NUR 216 HEALTH ASSESSMENT EXAM 2
MASTERY FILE 150 REAL EXAM STYLE
HEAD TO TOE CLINICAL SCENARIOS
WITH DETAILED CORRECT ANSWERS
WITH RATIONALES SCORE GRADE A+ |
INSTANT DOWNLOADNUR 216 – HEALTH
ASSESSMENT EXAM 2: PRACTICE
QUESTIONS
1. A nurse practitioner is performing a routine physical
assessment on a 64-year-old male with a history of chronic
hypertension. Upon auscultating the apex of the heart with the
bell of the stethoscope, the nurse notes a low-pitched, late
diastolic sound occurring immediately before the first heart
sound (S1). How should the nurse accurately document this
finding, and what does it pathologically reflect?
A. S3 gallop; reflects rapid ventricular filling into a fluid-overloaded,
dilated ventricular chamber.
B. S4 gallop; reflects an atrial kick forcing blood into a stiff,
non-compliant ventricular wall secondary to ventricular
hypertrophy.
C. Midsystolic click; reflects structural prolapse of the mitral valve
leaflets into the left atrium.
D. Pericardial friction rub; reflects inflammation of the visceral and
parietal layers of the pericardium.
Correct Answer: B
Rationale: An S4 heart sound (atrial gallop) is a low-pitched sound
heard at the apex immediately before S1 (late diastole). It is caused by
the atria contracting to force blood into a stiff, non-compliant ventricle.
It is a classic finding in patients with structural left ventricular
hypertrophy secondary to long-standing, poorly controlled systemic
hypertension.
,2. While conducting an abdominal assessment on a 42-year-
old female patient complaining of right upper quadrant pain,
the nurse instructs the patient to take a deep breath while
deeply palpating beneath the right costal margin. The patient
abruptly halts inspiration due to severe pain. Which clinical
sign is positive, and what acute pathology does it indicate?
A. McBurney’s sign; acute appendicitis.
B. Murphy’s sign; acute cholecystitis.
C. Rovsing’s sign; peritoneal inflammation.
D. Iliopsoas sign; retrocecal abscess.
Correct Answer: B
Rationale: Murphy’s sign is explicitly used to assess for gallbladder
inflammation (acute cholecystitis). The nurse palpates the right upper
quadrant beneath the liver border while the patient inhales. If the
gallbladder is inflamed, its descent against the fingers causes sharp
pain, forcing the patient to abruptly stop inspiration.
3. A nurse is performing a comprehensive neurological
evaluation on a patient who sustained a head injury. When
testing the pupillary light reflex, the nurse shines a light
directly into the patient's right eye and observes that the right
pupil constricts immediately, but the left pupil remains
dilated. How should the nurse interpret this finding?
A. A normal, reactive direct and consensual pupillary light reflex.
B. An intact right oculomotor nerve (CN III) but a damaged right optic
nerve (CN II).
C. An intact right optic nerve (CN II) but a damaged or
compressed left oculomotor nerve (CN III).
D. Global brainstem death with a completely preserved sympathetic
pathway.
Correct Answer: C
Rationale: Shining a light into the right eye tests the right afferent
pathway (Optic nerve, CN II). Because the right eye reacts, the afferent
path is intact. The failure of the left pupil to constrict concurrently
(consensual light reflex) indicates a defect in the left efferent pathway,
which is governed by the left Oculomotor nerve (CN III).
4. During a respiratory assessment of a 68-year-old patient
with advanced emphysema, the nurse performs tactile
fremitus across the posterior thorax. Which finding is most
characteristic of this patient's underlying lung pathology?
,A. Decreased or absent tactile fremitus bilaterally across the
lung fields.
B. Increased tactile fremitus over the bilateral lower lung segments.
C. Rhythmic, asymmetric fremitus that increases exclusively during
expiration.
D. Hyper-resonant fremitus that mirrors the cardiac silhouette.
Correct Answer: A
Rationale: Tactile fremitus measures the transmission of vocal
vibrations through lung tissue to the chest wall. In emphysema, chronic
hyperinflation of the alveoli traps air, increasing the distance between
the lungs and the chest wall. This trapped air acts as a barrier,
resulting in significantly decreased or absent tactile fremitus.
5. A nurse is conducting a peripheral vascular assessment on a
patient with suspected deep vein thrombosis (DVT) in the left
lower extremity. Which group of physical assessment signs
should the nurse prioritize to confirm localized lower limb
vascular congestion and deep venous obstruction?
A. Pale, cold skin with a capillary refill time exceeding 5 seconds and
absent pedal pulses.
B. Asymmetrical calf circumference, localized unilateral
edema, warmth, and erythema.
C. Bilateral pitting edema extending up to the sacrum with generalized
skin coolness.
D. Dry, scaly skin with hyperpigmented brown macules and multiple
shallow punch-out ulcers.
Correct Answer: B
Rationale: Unilateral lower extremity changes are the classic
hallmarks of a DVT. The obstruction of a deep vein triggers localized
venous congestion, presenting as asymmetrical calf swelling
(circumference difference greater than 3 cm), localized warmth,
erythema, and pitting edema in the affected leg.
