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GCU NSG 316 EXAM 2 - COMPREHENSIVE HEALTH ASSESSMENT STUDY GUIDE

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GCU NSG 316 EXAM 2 - COMPREHENSIVE HEALTH ASSESSMENT STUDY GUIDE

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GCU NSG 316 EXAM 2 -
COMPREHENSIVE HEALTH
ASSESSMENT STUDY GUIDE




1. When assessing for the S1 heart sound, the nurse knows that this sound is caused by which

physiological event?

A. Closure of the aortic and pulmonic valves


B. Closure of the mitral and tricuspid valves


C. Opening of the semilunar valves


D. The rapid filling phase of the ventricles


Answer: B


Conceptual Explanation: S1 occurs with the closure of the atrioventricular (mitral and

tricuspid) valves and signals the beginning of systole.


2. A patient presents with a history of chronic obstructive pulmonary disease (COPD). Which

chest configuration is the nurse most likely to observe?

A. Barrel chest


B. Kyphosis

,C. Pectus excavatum


D. Pectus carinatum


Answer: A


Conceptual Explanation: Barrel chest is characterized by an equal anteroposterior-to-

transverse diameter and is common in patients with chronic hyperinflation of the lungs,

such as in COPD.


3. In what order should the nurse perform an abdominal assessment?

A. Inspection, Palpation, Percussion, Auscultation


B. Inspection, Percussion, Palpation, Auscultation


C. Inspection, Auscultation, Percussion, Palpation


D. Auscultation, Inspection, Palpation, Percussion


Answer: C


Conceptual Explanation: Auscultation is performed second to prevent the manipulation

of the bowel during percussion or palpation from creating false bowel sounds.


4. During a cardiovascular assessment, the nurse notes a ‘thrill’ while palpating the fourth

intercostal space at the left sternal border. What does this finding indicate?

A. A normal heart contraction


B. A palpable vibration signifying a loud murmur


C. An enlarged lymph node

, D. Closure of the aortic valve


Answer: B


Conceptual Explanation: A thrill is a palpable vibration that often accompanies loud heart

murmurs (Grade IV or higher).


5. The nurse is assessing Cranial Nerve V (Trigeminal). Which of the following techniques is

appropriate?

A. Asking the patient to smile and puff out their cheeks


B. Testing the gag reflex


C. Testing visual acuity with a Snellen chart


D. Asking the patient to clench their teeth and testing light touch on the face


Answer: D


Conceptual Explanation: CN V is responsible for the muscles of mastication (motor) and

sensation to the face (sensory).


6. While assessing the lungs, the nurse hears high-pitched, musical sounds primarily during

expiration. How should the nurse document this?

A. Wheezes


B. Pleural friction rub


C. Coarse crackles


D. Stridor

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