NUR 2092/NUR2092 Final Exam V1 |
Health Assessment Q&A with Rationale |
Rasmussen University
1. During a respiratory assessment, the nurse notes a coarse, low-pitched, snoring sound that
clears with coughing. Which sound should the nurse document?
A. Fine crackles
B. Pleural friction rub
C. Rhonchi
D. Wheezes
Correct Answer: C
Expert Explanation: Rhonchi are continuous low-pitched, rattling lung sounds that often
resemble snoring. They are caused by secretions in the larger airways and frequently clear
after a patient coughs. In contrast, crackles are discontinuous popping sounds that do not
usually clear with coughing.
2. When assessing a patient for tactile fremitus, the nurse should expect to feel the strongest
vibrations in which area?
A. Over the lung bases
B. Between the scapulae
C. At the costodiaphragmatic recess
,D. In the axillary region
Correct Answer: B
Expert Explanation: Tactile fremitus is most intense between the scapulae and around the
sternum where the major bronchi are closest to the chest wall. As the nurse moves down
the chest, the vibrations decrease because more lung tissue filters the sound. Decreased
fremitus occurs when there is an obstruction like pleural effusion or pneumothorax.
3. Which technique should the nurse use first when performing a physical assessment of the
abdomen?
A. Palpation
B. Inspection
C. Percussion
D. Auscultation
Correct Answer: B
Expert Explanation: Inspection is always the first step in any physical assessment,
including the abdomen. Following inspection, the nurse must auscultate the abdomen
before percussing or palpating. This sequence prevents the alteration of bowel sounds that
can occur with physical manipulation of the abdominal wall.
4. A patient presents with a suspicious skin lesion. Which characteristic would the nurse
identify as a ‘D’ in the ABCDE acronym for melanoma?
A. Depth of the lesion
, B. Diameter greater than 6mm
C. Duration of the lesion
D. Density of pigment
Correct Answer: B
Expert Explanation: The ‘D’ in the ABCDE acronym stands for diameter, specifically noting
if it is greater than 6 mm (the size of a pencil eraser). The other letters stand for
Asymmetry, Border irregularity, Color variation, and Evolving. Monitoring these signs is
essential for early detection of malignant melanoma.
5. The nurse is auscultating the heart at the second right intercostal space. Which valve area
is being assessed?
A. Mitral area
B. Aortic area
C. Pulmonic area
D. Tricuspid area
Correct Answer: B
Expert Explanation: The aortic valve area is located at the second right intercostal space
at the right sternal border. This is the primary location for hearing S2 sounds clearly.
Accurate placement of the stethoscope is vital for differentiating between various heart
valves and detecting murmurs.
Health Assessment Q&A with Rationale |
Rasmussen University
1. During a respiratory assessment, the nurse notes a coarse, low-pitched, snoring sound that
clears with coughing. Which sound should the nurse document?
A. Fine crackles
B. Pleural friction rub
C. Rhonchi
D. Wheezes
Correct Answer: C
Expert Explanation: Rhonchi are continuous low-pitched, rattling lung sounds that often
resemble snoring. They are caused by secretions in the larger airways and frequently clear
after a patient coughs. In contrast, crackles are discontinuous popping sounds that do not
usually clear with coughing.
2. When assessing a patient for tactile fremitus, the nurse should expect to feel the strongest
vibrations in which area?
A. Over the lung bases
B. Between the scapulae
C. At the costodiaphragmatic recess
,D. In the axillary region
Correct Answer: B
Expert Explanation: Tactile fremitus is most intense between the scapulae and around the
sternum where the major bronchi are closest to the chest wall. As the nurse moves down
the chest, the vibrations decrease because more lung tissue filters the sound. Decreased
fremitus occurs when there is an obstruction like pleural effusion or pneumothorax.
3. Which technique should the nurse use first when performing a physical assessment of the
abdomen?
A. Palpation
B. Inspection
C. Percussion
D. Auscultation
Correct Answer: B
Expert Explanation: Inspection is always the first step in any physical assessment,
including the abdomen. Following inspection, the nurse must auscultate the abdomen
before percussing or palpating. This sequence prevents the alteration of bowel sounds that
can occur with physical manipulation of the abdominal wall.
4. A patient presents with a suspicious skin lesion. Which characteristic would the nurse
identify as a ‘D’ in the ABCDE acronym for melanoma?
A. Depth of the lesion
, B. Diameter greater than 6mm
C. Duration of the lesion
D. Density of pigment
Correct Answer: B
Expert Explanation: The ‘D’ in the ABCDE acronym stands for diameter, specifically noting
if it is greater than 6 mm (the size of a pencil eraser). The other letters stand for
Asymmetry, Border irregularity, Color variation, and Evolving. Monitoring these signs is
essential for early detection of malignant melanoma.
5. The nurse is auscultating the heart at the second right intercostal space. Which valve area
is being assessed?
A. Mitral area
B. Aortic area
C. Pulmonic area
D. Tricuspid area
Correct Answer: B
Expert Explanation: The aortic valve area is located at the second right intercostal space
at the right sternal border. This is the primary location for hearing S2 sounds clearly.
Accurate placement of the stethoscope is vital for differentiating between various heart
valves and detecting murmurs.
