NRSG 2220 HEALTH ASSESSMENT
EXAM 3 MASTER EVALUATOR 150
CLINICAL SCENARIOS WITH
DETAILED CORRECT ANSWERS WITH
RATIONALES CORRECT VERIFIED
ANSWERS GRADE A+ MATERIAL |
INSTANT DOWNLOAD | 100% PASS
GUARANTEE
1. A 64-year-old male client with a history of chronic
obstructive pulmonary disease (COPD) presents with
worsening shortness of breath. While performing a
respiratory assessment, the nurse utilizes chest percussion
to evaluate the underlying lung tissues. Which percussion
note does the nurse anticipate hearing over hyperinflated
lung fields, and what does this sound indicate?
A. Dullness; this indicates the presence of high-density
fluid or solid tumor tissue in the alveolar spaces.
B. Hyperresonance; this indicates a loud, low-
pitched sound representing an abnormal increase
in trapped air within the lungs.
C. Tympany; this indicates a drum-like sound normally
heard over air-filled abdominal structures like the
stomach.
D. Flatness; this indicates an absolute lack of resonance
over dense skeletal muscle groups or bone tissue.
Correct Answer: B. Rationale: Hyperresonance is
an abnormal, loud, low-pitched sound elicited over
hyperinflated lungs, characteristically found in clients
with emphysema or COPD due to air trapping. Dullness
, is heard over fluid or consolidation, tympany over air-
filled viscera, and flatness over dense bone or muscle.
[1]
2. During a routine comprehensive physical assessment of an
82-year-old female resident in a skilled nursing facility,
the nurse inspects the oral cavity. The nurse notes a dry,
bright red, shiny tongue that is completely devoid of
papillae. How should the nurse document this finding, and
what underlying nutritional deficiency does it typically
represent?
A. Leukoplakia; this condition represents a premalignant
lesion associated with chronic tobacco use.
B. Aphthous ulcer; this finding indicates a painful,
localized immunological reaction to emotional stress.
C. Atrophic glossitis; this finding indicates smooth
tongue surfaces highly characteristic of vitamin
B12 or iron deficiency anemia.
D. Black hairy tongue; this represents a benign fungal
overgrowth secondary to systemic broad-spectrum
antibiotic therapy.
Correct Answer: C. Rationale: Atrophic glossitis
is characterized by a smooth, glossy tongue surface
lacking papillae, which occurs because of epithelial
atrophy caused by nutritional deficiencies such as
vitamin B12, folic acid, or iron deficiency.
3. The nurse is assessing a 45-year-old female client who
complains of localized pain and swelling in her neck. To
palpate the thyroid gland using the posterior approach,
how should the nurse position the client and instruct them
to facilitate safe and accurate configuration mapping?
A. Stand in front of the client, tilt their head backward,
and ask them to perform deep inspiration.
B. Stand behind the client, have them flex their neck
toward the opposite shoulder, and ask them to cough
, forcefully.
C. Stand behind the client, tilt their head slightly
forward and to the right, and use the fingers of the
left hand to displace the trachea while the right
hand palpates the lobe as the client swallows a sip
of water.
D. Stand to the right side of the client, hyperextend their
neck, and press firmly against the cricoid cartilage while
they remain perfectly silent.
Correct Answer: C. Rationale: The posterior
approach requires the nurse to stand behind the client.
Tilting the head slightly forward and toward the side
being examined relaxes the sternocleidomastoid muscle.
Displacing the trachea allows the examining fingers to
palpate the thyroid tissue against the larynx as it rises
during swallowing.
4. A 22-year-old male client is brought to the emergency
department following a motor vehicle collision where his
chest struck the steering wheel. During the physical
examination, the nurse notes asymmetric chest expansion,
where the right side of the chest fails to expand during
inspiration. What is the nurse's immediate priority, and
what clinical condition does this finding strongly suggest?
