NUR 6001/NUR6001 Exam 2 V3 | Advanced
Health Assessment Q&A with Rationale |
William Paterson University
1. When performing an abdominal assessment, in what order should the physical
examination techniques be conducted?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Percussion, Palpation
D. Percussion, Auscultation, Palpation, Inspection
Correct Answer: A
Expert Explanation: The standard order for abdominal assessment is inspection followed
immediately by auscultation. This is done because percussion and palpation can increase
peristalsis and alter the natural bowel sounds. By auscultating first, the practitioner
ensures an accurate representation of the patient’s bowel activity.
2. Which heart sound is created by the closure of the atrioventricular valves (mitral and
tricuspid)?
A. S1
B. S2
C. S3
,D. S4
Correct Answer: A
Expert Explanation: The first heart sound, S1, occurs when the mitral and tricuspid valves
close during the onset of systole. It is typically heard loudest at the apex of the heart using
the diaphragm of the stethoscope. This sound marks the transition from ventricular filling
to ventricular contraction.
3. To assess for jaundice in a dark-skinned patient, where is the most reliable location to
inspect?
A. The palms of the hands
B. The nail beds
C. The hard palate or sclera
D. The skin on the abdomen
Correct Answer: C
Expert Explanation: Jaundice is often difficult to detect in dark-skinned individuals by
looking at the skin alone. The hard palate of the mouth and the sclera of the eyes are the
most reliable sites for detecting yellowing due to bilirubin buildup. These areas lack the
heavy pigmentation that can mask the clinical signs of icterus.
4. A patient presents with a ‘barrel chest’ appearance. This finding is most characteristic of
which condition?
A. Pneumonia
, B. Chronic obstructive pulmonary disease (COPD)
C. Pulmonary embolism
D. Pneumothorax
Correct Answer: B
Expert Explanation: A barrel chest occurs when the anteroposterior diameter of the chest
is equal to the transverse diameter. This is commonly seen in patients with COPD or
chronic emphysema due to chronic hyperinflation of the lungs. The increased air trapping
causes the rib cage to remain partially expanded at all times.
5. Which cranial nerve is being tested when the nurse asks a patient to stick out their tongue?
A. Cranial Nerve IX (Glossopharyngeal)
B. Cranial Nerve X (Vagus)
C. Cranial Nerve XI (Spinal Accessory)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: D
Expert Explanation: Cranial Nerve XII, the hypoglossal nerve, is responsible for the motor
movement of the tongue. When testing this nerve, the nurse observes for midline
protrusion and any signs of atrophy or tremors. Deviation to one side may indicate a lesion
on that specific nerve side.
Health Assessment Q&A with Rationale |
William Paterson University
1. When performing an abdominal assessment, in what order should the physical
examination techniques be conducted?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Percussion, Palpation
D. Percussion, Auscultation, Palpation, Inspection
Correct Answer: A
Expert Explanation: The standard order for abdominal assessment is inspection followed
immediately by auscultation. This is done because percussion and palpation can increase
peristalsis and alter the natural bowel sounds. By auscultating first, the practitioner
ensures an accurate representation of the patient’s bowel activity.
2. Which heart sound is created by the closure of the atrioventricular valves (mitral and
tricuspid)?
A. S1
B. S2
C. S3
,D. S4
Correct Answer: A
Expert Explanation: The first heart sound, S1, occurs when the mitral and tricuspid valves
close during the onset of systole. It is typically heard loudest at the apex of the heart using
the diaphragm of the stethoscope. This sound marks the transition from ventricular filling
to ventricular contraction.
3. To assess for jaundice in a dark-skinned patient, where is the most reliable location to
inspect?
A. The palms of the hands
B. The nail beds
C. The hard palate or sclera
D. The skin on the abdomen
Correct Answer: C
Expert Explanation: Jaundice is often difficult to detect in dark-skinned individuals by
looking at the skin alone. The hard palate of the mouth and the sclera of the eyes are the
most reliable sites for detecting yellowing due to bilirubin buildup. These areas lack the
heavy pigmentation that can mask the clinical signs of icterus.
4. A patient presents with a ‘barrel chest’ appearance. This finding is most characteristic of
which condition?
A. Pneumonia
, B. Chronic obstructive pulmonary disease (COPD)
C. Pulmonary embolism
D. Pneumothorax
Correct Answer: B
Expert Explanation: A barrel chest occurs when the anteroposterior diameter of the chest
is equal to the transverse diameter. This is commonly seen in patients with COPD or
chronic emphysema due to chronic hyperinflation of the lungs. The increased air trapping
causes the rib cage to remain partially expanded at all times.
5. Which cranial nerve is being tested when the nurse asks a patient to stick out their tongue?
A. Cranial Nerve IX (Glossopharyngeal)
B. Cranial Nerve X (Vagus)
C. Cranial Nerve XI (Spinal Accessory)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: D
Expert Explanation: Cranial Nerve XII, the hypoglossal nerve, is responsible for the motor
movement of the tongue. When testing this nerve, the nurse observes for midline
protrusion and any signs of atrophy or tremors. Deviation to one side may indicate a lesion
on that specific nerve side.
