NRS 420 Exam 2 V1 | NRS 420 Health
Assessment | Actual Q&A with Rationale
(NRS420 Exam 2) | Grand Canyon
University
1. A nurse is assessing a patient with suspected left-sided heart failure. Which of the
following clinical manifestations should the nurse expect to find? (Select all that apply.)
A. Orthopnea
B. Crackles at the lung bases
C. Peripheral edema
D. Dyspnea on exertion
E. Jugular venous distention
F. Paroxysmal nocturnal dyspnea
Correct Answer: A, B, D, F
Rationale: Left-sided heart failure typically presents with respiratory-related symptoms
due to pulmonary congestion. Symptoms such as orthopnea, crackles, and paroxysmal
nocturnal dyspnea occur when fluid backs up into the lungs. Peripheral edema and jugular
venous distention are more characteristic of right-sided heart failure.
,2. When performing a physical assessment of the abdomen, in which order should the nurse
perform the following techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Palpation, Inspection, Auscultation
Correct Answer: B
Rationale: The correct sequence for abdominal assessment is inspection, auscultation,
percussion, and then palpation. This specific order is used to ensure that percussion and
palpation do not alter the frequency and intensity of bowel sounds. Auscultating
immediately after inspection provides the most accurate clinical picture of bowel activity.
3. A nurse is assessing the cranial nerves of a patient. To test Cranial Nerve XII (Hypoglossal),
which action should the nurse ask the patient to perform?
A. Shrug the shoulders against resistance
B. Stick out the tongue and move it side to side
C. Follow an object through the six cardinal fields of gaze
D. Smile, frown, and puff out the cheeks
Correct Answer: B
, Rationale: The hypoglossal nerve (CN XII) is primarily a motor nerve that controls the
movement of the tongue. The nurse assesses this nerve by asking the patient to protrude
the tongue and move it from side to side to check for symmetry and strength. Shoulder
shrugging tests CN XI, cardinal gaze tests CN III, IV, and VI, and facial expressions test CN
VII.
4. During a musculoskeletal assessment, the nurse notes a grating sound and sensation when
the patient moves their knee. The nurse should document this finding as:
A. Subluxation
B. Ankylosis
C. Contracture
D. Crepitus
Correct Answer: D
Rationale: Crepitus is a dry, crackling, or grating sound or sensation produced by friction
between bone and cartilage or the fractured parts of a bone. It is frequently associated with
osteoarthritis or rheumatoid arthritis when joint surfaces are no longer smooth. This
finding should be carefully documented and reported to the provider for further diagnostic
evaluation.
5. The nurse is preparing to auscultate the heart sounds of a patient. Which location is the
best for hearing the S1 heart sound?
A. Second intercostal space at the right sternal border
Assessment | Actual Q&A with Rationale
(NRS420 Exam 2) | Grand Canyon
University
1. A nurse is assessing a patient with suspected left-sided heart failure. Which of the
following clinical manifestations should the nurse expect to find? (Select all that apply.)
A. Orthopnea
B. Crackles at the lung bases
C. Peripheral edema
D. Dyspnea on exertion
E. Jugular venous distention
F. Paroxysmal nocturnal dyspnea
Correct Answer: A, B, D, F
Rationale: Left-sided heart failure typically presents with respiratory-related symptoms
due to pulmonary congestion. Symptoms such as orthopnea, crackles, and paroxysmal
nocturnal dyspnea occur when fluid backs up into the lungs. Peripheral edema and jugular
venous distention are more characteristic of right-sided heart failure.
,2. When performing a physical assessment of the abdomen, in which order should the nurse
perform the following techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Palpation, Inspection, Auscultation
Correct Answer: B
Rationale: The correct sequence for abdominal assessment is inspection, auscultation,
percussion, and then palpation. This specific order is used to ensure that percussion and
palpation do not alter the frequency and intensity of bowel sounds. Auscultating
immediately after inspection provides the most accurate clinical picture of bowel activity.
3. A nurse is assessing the cranial nerves of a patient. To test Cranial Nerve XII (Hypoglossal),
which action should the nurse ask the patient to perform?
A. Shrug the shoulders against resistance
B. Stick out the tongue and move it side to side
C. Follow an object through the six cardinal fields of gaze
D. Smile, frown, and puff out the cheeks
Correct Answer: B
, Rationale: The hypoglossal nerve (CN XII) is primarily a motor nerve that controls the
movement of the tongue. The nurse assesses this nerve by asking the patient to protrude
the tongue and move it from side to side to check for symmetry and strength. Shoulder
shrugging tests CN XI, cardinal gaze tests CN III, IV, and VI, and facial expressions test CN
VII.
4. During a musculoskeletal assessment, the nurse notes a grating sound and sensation when
the patient moves their knee. The nurse should document this finding as:
A. Subluxation
B. Ankylosis
C. Contracture
D. Crepitus
Correct Answer: D
Rationale: Crepitus is a dry, crackling, or grating sound or sensation produced by friction
between bone and cartilage or the fractured parts of a bone. It is frequently associated with
osteoarthritis or rheumatoid arthritis when joint surfaces are no longer smooth. This
finding should be carefully documented and reported to the provider for further diagnostic
evaluation.
5. The nurse is preparing to auscultate the heart sounds of a patient. Which location is the
best for hearing the S1 heart sound?
A. Second intercostal space at the right sternal border