6. While assessing the musculoskeletal system of a 55-year-old
female with suspected osteoarthritis, the nurse notes hard,
non-tender, bony enlargements located on the distal
interphalangeal (DIP) joints of the patient’s fingers. How
should the nurse accurately document these physical findings?
A. Bouchard’s nodes.
B. Heberden’s nodes.
C. Tophi deposits.
, D. Rheumatoid nodules.
Correct Answer: B
Rationale: Heberden’s nodes are classic bony overgrowths
(osteophytes) that form on the distal interphalangeal (DIP) joints of the
fingers in patients with osteoarthritis. Similar enlargements on the
proximal interphalangeal (PIP) joints are called Bouchard’s nodes.
7. A nurse is testing the functions of the cranial nerves during
a routine physical examination. The nurse asks the patient to
tightly close their eyes, smile, frown, puff out their cheeks, and
elevate their eyebrows. Which specific cranial nerve is
evaluated by these motor movements?
A. Cranial Nerve V (Trigeminal Nerve).
B. Cranial Nerve VII (Facial Nerve).
C. Cranial Nerve IX (Glossopharyngeal Nerve).
D. Cranial Nerve XII (Hypoglossal Nerve).
Correct Answer: B
Rationale: Cranial Nerve VII (the Facial nerve) controls all muscles of
facial expression. Asking the patient to smile, frown, wrinkle the
forehead, tightly close the eyes against resistance, and puff out the
cheeks evaluates the motor branches of this nerve.
8. While performing a thoracic assessment on a 22-year-old
healthy college student, the nurse percusses the lung fields
across the intercostal spaces. Which percussion sound should
the nurse expect to elicit over normal, air-filled lung tissue?
A. Tympany.
B. Hyper-resonance.
C. Resonance.
D. Dullness.
Correct Answer: C
Rationale: Resonance is a clear, hollow sound elicited over normal, air-
filled lung parenchyma. Tympany is heard over air-filled viscera like
the stomach; hyper-resonance points to hyperinflated lungs (as in
COPD); and dullness occurs over solid organs or fluid collections.
9. A nurse is performing an abdominal assessment on a
patient suspected of having a mechanical bowel obstruction.
Which specific sequence of physical assessment techniques
must the nurse follow to prevent altering bowel sounds?
A. Inspection, Palpation, Percussion, Auscultation.
B. Inspection, Auscultation, Percussion, Palpation.
MASTERY FILE 150 REAL EXAM STYLE
HEAD TO TOE CLINICAL SCENARIOS
WITH DETAILED CORRECT ANSWERS
WITH RATIONALES SCORE GRADE A+ |
INSTANT DOWNLOADNUR 216 – HEALTH
ASSESSMENT EXAM 2: PRACTICE
QUESTIONS
1. A nurse practitioner is performing a routine physical
assessment on a 64-year-old male with a history of chronic
hypertension. Upon auscultating the apex of the heart with the
bell of the stethoscope, the nurse notes a low-pitched, late
diastolic sound occurring immediately before the first heart
sound (S1). How should the nurse accurately document this
finding, and what does it pathologically reflect?
A. S3 gallop; reflects rapid ventricular filling into a fluid-overloaded,
dilated ventricular chamber.
B. S4 gallop; reflects an atrial kick forcing blood into a stiff,
non-compliant ventricular wall secondary to ventricular
hypertrophy.
C. Midsystolic click; reflects structural prolapse of the mitral valve
leaflets into the left atrium.
D. Pericardial friction rub; reflects inflammation of the visceral and
parietal layers of the pericardium.
Correct Answer: B
Rationale: An S4 heart sound (atrial gallop) is a low-pitched sound
heard at the apex immediately before S1 (late diastole). It is caused by
the atria contracting to force blood into a stiff, non-compliant ventricle.
It is a classic finding in patients with structural left ventricular
hypertrophy secondary to long-standing, poorly controlled systemic
hypertension.
,2. While conducting an abdominal assessment on a 42-year-
old female patient complaining of right upper quadrant pain,
the nurse instructs the patient to take a deep breath while
deeply palpating beneath the right costal margin. The patient
abruptly halts inspiration due to severe pain. Which clinical
sign is positive, and what acute pathology does it indicate?
A. McBurney’s sign; acute appendicitis.
B. Murphy’s sign; acute cholecystitis.
C. Rovsing’s sign; peritoneal inflammation.
D. Iliopsoas sign; retrocecal abscess.
Correct Answer: B
Rationale: Murphy’s sign is explicitly used to assess for gallbladder
inflammation (acute cholecystitis). The nurse palpates the right upper
quadrant beneath the liver border while the patient inhales. If the
gallbladder is inflamed, its descent against the fingers causes sharp
pain, forcing the patient to abruptly stop inspiration.
