NUR 216 Health Assessment FINAL EXAM
Questions with Verified Correct Answers
Aortic Area
2nd intercostal space (ICS), right sternal border.
Pulmonic Area
2nd ICS, left sternal border.
Tricuspid Area
4th-5th ICS, left sternal border.
Apical Pulse
5th ICS at the left midclavicular line.
S1
First heart sound; "lub"; associated with closure of the AV valves.
S2
Second heart sound; "dub"; associated with closure of the semilunar valves.
S3
Third heart sound; can be abnormal in older adults and may indicate possible heart failure.
Murmur
Abnormal heart sound caused by turbulent blood flow through the heart or valves.
Pericardial Friction Rub
A scratchy or rubbing sound associated with inflammation of the pericardium.
,Pericarditis
Inflammation of the pericardium; chest pain with a friction rub is a clue.
Irregular Radial Pulse
Should be followed by assessment of the apical pulse for 60 seconds.
Apical Pulse
Heart rate assessed directly over the apex of the heart; use for confirmation when the radial
pulse is irregular.
High LDL
High LDL/cholesterol increases cardiovascular risk.
Normal Cardiac Findings
Regular rate/rhythm, normal S1/S2, regular apical pulse, and no murmurs or friction rub.
Crackles
Abnormal lung sounds associated with fluid in the alveoli/small airways.
Wheezes
High-pitched sounds associated with narrowed airways or bronchoconstriction.
Rhonchi
Low-pitched/coarse sounds associated with mucus or secretions in the airways.
Stridor
High-pitched sound caused by upper airway obstruction; treat as an airway emergency.
Pleural Friction Rub
, Scratchy sound caused by inflamed pleural surfaces rubbing together.
Tripod Position
Patient sits leaning forward and supporting the upper body to improve breathing; assess
oxygenation.
Normal Adult Respiratory Rate
12-20 breaths/minute; the study guide identifies 12/min as the low end.
Respiratory Assessment Priority
Airway and oxygenation take priority over comfort or routine assessment when respiratory
distress is present.
Crackles
Think: fluid.
Wheezes
Think: narrowed bronchioles/bronchoconstriction.
Rhonchi
Think: mucus.
Stridor
Think: airway obstruction and emergency.
Lethargic
Drowsy or sleepy but can be aroused.
Obtunded
Questions with Verified Correct Answers
Aortic Area
2nd intercostal space (ICS), right sternal border.
Pulmonic Area
2nd ICS, left sternal border.
Tricuspid Area
4th-5th ICS, left sternal border.
Apical Pulse
5th ICS at the left midclavicular line.
S1
First heart sound; "lub"; associated with closure of the AV valves.
S2
Second heart sound; "dub"; associated with closure of the semilunar valves.
S3
Third heart sound; can be abnormal in older adults and may indicate possible heart failure.
Murmur
Abnormal heart sound caused by turbulent blood flow through the heart or valves.
Pericardial Friction Rub
A scratchy or rubbing sound associated with inflammation of the pericardium.
,Pericarditis
Inflammation of the pericardium; chest pain with a friction rub is a clue.
Irregular Radial Pulse
Should be followed by assessment of the apical pulse for 60 seconds.
Apical Pulse
Heart rate assessed directly over the apex of the heart; use for confirmation when the radial
pulse is irregular.
High LDL
High LDL/cholesterol increases cardiovascular risk.
Normal Cardiac Findings
Regular rate/rhythm, normal S1/S2, regular apical pulse, and no murmurs or friction rub.
Crackles
Abnormal lung sounds associated with fluid in the alveoli/small airways.
Wheezes
High-pitched sounds associated with narrowed airways or bronchoconstriction.
Rhonchi
Low-pitched/coarse sounds associated with mucus or secretions in the airways.
Stridor
High-pitched sound caused by upper airway obstruction; treat as an airway emergency.
Pleural Friction Rub
, Scratchy sound caused by inflamed pleural surfaces rubbing together.
Tripod Position
Patient sits leaning forward and supporting the upper body to improve breathing; assess
oxygenation.
Normal Adult Respiratory Rate
12-20 breaths/minute; the study guide identifies 12/min as the low end.
Respiratory Assessment Priority
Airway and oxygenation take priority over comfort or routine assessment when respiratory
distress is present.
Crackles
Think: fluid.
Wheezes
Think: narrowed bronchioles/bronchoconstriction.
Rhonchi
Think: mucus.
Stridor
Think: airway obstruction and emergency.
Lethargic
Drowsy or sleepy but can be aroused.
Obtunded
