NR 302
Health Assessment I
Midterm Exam Review
2026
1. A 65-year-old patient presents with unilateral weakness and slurred speech. During neurological
assessment, which cranial nerve function should the nurse evaluate first? a) Cranial Nerve II
(Optic) b) Cranial Nerve VII (Facial) c) Cranial Nerve IX (Glossopharyngeal) d) Cranial Nerve XI
(Accessory) Answer: b) Cranial Nerve VII (Facial) Rationale: Facial asymmetry is a common
sign in stroke. CN VII controls facial muscles, so assessing facial nerve function quickly helps
determine extent and location of neurological deficit.
2. When auscultating lung sounds in a patient with suspected pneumonia, which finding would
most specifically indicate alveolar consolidation? a) Wheezing b) Coarse crackles c) Egophony
d) Pleural friction rub Answer: c) Egophony Rationale: Egophony (increased resonance of
voice sounds) indicates lung consolidation, common in pneumonia.
3. A patient’s blood pressure reading shows 150/95 mmHg. Which part of the physical assessment
should be prioritized next? a) Skin turgor b) Fundoscopic eye exam c) Peripheral pulse strength
d) Respiratory rate Answer: b) Fundoscopic eye exam Rationale: Hypertension can cause
retinal changes; assessing the eyes helps identify end-organ damage.
4. Which of the following is the best tool to assess deep tendon reflexes accurately? a)
Reinforcement technique b) Percussion hammer c) Doppler ultrasound d) Stethoscope
Answer: b) Percussion hammer Rationale: The percussion hammer is used routinely to test
reflexes such as patellar, biceps, and Achilles.
5. The nurse is performing an abdominal exam. What is the correct sequence? a) Percussion,
Palpation, Inspection, Auscultation b) Inspection, Palpation, Percussion, Auscultation c)
Inspection, Auscultation, Percussion, Palpation d) Palpation, Auscultation, Inspection,
Percussion Answer: c) Inspection, Auscultation, Percussion, Palpation Rationale: Auscultation
is done before percussion and palpation to avoid altering bowel sounds.
6. When assessing a patient’s mental status, aphasia primarily indicates dysfunction in which
area? a) Cerebellum b) Broca’s area c) Occipital lobe d) Basal ganglia Answer: b) Broca’s area
Rationale: Broca's area controls expressive language function; damage leads to aphasia.
7. Which vital sign abnormality would most likely indicate an early sign of shock in an adult
patient? a) Bradycardia b) Polyuria c) Tachycardia d) Hypothermia Answer: c) Tachycardia
Rationale: Tachycardia is the body's compensatory response to maintain cardiac output during
shock.
8. During a cardiovascular assessment, what feature of a peripheral pulse helps differentiate
between peripheral arterial disease and venous insufficiency? a) Pulse amplitude b) Pulse
symmetry c) Presence of thrill d) Pulse contour Answer: a) Pulse amplitude Rationale: In
arterial disease, pulses are diminished or absent; in venous disease, pulses are usually normal.
9. A patient with chronic obstructive pulmonary disease (COPD) presents with barrel chest. This
assessment finding most directly reflects: a) Chronic hypoxemia b) Increased anterior-posterior
diameter c) Increased diaphragmatic excursion d) Reduced tidal volume Answer: b) Increased
anterior-posterior diameter Rationale: Barrel chest results from hyperinflated lungs causing
increased AP diameter.
10. Which percussion note would be expected over a healthy adult’s lung? a) Dullness b) Flatness
c) Tympany d) Resonance Answer: d) Resonance Rationale: Resonance is the normal
percussion note over healthy lung tissue.
11. A nursing student learns that a normal capillary refill time is: a) Less than 2 seconds b) 2-3
seconds c) 3-4 seconds d) More than 5 seconds Answer: a) Less than 2 seconds Rationale:
, Normal peripheral perfusion is indicated by a refill time under 2 seconds.
12. During an assessment of a febrile patient, the nurse notes early systolic murmurs in the aortic
area. What additional signs might suggest infective endocarditis? a) Petechiae and Osler nodes
b) Dry skin and alopecia c) Jaundice and ascites d) Cyanosis and clubbing Answer: a)
Petechiae and Osler nodes Rationale: Infective endocarditis often presents with vascular and
immunologic phenomena like Osler nodes and petechiae.
