NUR 6001/NUR6001 Final Exam V2 |
Advanced Health Assessment Q&A with
Rationale | William Paterson University
1. During an abdominal assessment, the clinician performs Murphy’s sign. Which condition is
this maneuver specifically designed to detect?
A. Acute Appendicitis
B. Acute Cholecystitis
C. Splenomegaly
D. Nephrolithiasis
Answer: B
Rationale: Murphy’s sign is performed by palpating the right upper quadrant at the costal
margin while the patient inhales. A positive sign is indicated when the patient suddenly
stops breathing due to pain as the gallbladder touches the examiner’s hand. This test is
highly suggestive of inflammation of the gallbladder, known as acute cholecystitis.
2. A clinician hears a low-pitched extra heart sound early in diastole at the apex using the bell
of the stethoscope. What is the most likely interpretation of this S3 sound in an older adult?
A. Ventricular fluid overload or heart failure
B. Stenosis of the aortic valve
C. Normal physiological variant
,D. Incomplete closure of the mitral valve
Answer: A
Rationale: The S3 heart sound, or ventricular gallop, occurs right after S2 during the rapid
filling phase of the ventricles. In older adults, it is often a sign of decreased ventricular
compliance and fluid overload, common in congestive heart failure. It is best heard with the
bell at the apex while the patient is in the left lateral decubitus position.
3. When assessing Cranial Nerve XI (Spinal Accessory), which action should the clinician ask
the patient to perform?
A. Stick out the tongue and move it side to side
B. Shrug the shoulders against resistance
C. Smile, frown, and puff out the cheeks
D. Follow a moving finger through the six cardinal fields of gaze
Answer: B
Rationale: Cranial Nerve XI is a motor nerve that innervates the trapezius and
sternocleidomastoid muscles. To test its function, the clinician should evaluate the patient’s
ability to shrug their shoulders and turn their head against resistance. Weakness or
asymmetry during these maneuvers may indicate nerve damage or muscle pathology.
4. Which of the following physical exam findings is most characteristic of consolidated lung
tissue, such as in lobar pneumonia?
A. Increased tactile fremitus
, B. Hyperresonant percussion note
C. Decreased tactile fremitus
D. Vesicular breath sounds throughout
Answer: A
Rationale: Tactile fremitus is the vibration felt on the chest wall when the patient speaks.
Consolidation, like pneumonia, increases the density of the lung tissue, which conducts
vibrations better than air-filled tissue. Therefore, increased tactile fremitus is a hallmark
finding over areas of consolidated lung.
5. A positive Psoas sign is indicative of irritation to the psoas muscle. Which clinical condition
is this assessment maneuver primarily used to identify?
A. Diverticulitis
B. Pelvic Inflammatory Disease
C. Incarcerated Hernia
D. Acute Appendicitis
Answer: D
Rationale: The Psoas sign is elicited by having the patient lie on their left side while the
examiner extends the patient’s right hip. Pain during this maneuver suggests that an
inflamed appendix is irritating the underlying psoas muscle. It is one of several peritoneal
signs used to diagnose acute appendicitis in the clinical setting.
Advanced Health Assessment Q&A with
Rationale | William Paterson University
1. During an abdominal assessment, the clinician performs Murphy’s sign. Which condition is
this maneuver specifically designed to detect?
A. Acute Appendicitis
B. Acute Cholecystitis
C. Splenomegaly
D. Nephrolithiasis
Answer: B
Rationale: Murphy’s sign is performed by palpating the right upper quadrant at the costal
margin while the patient inhales. A positive sign is indicated when the patient suddenly
stops breathing due to pain as the gallbladder touches the examiner’s hand. This test is
highly suggestive of inflammation of the gallbladder, known as acute cholecystitis.
2. A clinician hears a low-pitched extra heart sound early in diastole at the apex using the bell
of the stethoscope. What is the most likely interpretation of this S3 sound in an older adult?
A. Ventricular fluid overload or heart failure
B. Stenosis of the aortic valve
C. Normal physiological variant
,D. Incomplete closure of the mitral valve
Answer: A
Rationale: The S3 heart sound, or ventricular gallop, occurs right after S2 during the rapid
filling phase of the ventricles. In older adults, it is often a sign of decreased ventricular
compliance and fluid overload, common in congestive heart failure. It is best heard with the
bell at the apex while the patient is in the left lateral decubitus position.
3. When assessing Cranial Nerve XI (Spinal Accessory), which action should the clinician ask
the patient to perform?
A. Stick out the tongue and move it side to side
B. Shrug the shoulders against resistance
C. Smile, frown, and puff out the cheeks
D. Follow a moving finger through the six cardinal fields of gaze
Answer: B
Rationale: Cranial Nerve XI is a motor nerve that innervates the trapezius and
sternocleidomastoid muscles. To test its function, the clinician should evaluate the patient’s
ability to shrug their shoulders and turn their head against resistance. Weakness or
asymmetry during these maneuvers may indicate nerve damage or muscle pathology.
4. Which of the following physical exam findings is most characteristic of consolidated lung
tissue, such as in lobar pneumonia?
A. Increased tactile fremitus
, B. Hyperresonant percussion note
C. Decreased tactile fremitus
D. Vesicular breath sounds throughout
Answer: A
Rationale: Tactile fremitus is the vibration felt on the chest wall when the patient speaks.
Consolidation, like pneumonia, increases the density of the lung tissue, which conducts
vibrations better than air-filled tissue. Therefore, increased tactile fremitus is a hallmark
finding over areas of consolidated lung.
5. A positive Psoas sign is indicative of irritation to the psoas muscle. Which clinical condition
is this assessment maneuver primarily used to identify?
A. Diverticulitis
B. Pelvic Inflammatory Disease
C. Incarcerated Hernia
D. Acute Appendicitis
Answer: D
Rationale: The Psoas sign is elicited by having the patient lie on their left side while the
examiner extends the patient’s right hip. Pain during this maneuver suggests that an
inflamed appendix is irritating the underlying psoas muscle. It is one of several peritoneal
signs used to diagnose acute appendicitis in the clinical setting.
