NURS 340 HEALTH ASSESSMENT EXAM 2 STUDY
GUIDE SPRING 2020 EXAM with Questions and
Answers/Plus a Rationale Updated 2026 A+/Instant
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EXAM COVERAGE
1. Assessment of the Skin, Hair, and Nails
2. Head, Face, and Neck Assessment
3. Eye and Ear Assessment
4. Nose, Mouth, and Throat Assessment
5. Thoracic and Lung Assessment
6. Heart and Peripheral Vascular Assessment
7. Abdominal Assessment
8. Musculoskeletal System Assessment
9. Neurological System Assessment
10. Documentation and Clinical Reasoning
1. A patient presents with a suspicious pigmented lesion on the forearm. Which characteristics,
identified during the physical examination, would warrant an urgent referral for biopsy based on
the ABCDE criteria for melanoma?
A. Symmetry of the lesion with a uniform tan color.
B. Irregular, scalloped borders and color variegation.
, C. A diameter of 3mm with a well-defined border.
D. Absence of crusting or bleeding at the site.
Answer: B
CORRECT ANSWER : B
Rationale: The ABCDE criteria for melanoma include Asymmetry, Border irregularity, Color
variegation, Diameter greater than 6mm, and Evolution. Option B matches the criteria for
borders and color, whereas A, C, and D are characteristic of benign nevi.
2. During the assessment of the thyroid gland, the nurse performs posterior palpation. What finding
should the nurse document as abnormal?
A. The thyroid isthmus is palpable at the suprasternal notch.
B. A firm, fixed, non-tender nodule that does not move with swallowing.
C. The lateral lobes are smooth and barely palpable.
D. The thyroid gland is not palpable in a normal, healthy adult.
Answer: B
CORRECT ANSWER : B
Rationale: A nodule that is fixed and does not move with swallowing is highly suspicious for
malignancy. Options A, C, and D are common findings or normal variants in the physical
assessment of the thyroid.
3. A patient reports a sudden decrease in visual acuity in the left eye, describing it as a "curtain
coming down." What is the most likely clinical interpretation, and what is the immediate
priority?
A. Acute conjunctivitis; initiate antibiotic eye drops.
B. Retinal detachment; urgent ophthalmological consultation.
C. Cataract formation; schedule elective surgery.
D. Migraine aura; provide analgesics and dark room.
Answer: B
CORRECT ANSWER : B
, Rationale: A "curtain" visual loss is a classic symptom of retinal detachment, a medical
emergency requiring rapid intervention to prevent permanent blindness. The other conditions do
not present with this specific sensory pattern or require the same level of emergent care.
4. During auscultation of the lungs, the nurse notes high-pitched, musical sounds primarily during
expiration. How should this be documented?
A. Crackles (rales).
B. Wheezes.
C. Rhonchi.
D. Pleural friction rub.
Answer: B
CORRECT ANSWER : B
Rationale: Wheezes are musical, high-pitched sounds caused by airway obstruction or
narrowing. Crackles are discontinuous popping sounds, rhonchi are low-pitched snoring sounds,
and friction rubs are grating sounds.
5. A patient presents with localized right upper quadrant pain. Which assessment technique is most
specific for identifying cholecystitis?
A. Rebound tenderness at McBurney's point.
B. Murphy's sign.
C. Psoas sign.
D. Obturator sign.
Answer: B
CORRECT ANSWER : B
Rationale: Murphy's sign is elicited by deep palpation under the right costal margin during
inspiration; pain and cessation of inspiration indicate cholecystitis. McBurney's, Psoas, and
Obturator signs are utilized for appendicitis.
6. While assessing the peripheral vascular system, the nurse notes +1 pitting edema in the lower
extremities bilaterally. What does this indicate?
A. Normal finding in elderly patients.
, B. Fluid volume excess or venous insufficiency.
C. Arterial occlusion.
D. Lymphatic obstruction only.
Answer: B
CORRECT ANSWER : B
Rationale: Pitting edema indicates excess interstitial fluid, commonly resulting from heart
failure, venous insufficiency, or fluid overload. Arterial occlusion typically presents with cool,
pale limbs, not edema.
7. During the neurological exam, the patient exhibits a positive Romberg test. What does this
finding indicate?
A. Cerebellar dysfunction with eyes open.
B. Loss of proprioception or vestibular function.
C. Visual impairment.
D. Pyramidal tract damage.
Answer: B
CORRECT ANSWER : B
Rationale: A positive Romberg test, characterized by significant swaying or loss of balance when
the eyes are closed, indicates a deficit in proprioception or vestibular input. It is not primarily a
test of vision or pyramidal tracts.
8. When assessing the cardiovascular system, where is the point of maximal impulse (PMI)
typically located?