13. Which of these tools is essential for assessment of diabetic neuropathy during a health
assessment? a) Monofilament b) Tuning fork (128 Hz) c) Both a and b d) Reflex hammer
Answer: c) Both a and b Rationale: Monofilament tests light touch; tuning fork assesses
vibration — both are key in diabetic neuropathy evaluation.
14. In the Glasgow Coma Scale, a patient opening eyes to speech, obeying commands, but
producing inappropriate words would score how many points? a) 12 b) 13 c) 14 d) 15 Answer:
a) 12 Rationale: Eye opening to speech (3), verbal inappropriate words (3), and obeys
commands (6) = 12 total points.
15. When performing a musculoskeletal assessment, which finding is consistent with rheumatoid
arthritis rather than osteoarthritis? a) Heberden’s nodes at DIP joints b) Symmetrical joint
swelling c) Pain worsening with use d) Stiffness lasting less than 30 minutes Answer: b)
Symmetrical joint swelling Rationale: Rheumatoid arthritis typically has symmetrical joint
involvement; OA is asymmetric.
True/False (10)
16. The presence of clubbing of the nails is usually associated with chronic hypoxia. True
Rationale: Clubbing often develops due to chronic hypoxemia associated with lung diseases.
17. Diaphragmatic excursion is normally symmetric and measures approximately 3-5 cm in healthy
adults. True Rationale: Normal diaphragmatic excursion ranges about 3-5 cm; asymmetry
suggests pulmonary disease.
18. Normal heart sounds include three distinct sounds named S1, S2, and S3 in all healthy adults.
False Rationale: S1 and S2 are normal; S3 can be normal in children and young adults but is
abnormal in older adults.
19. The assessment of jugular venous pressure (JVP) provides indirect information about right atrial
pressure. True Rationale: JVP reflects central venous pressure and indirectly estimates right
atrial pressure.
20. A decrease in tactile fremitus is expected over an area of lung consolidation. False Rationale:
Tactile fremitus is increased over consolidation due to denser lung tissue transmitting vibrations
better.
21. Hypothyroidism can present with delayed deep tendon reflex relaxation phase. True Rationale:
Hypothyroidism causes slowed neuromuscular relaxation, seen as delayed reflexes.
22. The ankle-brachial index (ABI) value above 1.3 suggests normal arterial perfusion. False
Rationale: ABI > 1.3 indicates vessel calcification and non-compressible arteries, often seen in
diabetes.
23. The capillary refill test is a reliable indicator of hydration status in elderly patients. False
Rationale: Capillary refill may be unreliable in elders due to reduced skin elasticity and
circulation changes.
24. In healthy adults, the trachea is slightly deviated to the left side. False Rationale: Normally the
trachea is midline; deviation indicates pathology.
25. Reactive hyperemia following blanching during peripheral vascular assessment indicates
arterial insufficiency. True Rationale: Prolonged pallor followed by bright red reactive
hyperemia suggests arterial insufficiency.
Short Answer (7)
26. Describe two clinical signs during an abdominal exam that suggest peritonitis. Answer:
Guarding and rebound tenderness. Rationale: Guarding is involuntary muscle contraction;
rebound tenderness signifies inflammation of peritoneum.
27. What is the significance of a positive Romberg test in neurological examination? Answer: It
indicates proprioceptive or vestibular dysfunction affecting balance. Rationale: Loss of balance
, when eyes closed suggests sensory ataxia.
28. Identify the lung lobes auscultated anteriorly and posteriorly in physical exams. Answer:
Anteriorly—Upper and middle lobes; Posteriorly—Lower lobes. Rationale: Anterior chest wall
mostly overlies upper and middle lobes; posteriorly you hear mainly the lower lobes.
29. Which pulse points are recommended for simultaneous palpation to assess pulse equality?
Answer: Radial and femoral pulses. Rationale: Comparing these allows early detection of
peripheral arterial obstruction.
30. What is the clinical importance of assessing the angle of Louis (sternal angle) during respiratory
assessment? Answer: It serves as a landmark to locate the second rib for counting ribs and
intercostal spaces. Rationale: Rib counting facilitates systematic lung assessment.
