Chamberlain NR 304 Final Exam (pdf) | 2026/2027 | Health
Assessment II Q&A | Health Assessment
1. A nurse is performing a comprehensive health history on a client. Which
component of the health history provides the client's description of their
current symptoms?
A) Past medical history
B) Review of systems
C) Family history
D) History of present illness
Correct Answer: History of present illness
Rationale: The history of present illness (HPI) is a detailed description of the
client's current symptoms, including onset, location, duration,
characteristics, aggravating and relieving factors, and associated
manifestations. The past medical history includes previous diagnoses and
treatments, the review of systems is a systematic inquiry about body
systems, and the family history includes health information about blood
relatives.
2. A nurse is assessing a client's abdomen and notes that bowel sounds are
absent in all four quadrants. Which of the following conditions is most
consistent with this finding?
A) Gastroenteritis
B) Diarrhea
C) Paralytic ileus
D) Early bowel obstruction
Correct Answer: Paralytic ileus
,Rationale: Absent bowel sounds are a sign of a paralytic ileus, which occurs
when the muscle contractions that move food through the intestines are
temporarily paralyzed. Gastroenteritis and diarrhea are associated with
hyperactive bowel sounds, and early bowel obstruction may present with
hyperactive bowel sounds.
3. A nurse is performing a breast examination on a female client and notes a
peau d'orange appearance of the skin. Which of the following conditions is
most strongly suggested by this finding?
A) Fibrocystic breast disease
B) Paget's disease
C) Inflammatory breast cancer
D) A benign cyst
Correct Answer: Inflammatory breast cancer
Rationale: Peau d'orange (orange peel skin) is characterized by edema and
dimpling of the breast tissue, often caused by lymphatic obstruction from an
underlying malignancy. Inflammatory breast cancer is a rare but aggressive
form of breast cancer that commonly presents with this classic sign, along
with redness, warmth, and swelling.
4. A nurse is assessing a client's peripheral vascular system and notes cool,
pale extremities with diminished pulses. Which of the following conditions is
most consistent with these findings?
A) Venous insufficiency
B) Arterial insufficiency
C) Lymphedema
D) Cellulitis
Correct Answer: Arterial insufficiency
,Rationale: Arterial insufficiency results from decreased arterial blood flow to
the extremities, leading to cool, pale skin, diminished pulses, and hair loss.
This condition is often caused by atherosclerosis. Venous insufficiency
presents with brownish discoloration and edema, lymphedema with non-
pitting edema, and cellulitis with redness and warmth.
5. A nurse is assessing a client's neurological system and notes that the
client has a positive Romberg test. Which of the following is the correct
interpretation of this finding?
A) Normal cerebellar function
B) Loss of position sense
C) Impaired proprioception or vestibular function
D) A sign of lower motor neuron disease
Correct Answer: Impaired proprioception or vestibular function
Rationale: A positive Romberg test indicates that the client has difficulty
maintaining balance with their eyes closed, which suggests impaired
proprioception or vestibular function. The test is performed by asking the
client to stand with feet together and eyes closed; swaying or loss of balance
indicates a positive test.
6. A nurse is assessing a client's musculoskeletal system. Which of the
following terms describes the audible and palpable crunching or grating that
accompanies movement?
A) Crepitus
B) Clonus
C) Fasciculation
D) Spasticity
, Correct Answer: Crepitus
Rationale: Crepitus is an audible and palpable crunching or grating that
accompanies movement and occurs when articular surfaces in the joints are
roughened, as with osteoarthritis. Clonus is a series of rhythmic contractions,
fasciculations are involuntary muscle twitches, and spasticity is increased
muscle tone.
7. A nurse is assessing a client's abdomen and notes a bruit over the
abdominal aorta. This finding is most consistent with which of the following
conditions?
A) Normal bowel sounds
B) An abdominal aortic aneurysm
C) Hyperactive bowel sounds
D) A hernia
Correct Answer: An abdominal aortic aneurysm
Rationale: A bruit over the abdominal aorta is an abnormal vascular sound
that may indicate turbulent blood flow, often associated with an abdominal
aortic aneurysm or atherosclerosis. Bruits over the renal, iliac, or femoral
arteries are also abnormal and may indicate stenosis.
8. Which of the following is the correct order of techniques for a physical
assessment?