A. Palpate for tactile fremitus; this indicates a normal
structural variation in young athletic males.
B. Assess for egophony; this indicates a mild bronchitic
condition requiring warm humidified oxygen therapy.
C. Auscultate bilateral lung sounds immediately;
this indicates potential pneumothorax or flail
chest requiring urgent stabilization.
D. Measure diaphragmatic excursion; this indicates a
paralyzed diaphragm that should be re-evaluated in 24
hours.
Correct Answer: C. Rationale: Asymmetric chest
, expansion is a critical finding that suggests a structural
collapse of the lung (pneumothorax), hemothorax, or rib
fractures (flail chest). The immediate priority is to assess
breath sounds to evaluate ventilation and determine if
emergency chest tube placement is required.
5. While performing a cardiovascular assessment on a 58-
year-old female client with a history of chronic mitral
valve insufficiency, the nurse auscultates the heart sounds.
The nurse identifies a high-pitched, blowing pansystolic
murmur heard loudest at the apex that radiates directly
into the left axilla. Which valvular defect is responsible for
this specific murmur?
A. Aortic stenosis
B. Mitral stenosis
C. Mitral regurgitation
D. Tricupisd stenosis
Correct Answer: C. Rationale: A mitral
regurgitation murmur is characteristically pansystolic
(holosystolic), loud, high-pitched, and blowing. It is heard
best at the apex (mitral area) and radiates to the left
axilla because backflow occurs throughout systole from
the left ventricle to the left atrium.
6. The nurse is executing a neurological and musculoskeletal
health assessment on a 70-year-old male client with
suspected Parkinson's disease. While assessing the client’s
upper extremities for muscle tone, the nurse notes a jerky,
rhythmic, intermittent resistance to passive elongation
that feels like a wheel with teeth catching. How should the
nurse document this specific clinical finding?
A. Flaccidity
B. Spasticity
C. Cogwheel rigidity
D. Lead-pipe rigidity
Correct Answer: C. Rationale: Cogwheel rigidity
EXAM 3 MASTER EVALUATOR 150
CLINICAL SCENARIOS WITH
DETAILED CORRECT ANSWERS WITH
RATIONALES CORRECT VERIFIED
ANSWERS GRADE A+ MATERIAL |
INSTANT DOWNLOAD | 100% PASS
GUARANTEE
1. A 64-year-old male client with a history of chronic
obstructive pulmonary disease (COPD) presents with
worsening shortness of breath. While performing a
respiratory assessment, the nurse utilizes chest percussion
to evaluate the underlying lung tissues. Which percussion
note does the nurse anticipate hearing over hyperinflated
lung fields, and what does this sound indicate?
A. Dullness; this indicates the presence of high-density
fluid or solid tumor tissue in the alveolar spaces.
B. Hyperresonance; this indicates a loud, low-
pitched sound representing an abnormal increase
in trapped air within the lungs.
C. Tympany; this indicates a drum-like sound normally
heard over air-filled abdominal structures like the
stomach.
D. Flatness; this indicates an absolute lack of resonance
over dense skeletal muscle groups or bone tissue.
Correct Answer: B. Rationale: Hyperresonance is
an abnormal, loud, low-pitched sound elicited over
hyperinflated lungs, characteristically found in clients
with emphysema or COPD due to air trapping. Dullness
, is heard over fluid or consolidation, tympany over air-
filled viscera, and flatness over dense bone or muscle.
[1]
2. During a routine comprehensive physical assessment of an
82-year-old female resident in a skilled nursing facility,
the nurse inspects the oral cavity. The nurse notes a dry,
bright red, shiny tongue that is completely devoid of
papillae. How should the nurse document this finding, and
what underlying nutritional deficiency does it typically
represent?
A. Leukoplakia; this condition represents a premalignant
lesion associated with chronic tobacco use.
B. Aphthous ulcer; this finding indicates a painful,
localized immunological reaction to emotional stress.
