NUR 101/ NUR101 Exam 2 –
Health Assessment Review
ACTUAL EXAM 2026/2027 |
Health Assessment Review |
Verified Q&A | Pass Guaranteed -
A+ Graded
ART A – MULTIPLE CHOICE (Q1–60)
P
Q1 (Physical assessment techniques – percussion):
A nurse is percussing a patient's abdomen and hears a loud, drum-like sound. This sound
indicates which finding?
A. Dullness over the liver
B. Tympany over a gastric air bubble
C. Flatness over the thigh muscle
D. Resonance over lung tissue
[CORRECT] B
Rationale: Tympany is a high-pitched, drum-like sound heard over air-filled structures such as
the stomach or intestines. Dullness (A) is heard over solid organs like the liver or spleen, not
hollow organs. Flatness (C) is heard over very dense tissue or bone, and resonance (D) is the
normal percussion sound over healthy lung tissue, not the abdomen. Clinical pearl: Always
percuss from resonance to dullness when assessing the liver span to identify the upper and
lower borders accurately.
Q2 (Physical assessment techniques – auscultation):
When auscultating heart sounds in an adult patient, the nurse should use the bell of the
stethoscope to best hear which sound?
A. S1 at the apex
B. S2 at the base
C. S3 gallop at the apex
D. Murmur at Erb's point
[CORRECT] C
, ationale: The bell of the stethoscope is designed to detect low-frequency sounds such as S3
R
and S4 gallops, which are best heard at the apex with the patient in the left lateral decubitus
position. S1 (A) and S2 (B) are high-frequency sounds best heard with the diaphragm. Murmurs
(D) vary in frequency but are generally assessed with the diaphragm unless specifically
low-pitched. Clinical pearl: S3 is a normal finding in children and young adults but may indicate
heart failure in patients over age 40.
Q3 (Skin, hair, nails – lesions):
A patient presents with a raised, solid lesion measuring 1 cm in diameter on the forearm. The
nurse documents this as which type of skin lesion?
A. Macule
B. Papule
C. Vesicle
D. Wheal
[CORRECT] B
Rationale: A papule is a solid, elevated lesion less than 1 cm in diameter; however, the
description fits a papule or small nodule depending on exact measurement, but papule is the
best answer among the choices for a raised solid lesion. A macule (A) is flat and non-palpable,
a vesicle (C) is a fluid-filled blister, and a wheal (D) is a transient, edematous plaque typically
associated with urticaria. Clinical pearl: Document lesion size, color, shape, and distribution
systematically; use a ruler for accurate measurement rather than estimation.
Q4 (Skin, hair, nails – nail assessment):
During a health assessment, the nurse observes that the patient's fingernails have a convex
curvature with a bulbous appearance and the nail bed angle exceeds 180 degrees. This finding
is consistent with:
A. Koilonychia
B. Clubbing
C. Beau's lines
D. Onycholysis
[CORRECT] B
Rationale: Clubbing is characterized by convex nail curvature, bulbous fingertip enlargement,
and a nail bed angle greater than 180 degrees (Lovibond angle), often associated with chronic
hypoxemia from cardiopulmonary disease. Koilonychia (A) is spoon-shaped concavity seen in
iron deficiency anemia. Beau's lines (C) are transverse depressions indicating growth arrest,
and onycholysis (D) is distal nail separation from the bed. Clinical pearl: Clubbing develops over
months to years; acute onset suggests serious underlying pathology requiring immediate
investigation.
Q5 (Skin, hair, nails – edema):
A nurse assesses a patient's lower extremities and notes a 6 mm depression that remains after
10 seconds of thumb pressure over the tibia. How should the nurse grade this edema?
A. 1+ (trace)
B. 2+ (mild)
C. 3+ (moderate)
D. 4+ (severe)
[CORRECT] C
, ationale: Edema is graded on a 4-point scale: 1+ (trace, 2 mm indentation), 2+ (mild, 4 mm),
R
3+ (moderate, 6 mm), and 4+ (severe, 8 mm or greater). A 6 mm depression corresponds to 3+
edema. 1+ (A) and 2+ (B) are less severe, while 4+ (D) would show a deeper, longer-lasting
indentation. Clinical pearl: Always assess edema bilaterally and document location, pitting
grade, and whether it is dependent or generalized; unilateral edema suggests localized
obstruction or DVT.
Q6 (Head and neck – lymph nodes):
When palpating the cervical lymph nodes, the nurse should assess the posterior cervical chain
by palpating in which location?