A. Second intercostal space, right sternal border.
B. Fifth intercostal space, midclavicular line.
C. Fourth intercostal space, left sternal border.
D. Epigastric area.
Answer: B
GUIDE SPRING 2020 EXAM with Questions and
Answers/Plus a Rationale Updated 2026 A+/Instant
Download PDF
EXAM COVERAGE
1. Assessment of the Skin, Hair, and Nails
2. Head, Face, and Neck Assessment
3. Eye and Ear Assessment
4. Nose, Mouth, and Throat Assessment
5. Thoracic and Lung Assessment
6. Heart and Peripheral Vascular Assessment
7. Abdominal Assessment
8. Musculoskeletal System Assessment
9. Neurological System Assessment
10. Documentation and Clinical Reasoning
1. A patient presents with a suspicious pigmented lesion on the forearm. Which characteristics,
identified during the physical examination, would warrant an urgent referral for biopsy based on
the ABCDE criteria for melanoma?
A. Symmetry of the lesion with a uniform tan color.
B. Irregular, scalloped borders and color variegation.
, C. A diameter of 3mm with a well-defined border.
D. Absence of crusting or bleeding at the site.
Answer: B
CORRECT ANSWER : B
Rationale: The ABCDE criteria for melanoma include Asymmetry, Border irregularity, Color
variegation, Diameter greater than 6mm, and Evolution. Option B matches the criteria for
borders and color, whereas A, C, and D are characteristic of benign nevi.
2. During the assessment of the thyroid gland, the nurse performs posterior palpation. What finding
should the nurse document as abnormal?
A. The thyroid isthmus is palpable at the suprasternal notch.
B. A firm, fixed, non-tender nodule that does not move with swallowing.
C. The lateral lobes are smooth and barely palpable.
D. The thyroid gland is not palpable in a normal, healthy adult.
Answer: B
CORRECT ANSWER : B
Rationale: A nodule that is fixed and does not move with swallowing is highly suspicious for
malignancy. Options A, C, and D are common findings or normal variants in the physical
assessment of the thyroid.
3. A patient reports a sudden decrease in visual acuity in the left eye, describing it as a "curtain
coming down." What is the most likely clinical interpretation, and what is the immediate
priority?
A. Acute conjunctivitis; initiate antibiotic eye drops.
B. Retinal detachment; urgent ophthalmological consultation.
C. Cataract formation; schedule elective surgery.
D. Migraine aura; provide analgesics and dark room.
Answer: B
CORRECT ANSWER : B
, Rationale: A "curtain" visual loss is a classic symptom of retinal detachment, a medical
emergency requiring rapid intervention to prevent permanent blindness. The other conditions do
not present with this specific sensory pattern or require the same level of emergent care.
4. During auscultation of the lungs, the nurse notes high-pitched, musical sounds primarily during
expiration. How should this be documented?
A. Crackles (rales).
B. Wheezes.
C. Rhonchi.
D. Pleural friction rub.
Answer: B
CORRECT ANSWER : B
Rationale: Wheezes are musical, high-pitched sounds caused by airway obstruction or
narrowing. Crackles are discontinuous popping sounds, rhonchi are low-pitched snoring sounds,
and friction rubs are grating sounds.
5. A patient presents with localized right upper quadrant pain. Which assessment technique is most
specific for identifying cholecystitis?
A. Rebound tenderness at McBurney's point.
B. Murphy's sign.
C. Psoas sign.
D. Obturator sign.
Answer: B
CORRECT ANSWER : B
Rationale: Murphy's sign is elicited by deep palpation under the right costal margin during
inspiration; pain and cessation of inspiration indicate cholecystitis. McBurney's, Psoas, and
Obturator signs are utilized for appendicitis.
6. While assessing the peripheral vascular system, the nurse notes +1 pitting edema in the lower
extremities bilaterally. What does this indicate?
A. Normal finding in elderly patients.
, B. Fluid volume excess or venous insufficiency.
C. Arterial occlusion.
D. Lymphatic obstruction only.
Answer: B
CORRECT ANSWER : B
Rationale: Pitting edema indicates excess interstitial fluid, commonly resulting from heart
failure, venous insufficiency, or fluid overload. Arterial occlusion typically presents with cool,
pale limbs, not edema.
7. During the neurological exam, the patient exhibits a positive Romberg test. What does this
finding indicate?
A. Cerebellar dysfunction with eyes open.
B. Loss of proprioception or vestibular function.
C. Visual impairment.
D. Pyramidal tract damage.
Answer: B
CORRECT ANSWER : B
Rationale: A positive Romberg test, characterized by significant swaying or loss of balance when
the eyes are closed, indicates a deficit in proprioception or vestibular input. It is not primarily a
test of vision or pyramidal tracts.
8. When assessing the cardiovascular system, where is the point of maximal impulse (PMI)
typically located?
A. Second intercostal space, right sternal border.
B. Fifth intercostal space, midclavicular line.
C. Fourth intercostal space, left sternal border.
D. Epigastric area.
Answer: B