C. Atrophic glossitis; this finding indicates smooth
tongue surfaces highly characteristic of vitamin
B12 or iron deficiency anemia.
D. Black hairy tongue; this represents a benign fungal
overgrowth secondary to systemic broad-spectrum
antibiotic therapy.
Correct Answer: C. Rationale: Atrophic glossitis
is characterized by a smooth, glossy tongue surface
lacking papillae, which occurs because of epithelial
atrophy caused by nutritional deficiencies such as
vitamin B12, folic acid, or iron deficiency.
3. The nurse is assessing a 45-year-old female client who
complains of localized pain and swelling in her neck. To
palpate the thyroid gland using the posterior approach,
how should the nurse position the client and instruct them
to facilitate safe and accurate configuration mapping?
A. Stand in front of the client, tilt their head backward,
and ask them to perform deep inspiration.
B. Stand behind the client, have them flex their neck
toward the opposite shoulder, and ask them to cough
, forcefully.
C. Stand behind the client, tilt their head slightly
forward and to the right, and use the fingers of the
left hand to displace the trachea while the right
hand palpates the lobe as the client swallows a sip
of water.
D. Stand to the right side of the client, hyperextend their
neck, and press firmly against the cricoid cartilage while
they remain perfectly silent.
Correct Answer: C. Rationale: The posterior
approach requires the nurse to stand behind the client.
Tilting the head slightly forward and toward the side
being examined relaxes the sternocleidomastoid muscle.
Displacing the trachea allows the examining fingers to
palpate the thyroid tissue against the larynx as it rises
during swallowing.
4. A 22-year-old male client is brought to the emergency
department following a motor vehicle collision where his
chest struck the steering wheel. During the physical
examination, the nurse notes asymmetric chest expansion,
where the right side of the chest fails to expand during
inspiration. What is the nurse's immediate priority, and
what clinical condition does this finding strongly suggest?
A. Palpate for tactile fremitus; this indicates a normal
structural variation in young athletic males.
B. Assess for egophony; this indicates a mild bronchitic
condition requiring warm humidified oxygen therapy.
C. Auscultate bilateral lung sounds immediately;
this indicates potential pneumothorax or flail
chest requiring urgent stabilization.
D. Measure diaphragmatic excursion; this indicates a
paralyzed diaphragm that should be re-evaluated in 24
hours.
Correct Answer: C. Rationale: Asymmetric chest
, expansion is a critical finding that suggests a structural
collapse of the lung (pneumothorax), hemothorax, or rib
fractures (flail chest). The immediate priority is to assess
breath sounds to evaluate ventilation and determine if
emergency chest tube placement is required.
5. While performing a cardiovascular assessment on a 58-
year-old female client with a history of chronic mitral
valve insufficiency, the nurse auscultates the heart sounds.
The nurse identifies a high-pitched, blowing pansystolic
murmur heard loudest at the apex that radiates directly
into the left axilla. Which valvular defect is responsible for
this specific murmur?
A. Aortic stenosis
B. Mitral stenosis
C. Mitral regurgitation
D. Tricupisd stenosis
Correct Answer: C. Rationale: A mitral
regurgitation murmur is characteristically pansystolic
(holosystolic), loud, high-pitched, and blowing. It is heard
best at the apex (mitral area) and radiates to the left
axilla because backflow occurs throughout systole from
the left ventricle to the left atrium.
6. The nurse is executing a neurological and musculoskeletal
health assessment on a 70-year-old male client with
suspected Parkinson's disease. While assessing the client’s
upper extremities for muscle tone, the nurse notes a jerky,
rhythmic, intermittent resistance to passive elongation
that feels like a wheel with teeth catching. How should the
nurse document this specific clinical finding?
A. Flaccidity
B. Spasticity
C. Cogwheel rigidity
D. Lead-pipe rigidity
Correct Answer: C. Rationale: Cogwheel rigidity
