NSG 3160 HEALTH ASSESSMENT EXAM
2 QUESTIONS AND ANSWERS
1. When auscultating the heart, the nurse identifies a high-pitched, scratchy sound that is
heard loudest at the apex with the patient leaning forward. This finding most likely indicates:
A. An S4 gallop
B. A Grade III/VI systolic murmur
C. An S3 gallop
D. A pericardial friction rub
Answer: D
Conceptual Explanation: A pericardial friction rub is a high-pitched, scratchy,
extracardiac sound heard best with the diaphragm at the apex, often during expiration
when the patient leans forward.
2. A patient presents with a ‘blowing’ holosystolic murmur heard best at the apex that
radiates to the left axilla. The nurse should document this as:
A. Aortic Stenosis
B. Pulmonary Regurgitation
C. Tricuspid Stenosis
,D. Mitral Regurgitation
Answer: D
Conceptual Explanation: Mitral regurgitation typically produces a holosystolic murmur
heard best at the apex with radiation to the axilla.
3. While assessing the jugular venous pressure (JVP), the nurse notes the pulsation is 5 cm
above the sternal angle when the head of the bed is at 45 degrees. How should the nurse
interpret this?
A. This is a normal finding.
B. This indicates elevated venous pressure, possibly from heart failure.
C. This indicates dehydration or hypovolemia.
D. This indicates aortic regurgitation.
Answer: B
Conceptual Explanation: A JVP measurement greater than 3 cm above the sternal angle is
considered elevated and is a sign of increased central venous pressure, often seen in heart
failure.
4. When grading a heart murmur, the nurse notes a moderately loud murmur that is
associated with a palpable thrill. This murmur should be graded as:
A. Grade II/VI
B. Grade IV/VI
, C. Grade III/VI
D. Grade V/VI
Answer: B
Conceptual Explanation: Grade IV murmurs are loud and are the first grade at which a
palpable thrill is detectable.
5. The nurse is assessing a patient for peripheral vascular disease. The patient describes a
cramping pain in the calves that occurs with walking and is relieved by rest. This is known as:
A. Venous insufficiency
B. Intermittent claudication
C. Deep vein thrombosis
D. Raynaud’s phenomenon
Answer: B
Conceptual Explanation: Intermittent claudication is a hallmark symptom of arterial
insufficiency where muscle ischemia causes pain during activity.
6. To evaluate for the presence of a ‘thrill’ during a cardiac assessment, the nurse should use
which part of the hand?
A. The fingertips
B. The dorsal surface (back) of the hand
C. The ulnar surface or base of the fingers
2 QUESTIONS AND ANSWERS
1. When auscultating the heart, the nurse identifies a high-pitched, scratchy sound that is
heard loudest at the apex with the patient leaning forward. This finding most likely indicates:
A. An S4 gallop
B. A Grade III/VI systolic murmur
C. An S3 gallop
D. A pericardial friction rub
Answer: D
Conceptual Explanation: A pericardial friction rub is a high-pitched, scratchy,
extracardiac sound heard best with the diaphragm at the apex, often during expiration
when the patient leans forward.
2. A patient presents with a ‘blowing’ holosystolic murmur heard best at the apex that
radiates to the left axilla. The nurse should document this as:
A. Aortic Stenosis
B. Pulmonary Regurgitation
C. Tricuspid Stenosis
,D. Mitral Regurgitation
Answer: D
Conceptual Explanation: Mitral regurgitation typically produces a holosystolic murmur
heard best at the apex with radiation to the axilla.
3. While assessing the jugular venous pressure (JVP), the nurse notes the pulsation is 5 cm
above the sternal angle when the head of the bed is at 45 degrees. How should the nurse
interpret this?
A. This is a normal finding.
B. This indicates elevated venous pressure, possibly from heart failure.
C. This indicates dehydration or hypovolemia.
D. This indicates aortic regurgitation.
Answer: B
Conceptual Explanation: A JVP measurement greater than 3 cm above the sternal angle is
considered elevated and is a sign of increased central venous pressure, often seen in heart
failure.
4. When grading a heart murmur, the nurse notes a moderately loud murmur that is
associated with a palpable thrill. This murmur should be graded as:
A. Grade II/VI
B. Grade IV/VI
, C. Grade III/VI
D. Grade V/VI
Answer: B
Conceptual Explanation: Grade IV murmurs are loud and are the first grade at which a
palpable thrill is detectable.
5. The nurse is assessing a patient for peripheral vascular disease. The patient describes a
cramping pain in the calves that occurs with walking and is relieved by rest. This is known as:
A. Venous insufficiency
B. Intermittent claudication
C. Deep vein thrombosis
D. Raynaud’s phenomenon
Answer: B
Conceptual Explanation: Intermittent claudication is a hallmark symptom of arterial
insufficiency where muscle ischemia causes pain during activity.
6. To evaluate for the presence of a ‘thrill’ during a cardiac assessment, the nurse should use
which part of the hand?
A. The fingertips
B. The dorsal surface (back) of the hand
C. The ulnar surface or base of the fingers