A. Anterior to the sternocleidomastoid muscle
B. Posterior to the sternocleidomastoid muscle along the trapezius
C. Submandibular region under the jaw
D. Supraclavicular fossa above the clavicle
[CORRECT] B
Rationale: The posterior cervical chain lies posterior to the sternocleidomastoid muscle along
the anterior edge of the trapezius muscle. The anterior cervical chain (A) is anterior to the SCM,
submandibular nodes (C) are under the jaw, and supraclavicular nodes (D) are above the
clavicle. Clinical pearl: Enlarged, hard, fixed supraclavicular nodes (Virchow's node) on the left
side may indicate intra-abdominal malignancy and require urgent evaluation.
Q7 (Head and neck – carotid arteries):
While assessing the carotid arteries, which action by the nurse is correct?
A. Palpate both carotid arteries simultaneously to compare symmetry
B. Auscultate the carotid arteries before palpating them
C. Apply firm pressure for 30 seconds to assess pulse quality
D. Palpate the carotid artery at the level of the cricoid cartilage
[CORRECT] B
Rationale: The correct sequence is to auscultate the carotid arteries first to detect bruits before
palpation, as palpation can alter blood flow and mask a bruit. Palpating both arteries
simultaneously (A) can compromise cerebral perfusion and cause syncope. Firm prolonged
pressure (C) can trigger the carotid sinus reflex and cause bradycardia. The carotid artery is
palpated at the level of the thyroid cartilage (Adam's apple), not the cricoid cartilage (D). Clinical
pearl: A carotid bruit suggests turbulent blood flow from stenosis; however, severe stenosis may
produce no bruit due to minimal flow.
Q8 (Head and neck – thyroid):
During thyroid palpation from behind the patient, the nurse asks the patient to swallow while
feeling the thyroid gland. The purpose of this maneuver is to:
A. Assess the consistency of the thyroid nodules
B. Determine if the thyroid moves with swallowing
C. Evaluate the thyroid's vascular supply
D. Measure the size of the thyroid lobes
[CORRECT] B
Rationale: The swallowing maneuver causes the thyroid gland (which is attached to the trachea)
to move upward, allowing the nurse to differentiate thyroid tissue from other neck masses and
assess its mobility. Consistency (A) is assessed by direct palpation, vascular supply (C) by
Health Assessment Review
ACTUAL EXAM 2026/2027 |
Health Assessment Review |
Verified Q&A | Pass Guaranteed -
A+ Graded
ART A – MULTIPLE CHOICE (Q1–60)
P
Q1 (Physical assessment techniques – percussion):
A nurse is percussing a patient's abdomen and hears a loud, drum-like sound. This sound
indicates which finding?
A. Dullness over the liver
B. Tympany over a gastric air bubble
C. Flatness over the thigh muscle
D. Resonance over lung tissue
[CORRECT] B
Rationale: Tympany is a high-pitched, drum-like sound heard over air-filled structures such as
the stomach or intestines. Dullness (A) is heard over solid organs like the liver or spleen, not
hollow organs. Flatness (C) is heard over very dense tissue or bone, and resonance (D) is the
normal percussion sound over healthy lung tissue, not the abdomen. Clinical pearl: Always
percuss from resonance to dullness when assessing the liver span to identify the upper and
lower borders accurately.
Q2 (Physical assessment techniques – auscultation):
When auscultating heart sounds in an adult patient, the nurse should use the bell of the
stethoscope to best hear which sound?
A. S1 at the apex
B. S2 at the base
C. S3 gallop at the apex
D. Murmur at Erb's point
[CORRECT] C
, ationale: The bell of the stethoscope is designed to detect low-frequency sounds such as S3
R
and S4 gallops, which are best heard at the apex with the patient in the left lateral decubitus
position. S1 (A) and S2 (B) are high-frequency sounds best heard with the diaphragm. Murmurs
(D) vary in frequency but are generally assessed with the diaphragm unless specifically
low-pitched. Clinical pearl: S3 is a normal finding in children and young adults but may indicate
heart failure in patients over age 40.
Q3 (Skin, hair, nails – lesions):
A patient presents with a raised, solid lesion measuring 1 cm in diameter on the forearm. The
nurse documents this as which type of skin lesion?
A. Macule
B. Papule
C. Vesicle
D. Wheal
[CORRECT] B
Rationale: A papule is a solid, elevated lesion less than 1 cm in diameter; however, the
description fits a papule or small nodule depending on exact measurement, but papule is the
best answer among the choices for a raised solid lesion. A macule (A) is flat and non-palpable,
a vesicle (C) is a fluid-filled blister, and a wheal (D) is a transient, edematous plaque typically
associated with urticaria. Clinical pearl: Document lesion size, color, shape, and distribution
systematically; use a ruler for accurate measurement rather than estimation.