A) Palpation, Inspection, Percussion, Auscultation
B) Inspection, Palpation, Percussion, Auscultation
C) Auscultation, Inspection, Palpation, Percussion
D) Percussion, Auscultation, Inspection, Palpation
Assessment II Q&A | Health Assessment
1. A nurse is performing a comprehensive health history on a client. Which
component of the health history provides the client's description of their
current symptoms?
A) Past medical history
B) Review of systems
C) Family history
D) History of present illness
Correct Answer: History of present illness
Rationale: The history of present illness (HPI) is a detailed description of the
client's current symptoms, including onset, location, duration,
characteristics, aggravating and relieving factors, and associated
manifestations. The past medical history includes previous diagnoses and
treatments, the review of systems is a systematic inquiry about body
systems, and the family history includes health information about blood
relatives.
2. A nurse is assessing a client's abdomen and notes that bowel sounds are
absent in all four quadrants. Which of the following conditions is most
consistent with this finding?
A) Gastroenteritis
B) Diarrhea
C) Paralytic ileus
D) Early bowel obstruction
Correct Answer: Paralytic ileus
,Rationale: Absent bowel sounds are a sign of a paralytic ileus, which occurs
when the muscle contractions that move food through the intestines are
temporarily paralyzed. Gastroenteritis and diarrhea are associated with
hyperactive bowel sounds, and early bowel obstruction may present with
hyperactive bowel sounds.
3. A nurse is performing a breast examination on a female client and notes a
peau d'orange appearance of the skin. Which of the following conditions is
most strongly suggested by this finding?
A) Fibrocystic breast disease
B) Paget's disease
C) Inflammatory breast cancer
D) A benign cyst
Correct Answer: Inflammatory breast cancer
Rationale: Peau d'orange (orange peel skin) is characterized by edema and
dimpling of the breast tissue, often caused by lymphatic obstruction from an
underlying malignancy. Inflammatory breast cancer is a rare but aggressive
form of breast cancer that commonly presents with this classic sign, along
with redness, warmth, and swelling.
4. A nurse is assessing a client's peripheral vascular system and notes cool,
pale extremities with diminished pulses. Which of the following conditions is
most consistent with these findings?
A) Venous insufficiency
B) Arterial insufficiency
C) Lymphedema
D) Cellulitis
Correct Answer: Arterial insufficiency
,Rationale: Arterial insufficiency results from decreased arterial blood flow to
the extremities, leading to cool, pale skin, diminished pulses, and hair loss.
This condition is often caused by atherosclerosis. Venous insufficiency
presents with brownish discoloration and edema, lymphedema with non-
pitting edema, and cellulitis with redness and warmth.
5. A nurse is assessing a client's neurological system and notes that the
client has a positive Romberg test. Which of the following is the correct
interpretation of this finding?
A) Normal cerebellar function
B) Loss of position sense
C) Impaired proprioception or vestibular function
D) A sign of lower motor neuron disease
Correct Answer: Impaired proprioception or vestibular function
Rationale: A positive Romberg test indicates that the client has difficulty
maintaining balance with their eyes closed, which suggests impaired
proprioception or vestibular function. The test is performed by asking the
client to stand with feet together and eyes closed; swaying or loss of balance
indicates a positive test.
6. A nurse is assessing a client's musculoskeletal system. Which of the
following terms describes the audible and palpable crunching or grating that
accompanies movement?
A) Crepitus
B) Clonus
C) Fasciculation
D) Spasticity
, Correct Answer: Crepitus
Rationale: Crepitus is an audible and palpable crunching or grating that
accompanies movement and occurs when articular surfaces in the joints are
roughened, as with osteoarthritis. Clonus is a series of rhythmic contractions,
fasciculations are involuntary muscle twitches, and spasticity is increased
muscle tone.
7. A nurse is assessing a client's abdomen and notes a bruit over the
abdominal aorta. This finding is most consistent with which of the following
conditions?
A) Normal bowel sounds
B) An abdominal aortic aneurysm
C) Hyperactive bowel sounds
D) A hernia
Correct Answer: An abdominal aortic aneurysm
Rationale: A bruit over the abdominal aorta is an abnormal vascular sound
that may indicate turbulent blood flow, often associated with an abdominal
aortic aneurysm or atherosclerosis. Bruits over the renal, iliac, or femoral
arteries are also abnormal and may indicate stenosis.
8. Which of the following is the correct order of techniques for a physical
assessment?
A) Palpation, Inspection, Percussion, Auscultation
B) Inspection, Palpation, Percussion, Auscultation
C) Auscultation, Inspection, Palpation, Percussion
D) Percussion, Auscultation, Inspection, Palpation
