NR304/NR 304 Final Exam V1 | Health
Assessment II Q&A with Rationale |
Chamberlain University
1. When assessing the abdomen, which of the following sequences is the correct physical
examination technique?
A. Inspection, Palpation, Percussion, Auscultation
B. Percussion, Inspection, Auscultation, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Inspection, Auscultation, Percussion, Palpation
Correct Answer: D
Rationale: The standard physical assessment sequence is modified for the abdomen to
avoid stimulating bowel activity. Auscultation is performed immediately after inspection to
ensure that the bowel sounds heard are natural and not induced by manual manipulation.
Percussion and palpation are done last because they can alter the frequency and intensity
of bowel sounds.
2. An S3 heart sound is heard in a 65-year-old patient. The nurse understands this finding
most likely indicates:
A. Early sign of heart failure or fluid overload
B. A normal physiological variation in aging
,C. Closure of the semilunar valves
D. Stenosis of the aortic valve
Correct Answer: A
Rationale: While an S3 sound can be normal in children and young adults, it is often a sign
of pathology in older adults. It typically indicates decreased ventricular compliance or
volume overload, commonly seen in congestive heart failure. The nurse should follow up
this finding with a thorough assessment of the patient’s fluid status and respiratory system.
3. Which cranial nerve is being tested when the nurse asks the patient to smile, frown, and
puff out their cheeks?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve XII (Hypoglossal)
C. Cranial Nerve VII (Facial)
D. Cranial Nerve X (Vagus)
Correct Answer: C
Rationale: Cranial Nerve VII, the facial nerve, is responsible for the motor movements of
the face including smiling and frowning. Assessing for facial symmetry during these
maneuvers is a key part of the neurological exam. Cranial Nerve V, by contrast, is primarily
responsible for facial sensation and the muscles of mastication.
, 4. During a breast examination, where is the most common site for breast tumors to occur?
A. Upper outer quadrant (Tail of Spence)
B. Lower outer quadrant
C. Upper inner quadrant
D. Areolar region
Correct Answer: A
Rationale: The upper outer quadrant, which includes the Tail of Spence, is the most
frequent site for breast malignancies. This area contains a higher concentration of
glandular tissue compared to other quadrants. Therefore, nurses must ensure they palpate
all the way into the axillary region during a comprehensive clinical breast exam.
5. Which assessment technique is used to check for large amounts of fluid in the knee joint?
A. Ballottement of the patella
B. Bulge sign
C. McMurray test
D. Phalen test
Correct Answer: A
Rationale: Ballottement of the patella is used when larger amounts of fluid are suspected
in the knee. The nurse compresses the suprapatellar pouch and then pushes the patella
Assessment II Q&A with Rationale |
Chamberlain University
1. When assessing the abdomen, which of the following sequences is the correct physical
examination technique?
A. Inspection, Palpation, Percussion, Auscultation
B. Percussion, Inspection, Auscultation, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Inspection, Auscultation, Percussion, Palpation
Correct Answer: D
Rationale: The standard physical assessment sequence is modified for the abdomen to
avoid stimulating bowel activity. Auscultation is performed immediately after inspection to
ensure that the bowel sounds heard are natural and not induced by manual manipulation.
Percussion and palpation are done last because they can alter the frequency and intensity
of bowel sounds.
2. An S3 heart sound is heard in a 65-year-old patient. The nurse understands this finding
most likely indicates:
A. Early sign of heart failure or fluid overload
B. A normal physiological variation in aging
,C. Closure of the semilunar valves
D. Stenosis of the aortic valve
Correct Answer: A
Rationale: While an S3 sound can be normal in children and young adults, it is often a sign
of pathology in older adults. It typically indicates decreased ventricular compliance or
volume overload, commonly seen in congestive heart failure. The nurse should follow up
this finding with a thorough assessment of the patient’s fluid status and respiratory system.
3. Which cranial nerve is being tested when the nurse asks the patient to smile, frown, and
puff out their cheeks?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve XII (Hypoglossal)
C. Cranial Nerve VII (Facial)
D. Cranial Nerve X (Vagus)
Correct Answer: C
Rationale: Cranial Nerve VII, the facial nerve, is responsible for the motor movements of
the face including smiling and frowning. Assessing for facial symmetry during these
maneuvers is a key part of the neurological exam. Cranial Nerve V, by contrast, is primarily
responsible for facial sensation and the muscles of mastication.
, 4. During a breast examination, where is the most common site for breast tumors to occur?
A. Upper outer quadrant (Tail of Spence)
B. Lower outer quadrant
C. Upper inner quadrant
D. Areolar region
Correct Answer: A
Rationale: The upper outer quadrant, which includes the Tail of Spence, is the most
frequent site for breast malignancies. This area contains a higher concentration of
glandular tissue compared to other quadrants. Therefore, nurses must ensure they palpate
all the way into the axillary region during a comprehensive clinical breast exam.
5. Which assessment technique is used to check for large amounts of fluid in the knee joint?
A. Ballottement of the patella
B. Bulge sign
C. McMurray test
D. Phalen test
Correct Answer: A
Rationale: Ballottement of the patella is used when larger amounts of fluid are suspected
in the knee. The nurse compresses the suprapatellar pouch and then pushes the patella
