NUR 3270/NUR3270 Exam 2 V3 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. When performing an abdominal assessment, which order of techniques should the nurse
follow?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Inspection, Percussion, Palpation, Auscultation
D. Auscultation, Inspection, Palpation, Percussion
Answer: A
Rationale: The abdomen is assessed in the sequence of inspection, auscultation,
percussion, and palpation. This order is unique because percussion and palpation can alter
bowel sounds and lead to an inaccurate assessment. By auscultating first, the nurse can
hear the natural sounds of the intestines before they are disturbed.
2. Where is the best anatomical location to auscultate the aortic valve?
A. Second intercostal space at the left sternal border
B. Second intercostal space at the right sternal border
C. Fifth intercostal space at the left midclavicular line
D. Fourth intercostal space at the left sternal border
,Answer: B
Rationale: The aortic valve is best heard at the second intercostal space to the right of the
sternum. This area corresponds to the outflow of blood from the left ventricle into the
aorta. Accurate placement of the stethoscope is essential for distinguishing heart sounds
during a cardiac exam.
3. During percussion of a healthy adult’s lung, what sound does the nurse expect to hear?
A. Tympany
B. Dullness
C. Hyperresonance
D. Resonance
Answer: D
Rationale: Resonance is the normal, low-pitched, clear, and hollow sound found in healthy
lung tissue. Dullness is typically heard over solid organs like the liver or over a
consolidated lung. Hyperresonance might indicate trapped air, such as in patients with
emphysema or pneumothorax.
4. Which cranial nerve is responsible for the movement of the tongue?
A. CN IX (Glossopharyngeal)
B. CN X (Vagus)
C. CN XI (Accessory)
, D. CN XII (Hypoglossal)
Answer: D
Rationale: The hypoglossal nerve, or cranial nerve XII, controls the muscles that move the
tongue. Nurses assess this by asking the patient to stick out their tongue and move it from
side to side. Any deviation or weakness could indicate a deficit in this specific cranial nerve.
5. What is the significance of hearing a ‘bruit’ during carotid artery auscultation?
A. It indicates normal laminar blood flow
B. It represents the closing of the carotid valves
C. It is a sign of healthy cardiac output
D. It suggests turbulent blood flow, often due to narrowing
Answer: D
Rationale: A bruit is a blowing or swishing sound heard through the stethoscope over a
vessel. It indicates turbulent blood flow, which is often caused by atherosclerotic
narrowing of the artery. Finding a bruit during an assessment may suggest an increased
risk for stroke or cardiovascular events.
6. Which heart sound is associated with the closure of the mitral and tricuspid valves?
A. S1
B. S2
C. S3
Health Assessment Q&A with Rationale |
William Paterson University
1. When performing an abdominal assessment, which order of techniques should the nurse
follow?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Inspection, Percussion, Palpation, Auscultation
D. Auscultation, Inspection, Palpation, Percussion
Answer: A
Rationale: The abdomen is assessed in the sequence of inspection, auscultation,
percussion, and palpation. This order is unique because percussion and palpation can alter
bowel sounds and lead to an inaccurate assessment. By auscultating first, the nurse can
hear the natural sounds of the intestines before they are disturbed.
2. Where is the best anatomical location to auscultate the aortic valve?
A. Second intercostal space at the left sternal border
B. Second intercostal space at the right sternal border
C. Fifth intercostal space at the left midclavicular line
D. Fourth intercostal space at the left sternal border
,Answer: B
Rationale: The aortic valve is best heard at the second intercostal space to the right of the
sternum. This area corresponds to the outflow of blood from the left ventricle into the
aorta. Accurate placement of the stethoscope is essential for distinguishing heart sounds
during a cardiac exam.
3. During percussion of a healthy adult’s lung, what sound does the nurse expect to hear?
A. Tympany
B. Dullness
C. Hyperresonance
D. Resonance
Answer: D
Rationale: Resonance is the normal, low-pitched, clear, and hollow sound found in healthy
lung tissue. Dullness is typically heard over solid organs like the liver or over a
consolidated lung. Hyperresonance might indicate trapped air, such as in patients with
emphysema or pneumothorax.
4. Which cranial nerve is responsible for the movement of the tongue?
A. CN IX (Glossopharyngeal)
B. CN X (Vagus)
C. CN XI (Accessory)
, D. CN XII (Hypoglossal)
Answer: D
Rationale: The hypoglossal nerve, or cranial nerve XII, controls the muscles that move the
tongue. Nurses assess this by asking the patient to stick out their tongue and move it from
side to side. Any deviation or weakness could indicate a deficit in this specific cranial nerve.
5. What is the significance of hearing a ‘bruit’ during carotid artery auscultation?
A. It indicates normal laminar blood flow
B. It represents the closing of the carotid valves
C. It is a sign of healthy cardiac output
D. It suggests turbulent blood flow, often due to narrowing
Answer: D
Rationale: A bruit is a blowing or swishing sound heard through the stethoscope over a
vessel. It indicates turbulent blood flow, which is often caused by atherosclerotic
narrowing of the artery. Finding a bruit during an assessment may suggest an increased
risk for stroke or cardiovascular events.
6. Which heart sound is associated with the closure of the mitral and tricuspid valves?
A. S1
B. S2
C. S3