31. How does the nurse perform a focused skin assessment to detect potential pressure ulcers?
Answer: Inspect bony prominences for color changes, blanching, skin breakdown, moisture,
and temperature differences. Rationale: Early identification prevents worsening of ulcers.
32. Define the term ‘anisocoria’ and state what neurological conditions it may indicate. Answer:
Anisocoria is unequal pupil size; it may indicate cranial nerve III palsy, brain herniation, or
ocular trauma. Rationale: Pupil size and reaction provide clues to neurological integrity.
Matching (5 sets)
Match the following signs/symptoms to the correct pathological condition:
Signs/Symptoms Conditions
33. Kayser- A. Wilson’s
Fleischer rings disease
B.
34. Bouchard’s
Osteoarthr
nodes
itis
C. Deep vein
35. Positive
thrombosi
Homan’s sign
s
D.
36. Trousseau’s
Hypocalce
sign
mia
37. McBurney’s E.
point Appendicit
tenderness is
Answers: 33-A (Copper deposition in Wilson’s disease causes Kayser-Fleischer
rings) 34-B (Bouchard’s nodes involve PIP joints in osteoarthritis) 35-C
(Homan’s sign suggests DVT) 36-D (Trousseau’s sign is indicative of
hypocalcemia) 37-E (McBurney’s point tenderness is classic for appendicitis)
Fill in the Blank (3)
38. The normal range for adult respiratory rate is _________ breaths per minute. Answer: 12-20
Rationale: The standard reference range for euthyroid adult respiratory rate.
39. The presence of ________ indicates accumulation of fluid in the pleural space. Answer: Pleural
effusion Rationale: Defined as fluid between pleural layers; assessed by decreased breath
sounds and dullness on percussion.
40. ________ test is used to evaluate the integrity of the ulnar nerve during a neurological exam.
Answer: Froment’s Rationale: Froment’s sign assesses ulnar nerve motor function, especially
adductor pollicis.
I. Multiple Choice (12 Questions)
1. Case: A 65-year-old patient presents with unilateral wheezing and decreased breath sounds.
Health Assessment I
Midterm Exam Review
2026
1. A 65-year-old patient presents with unilateral weakness and slurred speech. During neurological
assessment, which cranial nerve function should the nurse evaluate first? a) Cranial Nerve II
(Optic) b) Cranial Nerve VII (Facial) c) Cranial Nerve IX (Glossopharyngeal) d) Cranial Nerve XI
(Accessory) Answer: b) Cranial Nerve VII (Facial) Rationale: Facial asymmetry is a common
sign in stroke. CN VII controls facial muscles, so assessing facial nerve function quickly helps
determine extent and location of neurological deficit.
2. When auscultating lung sounds in a patient with suspected pneumonia, which finding would
most specifically indicate alveolar consolidation? a) Wheezing b) Coarse crackles c) Egophony
d) Pleural friction rub Answer: c) Egophony Rationale: Egophony (increased resonance of
voice sounds) indicates lung consolidation, common in pneumonia.
3. A patient’s blood pressure reading shows 150/95 mmHg. Which part of the physical assessment
should be prioritized next? a) Skin turgor b) Fundoscopic eye exam c) Peripheral pulse strength
d) Respiratory rate Answer: b) Fundoscopic eye exam Rationale: Hypertension can cause
retinal changes; assessing the eyes helps identify end-organ damage.
4. Which of the following is the best tool to assess deep tendon reflexes accurately? a)
Reinforcement technique b) Percussion hammer c) Doppler ultrasound d) Stethoscope
Answer: b) Percussion hammer Rationale: The percussion hammer is used routinely to test
reflexes such as patellar, biceps, and Achilles.
5. The nurse is performing an abdominal exam. What is the correct sequence? a) Percussion,
Palpation, Inspection, Auscultation b) Inspection, Palpation, Percussion, Auscultation c)
Inspection, Auscultation, Percussion, Palpation d) Palpation, Auscultation, Inspection,
Percussion Answer: c) Inspection, Auscultation, Percussion, Palpation Rationale: Auscultation
is done before percussion and palpation to avoid altering bowel sounds.
