1
HEALTH ASSESSMENT NURSING EXAM – HEAD-TO-
TOE & SYSTEM-BASED ASSESSMENT
(2026-27 LATEST VERSION)
1. During cardiovascular assessment, you hear a systolic
murmur at the apex radiating to the axilla. Which valve is
most likely affected?
A. Aortic
B. Pulmonic
C. Mitral
D. Tricuspid
Correct Answer: C
Rationale:
Mitral regurgitation produces a systolic murmur at the apex,
radiating to the left axilla, best heard with the bell of the
stethoscope.
2. A patient presents with jaundice, dark urine, and clay-
colored stools. Which system is primarily affected?
A. Renal
B. Cardiac
,2
C. Hepatic
D. Endocrine
Correct Answer: C
Rationale:
These signs indicate liver dysfunction affecting bilirubin
metabolism.
3. Which lung sound indicates fluid in alveoli?
A. Stridor
B. Wheezing
C. Crackles (rales)
D. Bronchial breath sounds
Correct Answer: C
Rationale:
Crackles occur when fluid or exudate is present in the alveoli,
often in heart failure or pneumonia.
4. During abdominal assessment, a nurse notes hypoactive
bowel sounds. Which is an appropriate interpretation?
A. Normal
B. Possible ileus or obstruction
,3
C. Gastroenteritis
D. Excessive peristalsis
Correct Answer: B
Rationale:
Hypoactive bowel sounds suggest decreased GI motility,
possibly from obstruction, post-op ileus, or peritonitis.
5. A patient exhibits bulging eyes, heat intolerance, and fine
tremors. Which system assessment is priority?
A. Cardiac
B. Neurologic
C. Endocrine (thyroid)
D. Musculoskeletal
Correct Answer: C
Rationale:
Symptoms suggest hyperthyroidism; assessment of thyroid and
metabolic function is essential.
6. Which cranial nerve is tested by shrugging shoulders against
resistance?
A. CN V
B. CN VII
, 4
C. CN XI (Accessory)
D. CN XII
Correct Answer: C
Rationale:
The spinal accessory nerve (CN XI) controls the
sternocleidomastoid and trapezius muscles.
7. A patient’s capillary refill is 5 seconds. What does this
indicate?
A. Normal perfusion
B. Hypoglycemia
C. Poor peripheral perfusion
D. Normal finding in adults
Correct Answer: C
Rationale:
Normal refill is <2 seconds; >3 seconds indicates reduced blood
flow, possibly from shock or hypovolemia.
8. During musculoskeletal assessment, a nurse detects
Heberden’s nodes. Which condition is most likely?
A. Rheumatoid arthritis
B. Gout
HEALTH ASSESSMENT NURSING EXAM – HEAD-TO-
TOE & SYSTEM-BASED ASSESSMENT
(2026-27 LATEST VERSION)
1. During cardiovascular assessment, you hear a systolic
murmur at the apex radiating to the axilla. Which valve is
most likely affected?
A. Aortic
B. Pulmonic
C. Mitral
D. Tricuspid
Correct Answer: C
Rationale:
Mitral regurgitation produces a systolic murmur at the apex,
radiating to the left axilla, best heard with the bell of the
stethoscope.
2. A patient presents with jaundice, dark urine, and clay-
colored stools. Which system is primarily affected?
A. Renal
B. Cardiac
,2
C. Hepatic
D. Endocrine
Correct Answer: C
Rationale:
These signs indicate liver dysfunction affecting bilirubin
metabolism.
3. Which lung sound indicates fluid in alveoli?
A. Stridor
B. Wheezing
C. Crackles (rales)
D. Bronchial breath sounds
Correct Answer: C
Rationale:
Crackles occur when fluid or exudate is present in the alveoli,
often in heart failure or pneumonia.
4. During abdominal assessment, a nurse notes hypoactive
bowel sounds. Which is an appropriate interpretation?
A. Normal
B. Possible ileus or obstruction
,3
C. Gastroenteritis
D. Excessive peristalsis
Correct Answer: B
Rationale:
Hypoactive bowel sounds suggest decreased GI motility,
possibly from obstruction, post-op ileus, or peritonitis.
5. A patient exhibits bulging eyes, heat intolerance, and fine
tremors. Which system assessment is priority?
A. Cardiac
B. Neurologic
C. Endocrine (thyroid)
D. Musculoskeletal
Correct Answer: C
Rationale:
Symptoms suggest hyperthyroidism; assessment of thyroid and
metabolic function is essential.
6. Which cranial nerve is tested by shrugging shoulders against
resistance?
A. CN V
B. CN VII
, 4
C. CN XI (Accessory)
D. CN XII
Correct Answer: C
Rationale:
The spinal accessory nerve (CN XI) controls the
sternocleidomastoid and trapezius muscles.
7. A patient’s capillary refill is 5 seconds. What does this
indicate?
A. Normal perfusion
B. Hypoglycemia
C. Poor peripheral perfusion
D. Normal finding in adults
Correct Answer: C
Rationale:
Normal refill is <2 seconds; >3 seconds indicates reduced blood
flow, possibly from shock or hypovolemia.
8. During musculoskeletal assessment, a nurse detects
Heberden’s nodes. Which condition is most likely?
A. Rheumatoid arthritis
B. Gout
