, and an S3 heart sound on auscultation. Which
condition is most likely?
A) Peripheral vascular disease
B) Right-sided heart failure
C) Left-sided heart failure
D) Deep vein thrombosis
ANS: B) Right-sided heart failure
Rationale: Bilateral edema and jugular vein distention are hallmark signs
of systemic venous congestion seen in right-sided heart failure. An S3 can
be present but is more associated with left-sided failure.
During a respiratory assessment, a nurse identifies a high-pitched musical
sound on expiration in a patient with asthma. This is best classified as:
A) Crackles
B) Wheezes
C) Rhonchi
D) Stridor
ANS: B) Wheezes
Rationale: Wheezes indicate airway narrowing or obstruction, typically
high-pitched and musical, frequently heard in asthma during expiration.
When assessing a patient’s neurological status using the Glasgow Coma
Scale (GCS), which score would indicate severe brain injury?
A) 15
B) 13
C) 8
D) 10
ANS: C) 8
Rationale: A GCS score of ≤8 indicates severe brain injury and typically
correlates with coma or unconscious state.
A nurse is assessing peripheral pulses and finds a diminished dorsalis
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,pedis pulse. Which additional test can best evaluate arterial blood flow to
the lower extremities?
A) Ankle-Brachial Index (ABI)
B) Venous Doppler Ultrasound
C) Phalen’s Test
D) Allen’s Test
ANS: A) Ankle-Brachial Index (ABI)
Rationale: ABI compares ankle to brachial artery pressures assessing
arterial circulation adequacy; used in peripheral arterial disease.
During abdominal auscultation, the nurse hears high-pitched tinkling
sounds and notes abdominal distention. What condition could this
suggest?
A) Normal bowel sounds
B) Small bowel obstruction
C) Gastroenteritis
D) Peptic ulcer disease
ANS: B) Small bowel obstruction
Rationale: High-pitched tinkling sounds are often a sign of bowel
obstruction due to intestinal fluid and gas under pressure.
Fill-in-the-Blank Questions
The ________ reflex is tested by stroking the lateral sole of the foot,
which normally causes plantar flexion of the toes.
ANS: Babinski
Rationale: The Babinski reflex is abnormal if dorsiflexion (extension) of
the big toe occurs in adults, indicating CNS pathology.
A pulse rate below 60 beats per minute is defined as _________.
ANS: Bradycardia
Rationale: Bradycardia is heart rate slower than 60 bpm, which can be
normal in athletes or pathological.
The technique of tapping on the surface of the body to evaluate
underlying structures is known as ________.
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, ANS: Percussion
Rationale: Percussion produces sounds that help assess organ size,
density, and presence of fluid or air.
The correct order for performing an abdominal examination is inspection,
________, percussion, and palpation.
ANS: Auscultation
Rationale: Auscultation comes before percussion and palpation to avoid
altering bowel sounds.
The spinal nerve responsible for sensation on the lateral forearm is the
________ nerve.
ANS: Radial
Rationale: The radial nerve supplies sensation to the posterior arm and
lateral forearm.
True/False Questions
True or False: Normal lung sounds include crackles, which are always
indicative of pathology.
ANS: False
Rationale: Fine crackles may be normal in healthy individuals at the base
of the lungs, especially on inspiration.
True or False: A positive Homan’s sign is a reliable indicator of deep vein
thrombosis.
ANS: False
Rationale: Homan's sign lacks sensitivity and specificity and is no longer
relied upon for DVT diagnosis.
True or False: The presence of nystagmus can be a sign of vestibular
dysfunction.
ANS: True
Rationale: Nystagmus is involuntary eye movement often associated with
inner ear or cerebellar pathology.
©2025
Final Assessment Review
Questions & Solutions
2025
©2025
,Multiple Choice Questions (MCQs)
A 65-year-old patient presents with bilateral lower extremity swelling,
jugular vein distention, and an S3 heart sound on auscultation. Which
condition is most likely?
A) Peripheral vascular disease
B) Right-sided heart failure
C) Left-sided heart failure
D) Deep vein thrombosis
ANS: B) Right-sided heart failure
Rationale: Bilateral edema and jugular vein distention are hallmark signs
of systemic venous congestion seen in right-sided heart failure. An S3 can
be present but is more associated with left-sided failure.
During a respiratory assessment, a nurse identifies a high-pitched musical
sound on expiration in a patient with asthma. This is best classified as:
A) Crackles
B) Wheezes
C) Rhonchi
D) Stridor
ANS: B) Wheezes
Rationale: Wheezes indicate airway narrowing or obstruction, typically
high-pitched and musical, frequently heard in asthma during expiration.
When assessing a patient’s neurological status using the Glasgow Coma
Scale (GCS), which score would indicate severe brain injury?
A) 15
B) 13
C) 8
D) 10
ANS: C) 8
Rationale: A GCS score of ≤8 indicates severe brain injury and typically
correlates with coma or unconscious state.
A nurse is assessing peripheral pulses and finds a diminished dorsalis
©2025
,pedis pulse. Which additional test can best evaluate arterial blood flow to
the lower extremities?
A) Ankle-Brachial Index (ABI)
B) Venous Doppler Ultrasound
C) Phalen’s Test
D) Allen’s Test
ANS: A) Ankle-Brachial Index (ABI)
Rationale: ABI compares ankle to brachial artery pressures assessing
arterial circulation adequacy; used in peripheral arterial disease.
During abdominal auscultation, the nurse hears high-pitched tinkling
sounds and notes abdominal distention. What condition could this
suggest?
A) Normal bowel sounds
B) Small bowel obstruction
C) Gastroenteritis
D) Peptic ulcer disease
ANS: B) Small bowel obstruction
Rationale: High-pitched tinkling sounds are often a sign of bowel
obstruction due to intestinal fluid and gas under pressure.
Fill-in-the-Blank Questions
The ________ reflex is tested by stroking the lateral sole of the foot,
which normally causes plantar flexion of the toes.
ANS: Babinski
Rationale: The Babinski reflex is abnormal if dorsiflexion (extension) of
the big toe occurs in adults, indicating CNS pathology.
A pulse rate below 60 beats per minute is defined as _________.
ANS: Bradycardia
Rationale: Bradycardia is heart rate slower than 60 bpm, which can be
normal in athletes or pathological.
The technique of tapping on the surface of the body to evaluate
underlying structures is known as ________.
©2025
, ANS: Percussion
Rationale: Percussion produces sounds that help assess organ size,
density, and presence of fluid or air.
The correct order for performing an abdominal examination is inspection,
________, percussion, and palpation.
ANS: Auscultation
Rationale: Auscultation comes before percussion and palpation to avoid
altering bowel sounds.
The spinal nerve responsible for sensation on the lateral forearm is the
________ nerve.
ANS: Radial
Rationale: The radial nerve supplies sensation to the posterior arm and
lateral forearm.
True/False Questions
True or False: Normal lung sounds include crackles, which are always
indicative of pathology.
ANS: False
Rationale: Fine crackles may be normal in healthy individuals at the base
of the lungs, especially on inspiration.
True or False: A positive Homan’s sign is a reliable indicator of deep vein
thrombosis.
ANS: False
Rationale: Homan's sign lacks sensitivity and specificity and is no longer
relied upon for DVT diagnosis.
True or False: The presence of nystagmus can be a sign of vestibular
dysfunction.
ANS: True
Rationale: Nystagmus is involuntary eye movement often associated with
inner ear or cerebellar pathology.
©2025