3. A nurse is performing a comprehensive neurological
evaluation on a patient who sustained a head injury. When
testing the pupillary light reflex, the nurse shines a light
directly into the patient's right eye and observes that the right
pupil constricts immediately, but the left pupil remains
dilated. How should the nurse interpret this finding?
A. A normal, reactive direct and consensual pupillary light reflex.
B. An intact right oculomotor nerve (CN III) but a damaged right optic
nerve (CN II).
C. An intact right optic nerve (CN II) but a damaged or
compressed left oculomotor nerve (CN III).
D. Global brainstem death with a completely preserved sympathetic
pathway.
Correct Answer: C
Rationale: Shining a light into the right eye tests the right afferent
pathway (Optic nerve, CN II). Because the right eye reacts, the afferent
path is intact. The failure of the left pupil to constrict concurrently
(consensual light reflex) indicates a defect in the left efferent pathway,
which is governed by the left Oculomotor nerve (CN III).
4. During a respiratory assessment of a 68-year-old patient
with advanced emphysema, the nurse performs tactile
fremitus across the posterior thorax. Which finding is most
characteristic of this patient's underlying lung pathology?
,A. Decreased or absent tactile fremitus bilaterally across the
lung fields.
B. Increased tactile fremitus over the bilateral lower lung segments.
C. Rhythmic, asymmetric fremitus that increases exclusively during
expiration.
D. Hyper-resonant fremitus that mirrors the cardiac silhouette.
Correct Answer: A
Rationale: Tactile fremitus measures the transmission of vocal
vibrations through lung tissue to the chest wall. In emphysema, chronic
hyperinflation of the alveoli traps air, increasing the distance between
the lungs and the chest wall. This trapped air acts as a barrier,
resulting in significantly decreased or absent tactile fremitus.
5. A nurse is conducting a peripheral vascular assessment on a
patient with suspected deep vein thrombosis (DVT) in the left
lower extremity. Which group of physical assessment signs
should the nurse prioritize to confirm localized lower limb
vascular congestion and deep venous obstruction?
A. Pale, cold skin with a capillary refill time exceeding 5 seconds and
absent pedal pulses.
B. Asymmetrical calf circumference, localized unilateral
edema, warmth, and erythema.
C. Bilateral pitting edema extending up to the sacrum with generalized
skin coolness.
D. Dry, scaly skin with hyperpigmented brown macules and multiple
shallow punch-out ulcers.
Correct Answer: B
Rationale: Unilateral lower extremity changes are the classic
hallmarks of a DVT. The obstruction of a deep vein triggers localized
venous congestion, presenting as asymmetrical calf swelling
(circumference difference greater than 3 cm), localized warmth,
erythema, and pitting edema in the affected leg.
6. While assessing the musculoskeletal system of a 55-year-old
female with suspected osteoarthritis, the nurse notes hard,
non-tender, bony enlargements located on the distal
interphalangeal (DIP) joints of the patient’s fingers. How
should the nurse accurately document these physical findings?
A. Bouchard’s nodes.
B. Heberden’s nodes.
C. Tophi deposits.
, D. Rheumatoid nodules.
Correct Answer: B
Rationale: Heberden’s nodes are classic bony overgrowths
(osteophytes) that form on the distal interphalangeal (DIP) joints of the
fingers in patients with osteoarthritis. Similar enlargements on the
proximal interphalangeal (PIP) joints are called Bouchard’s nodes.
7. A nurse is testing the functions of the cranial nerves during
a routine physical examination. The nurse asks the patient to
tightly close their eyes, smile, frown, puff out their cheeks, and
elevate their eyebrows. Which specific cranial nerve is
evaluated by these motor movements?
A. Cranial Nerve V (Trigeminal Nerve).
B. Cranial Nerve VII (Facial Nerve).
C. Cranial Nerve IX (Glossopharyngeal Nerve).
D. Cranial Nerve XII (Hypoglossal Nerve).
Correct Answer: B
Rationale: Cranial Nerve VII (the Facial nerve) controls all muscles of
facial expression. Asking the patient to smile, frown, wrinkle the
forehead, tightly close the eyes against resistance, and puff out the
cheeks evaluates the motor branches of this nerve.
8. While performing a thoracic assessment on a 22-year-old
healthy college student, the nurse percusses the lung fields
across the intercostal spaces. Which percussion sound should
the nurse expect to elicit over normal, air-filled lung tissue?
A. Tympany.
B. Hyper-resonance.
C. Resonance.
D. Dullness.
Correct Answer: C
Rationale: Resonance is a clear, hollow sound elicited over normal, air-
filled lung parenchyma. Tympany is heard over air-filled viscera like
the stomach; hyper-resonance points to hyperinflated lungs (as in
COPD); and dullness occurs over solid organs or fluid collections.
9. A nurse is performing an abdominal assessment on a
patient suspected of having a mechanical bowel obstruction.
Which specific sequence of physical assessment techniques
must the nurse follow to prevent altering bowel sounds?
A. Inspection, Palpation, Percussion, Auscultation.
B. Inspection, Auscultation, Percussion, Palpation.
