,NSG3160/NSG 3160 Exam 3 | Health Assessment |
Galen College | 26/27 Updated (PDF)
1. Which anatomical landmark is commonly used to count ribs and intercostal spaces during a thoracic
examination?
A) The sternal angle
B) The xiphoid process
C) The vertebra prominens
D) The clavicle
Correct Answer: The sternal angle
Rationale: The sternal angle, or angle of Louis, is the articulation of the manubrium and the body of
the sternum. It is a key landmark for counting ribs and intercostal spaces, as it marks the attachment
of the second rib. The xiphoid process is at the lower end of the sternum, the vertebra prominens is
the prominent spinous process of C7, and the clavicle is not used for this specific counting purpose.
2. A nurse is assessing a patient's anterior chest wall. Which finding would be considered an expected,
normal variation?
A) Asymmetrical chest expansion
B) A barrel-shaped chest
C) A costal angle of approximately 90 degrees
D) The presence of retractions during inspiration
Correct Answer: A costal angle of approximately 90 degrees
Rationale: A costal angle of approximately 90 degrees is a normal finding in a healthy adult.
Asymmetrical chest expansion, a barrel chest (often associated with COPD), and retractions (signs of
respiratory distress) are all abnormal findings that require further investigation.
3. During a respiratory assessment, the nurse notes a dull percussion note over the right lower lung
lobe. This finding is most consistent with which condition?
,A) Normal lung function
B) Asthma exacerbation
C) Pneumonia or pleural effusion
D) Chronic obstructive pulmonary disease
Correct Answer: Pneumonia or pleural effusion
Rationale: A dull percussion note indicates increased density of lung tissue, which is a typical finding in
conditions like pneumonia or pleural effusion, where fluid or consolidation replaces air. Resonance is
the normal sound over healthy lung tissue. Hyperresonance is heard in COPD or asthma, while a
normal finding would be a resonant note.
4. The nurse is auscultating a patient's lungs and identifies bronchovesicular breath sounds over the
peripheral lung fields. How should the nurse interpret this finding?
A) As a normal finding
B) As a sign of early pneumonia
C) As an indication of airway obstruction
D) As an abnormal finding requiring further assessment
Correct Answer: As an abnormal finding requiring further assessment
Rationale: Bronchovesicular breath sounds are normally heard over the major airways (e.g., the main
bronchi) and are not expected over the peripheral lung fields. Vesicular breath sounds, which are
softer and lower-pitched, are the normal sounds heard over most of the peripheral lung fields. Finding
bronchovesicular sounds in this location is an abnormal finding that warrants further evaluation.
5. A patient presents with tachypnea, decreased tactile fremitus on the left, and decreased breath
sounds on the left. These assessment findings are most suggestive of which condition?
A) Pneumonia
B) Early COPD
C) Asthma
D) Pneumothorax
, Correct Answer: Pneumothorax
Rationale: A pneumothorax involves air in the pleural space, which prevents the transmission of
sound and vibration. This results in decreased tactile fremitus and decreased or absent breath sounds
on the affected side. Tachypnea is a common compensatory response. Pneumonia would typically
present with increased fremitus and crackles, while COPD and asthma are more diffuse conditions.
6. A nurse is preparing to palpate the carotid artery of an older adult patient. Which action is
contraindicated for this assessment?
A) Using gentle palpation
B) Avoiding excessive pressure
C) Palpating only one carotid artery at a time
D) Palpating both carotid arteries simultaneously to compare pulse strength
Correct Answer: Palpating both carotid arteries simultaneously to compare pulse strength
Rationale: Palpating both carotid arteries simultaneously is contraindicated because it can
compromise cerebral blood flow and induce bradycardia or syncope. The carotid pulse should be
assessed on one side at a time, using gentle pressure and avoiding excessive pressure which could
stimulate the carotid sinus and alter heart rate.
7. A nurse is assessing an older adult patient who experiences a sudden drop in blood pressure when
rising from a sitting to a standing position. This finding is correctly identified as:
A) Aortic impulse
B) Orthostatic hypotension
C) Cardiac thrill
D) Bradypnea
Correct Answer: Orthostatic hypotension
Galen College | 26/27 Updated (PDF)
1. Which anatomical landmark is commonly used to count ribs and intercostal spaces during a thoracic
examination?