6. When assessing a patient’s mental status, aphasia primarily indicates dysfunction in which
area? a) Cerebellum b) Broca’s area c) Occipital lobe d) Basal ganglia Answer: b) Broca’s area
Rationale: Broca's area controls expressive language function; damage leads to aphasia.
7. Which vital sign abnormality would most likely indicate an early sign of shock in an adult
patient? a) Bradycardia b) Polyuria c) Tachycardia d) Hypothermia Answer: c) Tachycardia
Rationale: Tachycardia is the body's compensatory response to maintain cardiac output during
shock.
8. During a cardiovascular assessment, what feature of a peripheral pulse helps differentiate
between peripheral arterial disease and venous insufficiency? a) Pulse amplitude b) Pulse
symmetry c) Presence of thrill d) Pulse contour Answer: a) Pulse amplitude Rationale: In
arterial disease, pulses are diminished or absent; in venous disease, pulses are usually normal.
9. A patient with chronic obstructive pulmonary disease (COPD) presents with barrel chest. This
assessment finding most directly reflects: a) Chronic hypoxemia b) Increased anterior-posterior
diameter c) Increased diaphragmatic excursion d) Reduced tidal volume Answer: b) Increased
anterior-posterior diameter Rationale: Barrel chest results from hyperinflated lungs causing
increased AP diameter.
10. Which percussion note would be expected over a healthy adult’s lung? a) Dullness b) Flatness
c) Tympany d) Resonance Answer: d) Resonance Rationale: Resonance is the normal
percussion note over healthy lung tissue.
11. A nursing student learns that a normal capillary refill time is: a) Less than 2 seconds b) 2-3
seconds c) 3-4 seconds d) More than 5 seconds Answer: a) Less than 2 seconds Rationale:
, Normal peripheral perfusion is indicated by a refill time under 2 seconds.
12. During an assessment of a febrile patient, the nurse notes early systolic murmurs in the aortic
area. What additional signs might suggest infective endocarditis? a) Petechiae and Osler nodes
b) Dry skin and alopecia c) Jaundice and ascites d) Cyanosis and clubbing Answer: a)
Petechiae and Osler nodes Rationale: Infective endocarditis often presents with vascular and
immunologic phenomena like Osler nodes and petechiae.
13. Which of these tools is essential for assessment of diabetic neuropathy during a health
assessment? a) Monofilament b) Tuning fork (128 Hz) c) Both a and b d) Reflex hammer
Answer: c) Both a and b Rationale: Monofilament tests light touch; tuning fork assesses
vibration — both are key in diabetic neuropathy evaluation.
14. In the Glasgow Coma Scale, a patient opening eyes to speech, obeying commands, but
producing inappropriate words would score how many points? a) 12 b) 13 c) 14 d) 15 Answer:
a) 12 Rationale: Eye opening to speech (3), verbal inappropriate words (3), and obeys
commands (6) = 12 total points.
15. When performing a musculoskeletal assessment, which finding is consistent with rheumatoid
arthritis rather than osteoarthritis? a) Heberden’s nodes at DIP joints b) Symmetrical joint
swelling c) Pain worsening with use d) Stiffness lasting less than 30 minutes Answer: b)
Symmetrical joint swelling Rationale: Rheumatoid arthritis typically has symmetrical joint
involvement; OA is asymmetric.
True/False (10)
16. The presence of clubbing of the nails is usually associated with chronic hypoxia. True
Rationale: Clubbing often develops due to chronic hypoxemia associated with lung diseases.
17. Diaphragmatic excursion is normally symmetric and measures approximately 3-5 cm in healthy
adults. True Rationale: Normal diaphragmatic excursion ranges about 3-5 cm; asymmetry
suggests pulmonary disease.
18. Normal heart sounds include three distinct sounds named S1, S2, and S3 in all healthy adults.
False Rationale: S1 and S2 are normal; S3 can be normal in children and young adults but is
abnormal in older adults.
19. The assessment of jugular venous pressure (JVP) provides indirect information about right atrial
pressure. True Rationale: JVP reflects central venous pressure and indirectly estimates right
atrial pressure.
20. A decrease in tactile fremitus is expected over an area of lung consolidation. False Rationale:
Tactile fremitus is increased over consolidation due to denser lung tissue transmitting vibrations
better.
