NUR 6001/NUR6001 Exam 2 V3 | Advanced
Health Assessment Q&A with Rationale |
William Paterson University
1. During a cardiac assessment, the nurse notes the S1 heart sound. Which physiological
event corresponds to this sound?
A. Closure of the mitral and tricuspid valves
B. Closure of the aortic and pulmonic valves
C. Opening of the semilunar valves
D. The beginning of diastole
Answer: A
Rationale: The S1 heart sound, often described as ‘lub’, is produced by the closure of the
atrioventricular (AV) valves, which are the mitral and tricuspid valves. This sound signals
the beginning of systole as the ventricles contract and pressure rises. S2, on the other hand,
is the sound produced by the closure of the semilunar valves at the start of diastole.
2. When percussing the lungs of a patient with a large pneumothorax, what sound is the
nurse most likely to hear?
A. Hyperresonance
B. Dullness
C. Resonance
,D. Tympany
Answer: A
Rationale: Hyperresonance is a lower-pitched, booming sound found when too much air is
present in the lung or pleural space. This occurs in conditions such as emphysema or a
pneumothorax. Resonance is the normal sound found over healthy lung tissue, while
dullness indicates fluid or solid tissue.
3. In what order should the nurse perform the physical assessment of the abdomen?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Percussion, Auscultation, Inspection, Palpation
Answer: C
Rationale: The abdomen is assessed in the order of inspection, auscultation, percussion,
and then palpation. This specific sequence is used because percussion and palpation can
increase peristalsis, which would give a false interpretation of bowel sounds. By
auscultating first, the nurse captures the natural state of the gastrointestinal motility.
4. Where is the Tail of Spence located in the female breast?
A. Upper outer quadrant extending into the axilla
B. Upper inner quadrant near the clavicle
, C. Lower outer quadrant near the inframammary ridge
D. Lower inner quadrant near the sternum
Answer: A
Rationale: The Tail of Spence is the superior lateral corner of breast tissue that projects up
and laterally into the axilla. This area is particularly important because it is a common site
for the development of breast tumors. Assessment must always include this region to
ensure no masses are overlooked during a clinical breast exam.
5. A patient presents with a positive Murphy’s sign. This finding is highly suggestive of which
condition?
A. Appendicitis
B. Splenomegaly
C. Cholecystitis
D. Peritonitis
Answer: C
Rationale: Murphy’s sign is a test for gallbladder inflammation, also known as
cholecystitis. The test is performed by asking the patient to take a deep breath while the
examiner’s fingers are held under the liver border at the bottom of the right rib cage. A
positive sign is recorded if the patient experiences sharp pain and abruptly stops inhaling.
Health Assessment Q&A with Rationale |
William Paterson University
1. During a cardiac assessment, the nurse notes the S1 heart sound. Which physiological
event corresponds to this sound?
A. Closure of the mitral and tricuspid valves
B. Closure of the aortic and pulmonic valves
C. Opening of the semilunar valves
D. The beginning of diastole
Answer: A
Rationale: The S1 heart sound, often described as ‘lub’, is produced by the closure of the
atrioventricular (AV) valves, which are the mitral and tricuspid valves. This sound signals
the beginning of systole as the ventricles contract and pressure rises. S2, on the other hand,
is the sound produced by the closure of the semilunar valves at the start of diastole.
2. When percussing the lungs of a patient with a large pneumothorax, what sound is the
nurse most likely to hear?
A. Hyperresonance
B. Dullness
C. Resonance
,D. Tympany
Answer: A
Rationale: Hyperresonance is a lower-pitched, booming sound found when too much air is
present in the lung or pleural space. This occurs in conditions such as emphysema or a
pneumothorax. Resonance is the normal sound found over healthy lung tissue, while
dullness indicates fluid or solid tissue.
3. In what order should the nurse perform the physical assessment of the abdomen?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Percussion, Auscultation, Inspection, Palpation
Answer: C
Rationale: The abdomen is assessed in the order of inspection, auscultation, percussion,
and then palpation. This specific sequence is used because percussion and palpation can
increase peristalsis, which would give a false interpretation of bowel sounds. By
auscultating first, the nurse captures the natural state of the gastrointestinal motility.
4. Where is the Tail of Spence located in the female breast?
A. Upper outer quadrant extending into the axilla
B. Upper inner quadrant near the clavicle
, C. Lower outer quadrant near the inframammary ridge
D. Lower inner quadrant near the sternum
Answer: A
Rationale: The Tail of Spence is the superior lateral corner of breast tissue that projects up
and laterally into the axilla. This area is particularly important because it is a common site
for the development of breast tumors. Assessment must always include this region to
ensure no masses are overlooked during a clinical breast exam.
5. A patient presents with a positive Murphy’s sign. This finding is highly suggestive of which
condition?
A. Appendicitis
B. Splenomegaly
C. Cholecystitis
D. Peritonitis
Answer: C
Rationale: Murphy’s sign is a test for gallbladder inflammation, also known as
cholecystitis. The test is performed by asking the patient to take a deep breath while the
examiner’s fingers are held under the liver border at the bottom of the right rib cage. A
positive sign is recorded if the patient experiences sharp pain and abruptly stops inhaling.