A) The sternal angle
B) The xiphoid process
C) The vertebra prominens
D) The clavicle
Correct Answer: The sternal angle
Rationale: The sternal angle, or angle of Louis, is the articulation of the manubrium and the body of
the sternum. It is a key landmark for counting ribs and intercostal spaces, as it marks the attachment
of the second rib. The xiphoid process is at the lower end of the sternum, the vertebra prominens is
the prominent spinous process of C7, and the clavicle is not used for this specific counting purpose.
2. A nurse is assessing a patient's anterior chest wall. Which finding would be considered an expected,
normal variation?
A) Asymmetrical chest expansion
B) A barrel-shaped chest
C) A costal angle of approximately 90 degrees
D) The presence of retractions during inspiration
Correct Answer: A costal angle of approximately 90 degrees
Rationale: A costal angle of approximately 90 degrees is a normal finding in a healthy adult.
Asymmetrical chest expansion, a barrel chest (often associated with COPD), and retractions (signs of
respiratory distress) are all abnormal findings that require further investigation.
3. During a respiratory assessment, the nurse notes a dull percussion note over the right lower lung
lobe. This finding is most consistent with which condition?
,A) Normal lung function
B) Asthma exacerbation
C) Pneumonia or pleural effusion
D) Chronic obstructive pulmonary disease
Correct Answer: Pneumonia or pleural effusion
Rationale: A dull percussion note indicates increased density of lung tissue, which is a typical finding in
conditions like pneumonia or pleural effusion, where fluid or consolidation replaces air. Resonance is
the normal sound over healthy lung tissue. Hyperresonance is heard in COPD or asthma, while a
normal finding would be a resonant note.
4. The nurse is auscultating a patient's lungs and identifies bronchovesicular breath sounds over the
peripheral lung fields. How should the nurse interpret this finding?
A) As a normal finding
B) As a sign of early pneumonia
C) As an indication of airway obstruction
D) As an abnormal finding requiring further assessment
Correct Answer: As an abnormal finding requiring further assessment
Rationale: Bronchovesicular breath sounds are normally heard over the major airways (e.g., the main
bronchi) and are not expected over the peripheral lung fields. Vesicular breath sounds, which are
softer and lower-pitched, are the normal sounds heard over most of the peripheral lung fields. Finding
bronchovesicular sounds in this location is an abnormal finding that warrants further evaluation.
5. A patient presents with tachypnea, decreased tactile fremitus on the left, and decreased breath
sounds on the left. These assessment findings are most suggestive of which condition?
A) Pneumonia
B) Early COPD
C) Asthma
D) Pneumothorax
, Correct Answer: Pneumothorax
Rationale: A pneumothorax involves air in the pleural space, which prevents the transmission of
sound and vibration. This results in decreased tactile fremitus and decreased or absent breath sounds
on the affected side. Tachypnea is a common compensatory response. Pneumonia would typically
present with increased fremitus and crackles, while COPD and asthma are more diffuse conditions.
6. A nurse is preparing to palpate the carotid artery of an older adult patient. Which action is
contraindicated for this assessment?
A) Using gentle palpation
B) Avoiding excessive pressure
C) Palpating only one carotid artery at a time
D) Palpating both carotid arteries simultaneously to compare pulse strength
Correct Answer: Palpating both carotid arteries simultaneously to compare pulse strength
Rationale: Palpating both carotid arteries simultaneously is contraindicated because it can
compromise cerebral blood flow and induce bradycardia or syncope. The carotid pulse should be
assessed on one side at a time, using gentle pressure and avoiding excessive pressure which could
stimulate the carotid sinus and alter heart rate.
7. A nurse is assessing an older adult patient who experiences a sudden drop in blood pressure when
rising from a sitting to a standing position. This finding is correctly identified as:
A) Aortic impulse
B) Orthostatic hypotension
C) Cardiac thrill
D) Bradypnea
Correct Answer: Orthostatic hypotension