Q4 (Skin, hair, nails – nail assessment):
During a health assessment, the nurse observes that the patient's fingernails have a convex
curvature with a bulbous appearance and the nail bed angle exceeds 180 degrees. This finding
is consistent with:
A. Koilonychia
B. Clubbing
C. Beau's lines
D. Onycholysis
[CORRECT] B
Rationale: Clubbing is characterized by convex nail curvature, bulbous fingertip enlargement,
and a nail bed angle greater than 180 degrees (Lovibond angle), often associated with chronic
hypoxemia from cardiopulmonary disease. Koilonychia (A) is spoon-shaped concavity seen in
iron deficiency anemia. Beau's lines (C) are transverse depressions indicating growth arrest,
and onycholysis (D) is distal nail separation from the bed. Clinical pearl: Clubbing develops over
months to years; acute onset suggests serious underlying pathology requiring immediate
investigation.
Q5 (Skin, hair, nails – edema):
A nurse assesses a patient's lower extremities and notes a 6 mm depression that remains after
10 seconds of thumb pressure over the tibia. How should the nurse grade this edema?
A. 1+ (trace)
B. 2+ (mild)
C. 3+ (moderate)
D. 4+ (severe)
[CORRECT] C
, ationale: Edema is graded on a 4-point scale: 1+ (trace, 2 mm indentation), 2+ (mild, 4 mm),
R
3+ (moderate, 6 mm), and 4+ (severe, 8 mm or greater). A 6 mm depression corresponds to 3+
edema. 1+ (A) and 2+ (B) are less severe, while 4+ (D) would show a deeper, longer-lasting
indentation. Clinical pearl: Always assess edema bilaterally and document location, pitting
grade, and whether it is dependent or generalized; unilateral edema suggests localized
obstruction or DVT.
Q6 (Head and neck – lymph nodes):
When palpating the cervical lymph nodes, the nurse should assess the posterior cervical chain
by palpating in which location?
A. Anterior to the sternocleidomastoid muscle
B. Posterior to the sternocleidomastoid muscle along the trapezius
C. Submandibular region under the jaw
D. Supraclavicular fossa above the clavicle
[CORRECT] B
Rationale: The posterior cervical chain lies posterior to the sternocleidomastoid muscle along
the anterior edge of the trapezius muscle. The anterior cervical chain (A) is anterior to the SCM,
submandibular nodes (C) are under the jaw, and supraclavicular nodes (D) are above the
clavicle. Clinical pearl: Enlarged, hard, fixed supraclavicular nodes (Virchow's node) on the left
side may indicate intra-abdominal malignancy and require urgent evaluation.
Q7 (Head and neck – carotid arteries):
While assessing the carotid arteries, which action by the nurse is correct?
A. Palpate both carotid arteries simultaneously to compare symmetry
B. Auscultate the carotid arteries before palpating them
C. Apply firm pressure for 30 seconds to assess pulse quality
D. Palpate the carotid artery at the level of the cricoid cartilage
[CORRECT] B
Rationale: The correct sequence is to auscultate the carotid arteries first to detect bruits before
palpation, as palpation can alter blood flow and mask a bruit. Palpating both arteries
simultaneously (A) can compromise cerebral perfusion and cause syncope. Firm prolonged
pressure (C) can trigger the carotid sinus reflex and cause bradycardia. The carotid artery is
palpated at the level of the thyroid cartilage (Adam's apple), not the cricoid cartilage (D). Clinical
pearl: A carotid bruit suggests turbulent blood flow from stenosis; however, severe stenosis may
produce no bruit due to minimal flow.
Q8 (Head and neck – thyroid):
During thyroid palpation from behind the patient, the nurse asks the patient to swallow while
feeling the thyroid gland. The purpose of this maneuver is to:
A. Assess the consistency of the thyroid nodules
B. Determine if the thyroid moves with swallowing
C. Evaluate the thyroid's vascular supply
D. Measure the size of the thyroid lobes
[CORRECT] B
Rationale: The swallowing maneuver causes the thyroid gland (which is attached to the trachea)
to move upward, allowing the nurse to differentiate thyroid tissue from other neck masses and
assess its mobility. Consistency (A) is assessed by direct palpation, vascular supply (C) by