21. Hypothyroidism can present with delayed deep tendon reflex relaxation phase. True Rationale:
Hypothyroidism causes slowed neuromuscular relaxation, seen as delayed reflexes.
22. The ankle-brachial index (ABI) value above 1.3 suggests normal arterial perfusion. False
Rationale: ABI > 1.3 indicates vessel calcification and non-compressible arteries, often seen in
diabetes.
23. The capillary refill test is a reliable indicator of hydration status in elderly patients. False
Rationale: Capillary refill may be unreliable in elders due to reduced skin elasticity and
circulation changes.
24. In healthy adults, the trachea is slightly deviated to the left side. False Rationale: Normally the
trachea is midline; deviation indicates pathology.
25. Reactive hyperemia following blanching during peripheral vascular assessment indicates
arterial insufficiency. True Rationale: Prolonged pallor followed by bright red reactive
hyperemia suggests arterial insufficiency.
Short Answer (7)
26. Describe two clinical signs during an abdominal exam that suggest peritonitis. Answer:
Guarding and rebound tenderness. Rationale: Guarding is involuntary muscle contraction;
rebound tenderness signifies inflammation of peritoneum.
27. What is the significance of a positive Romberg test in neurological examination? Answer: It
indicates proprioceptive or vestibular dysfunction affecting balance. Rationale: Loss of balance
, when eyes closed suggests sensory ataxia.
28. Identify the lung lobes auscultated anteriorly and posteriorly in physical exams. Answer:
Anteriorly—Upper and middle lobes; Posteriorly—Lower lobes. Rationale: Anterior chest wall
mostly overlies upper and middle lobes; posteriorly you hear mainly the lower lobes.
29. Which pulse points are recommended for simultaneous palpation to assess pulse equality?
Answer: Radial and femoral pulses. Rationale: Comparing these allows early detection of
peripheral arterial obstruction.
30. What is the clinical importance of assessing the angle of Louis (sternal angle) during respiratory
assessment? Answer: It serves as a landmark to locate the second rib for counting ribs and
intercostal spaces. Rationale: Rib counting facilitates systematic lung assessment.
31. How does the nurse perform a focused skin assessment to detect potential pressure ulcers?
Answer: Inspect bony prominences for color changes, blanching, skin breakdown, moisture,
and temperature differences. Rationale: Early identification prevents worsening of ulcers.
32. Define the term ‘anisocoria’ and state what neurological conditions it may indicate. Answer:
Anisocoria is unequal pupil size; it may indicate cranial nerve III palsy, brain herniation, or
ocular trauma. Rationale: Pupil size and reaction provide clues to neurological integrity.
Matching (5 sets)
Match the following signs/symptoms to the correct pathological condition:
Signs/Symptoms Conditions
33. Kayser- A. Wilson’s
Fleischer rings disease
B.
34. Bouchard’s
Osteoarthr
nodes
itis
C. Deep vein
35. Positive
thrombosi
Homan’s sign
s
D.
36. Trousseau’s
Hypocalce
sign
mia
37. McBurney’s E.
point Appendicit
tenderness is
Answers: 33-A (Copper deposition in Wilson’s disease causes Kayser-Fleischer
rings) 34-B (Bouchard’s nodes involve PIP joints in osteoarthritis) 35-C
(Homan’s sign suggests DVT) 36-D (Trousseau’s sign is indicative of
hypocalcemia) 37-E (McBurney’s point tenderness is classic for appendicitis)
Fill in the Blank (3)
38. The normal range for adult respiratory rate is _________ breaths per minute. Answer: 12-20
Rationale: The standard reference range for euthyroid adult respiratory rate.
39. The presence of ________ indicates accumulation of fluid in the pleural space. Answer: Pleural
effusion Rationale: Defined as fluid between pleural layers; assessed by decreased breath
sounds and dullness on percussion.
40. ________ test is used to evaluate the integrity of the ulnar nerve during a neurological exam.
Answer: Froment’s Rationale: Froment’s sign assesses ulnar nerve motor function, especially
adductor pollicis.
I. Multiple Choice (12 Questions)
1. Case: A 65-year-old patient presents with unilateral wheezing and decreased breath sounds.
