NURS 5220 Exam 2 (2026/2027) (PDF) | Advanced
Health Assessment | UTA
Question 1. A 65-year-old male presents with complaints of chest pain that
radiates to his left arm and jaw. He is diaphoretic and nauseated. Which of the
following is the most appropriate initial action?
A. Obtain a detailed dietary history
B. Perform a focused cardiovascular assessment and obtain an ECG
C. Administer an antacid and reassess in 30 minutes
D. Schedule an outpatient stress test
Correct Answer: B
Rationale:
The patient's presentation is classic for acute coronary syndrome (ACS). The most
appropriate initial action is to perform a focused cardiovascular assessment and obtain
an ECG immediately to evaluate for ischemia or infarction. A dietary history (A) is not
urgent. Administering an antacid (C) delays critical treatment. Scheduling an outpatient
stress test (D) is inappropriate for an acute presentation.
Question 2. During auscultation of the heart, the "lub" sound (S1) is best heard at
which location?
A. The base of the heart (aortic area)
B. The apex of the heart (mitral area)
C. The left sternal border (pulmonic area)
D. Erb's point
Correct Answer: B
Rationale:
S1, the first heart sound, is caused by closure of the mitral and tricuspid valves. It is best
heard at the apex (mitral area) using the bell of the stethoscope. The base (A) is where
S2 is best heard. The left sternal border (C) is the pulmonic area. Erb's point (D) is a
secondary aortic area.
,Question 3. A patient presents with a blood pressure of 150/95 mmHg. According
to the American College of Cardiology/American Heart Association, this is
classified as:
A. Normal
B. Elevated
C. Stage 1 hypertension
D. Stage 2 hypertension
Correct Answer: C
Rationale:
According to ACC/AHA guidelines, Stage 1 hypertension is defined as systolic 130-139
mmHg or diastolic 80-89 mmHg. Wait, that's for Stage 1. Actually, Stage 2 is ≥140/90.
So 150/95 is Stage 2. Let me correct: ACC/AHA 2017: Normal <120/80, Elevated 120-
129/<80, Stage 1 130-139 or 80-89, Stage 2 ≥140 or ≥90. So 150/95 is Stage 2
hypertension. The correct answer should be D. I'll change options: A. Normal, B.
Elevated, C. Stage 1, D. Stage 2. Correct is D. Let me redo question.
Question 3. A patient presents with a blood pressure of 150/95 mmHg. According
to the American College of Cardiology/American Heart Association, this is
classified as:
A. Normal
B. Elevated
C. Stage 1 hypertension
D. Stage 2 hypertension
Correct Answer: D
Rationale:
According to the 2017 ACC/AHA guidelines, Stage 2 hypertension is defined as a systolic
blood pressure ≥140 mmHg or a diastolic blood pressure ≥90 mmHg. A reading of
150/95 mmHg falls into this category. Normal (A) is <120/80. Elevated (B) is 120-
129/<80. Stage 1 (C) is 130-139 or 80-89.
Question 4. Which of the following is the correct technique for palpating the radial
pulse?
A. Use the thumb to palpate the pulse
B. Use the index and middle fingers to palpate the pulse
,C. Use the palm of the hand to palpate the pulse
D. Use the little finger to palpate the pulse
Correct Answer: B
Rationale:
The radial pulse is best palpated using the index and middle fingers, which are most
sensitive to tactile stimuli. The thumb (A) has its own pulse and should not be used. The
palm (C) is not sensitive enough. The little finger (D) is not standard.
Question 5. A nurse is assessing a patient's respiratory rate. Which of the following
is the correct procedure?
A. Inform the patient that you are counting their breaths
B. Count the breaths for 15 seconds and multiply by 4
C. Count the breaths for a full 60 seconds if the rhythm is irregular
D. Count the breaths for 30 seconds and multiply by 2
Correct Answer: C
Rationale:
If the respiratory rhythm is irregular, it is best to count for a full 60 seconds to obtain an
accurate rate. Informing the patient (A) may cause them to alter their breathing.
Counting for 15 seconds (B) or 30 seconds (D) is acceptable for regular rhythms but less
accurate for irregular ones.
Question 6. Which of the following is a normal finding when assessing the skin of
an older adult?
A. Increased skin turgor
B. Decreased skin elasticity
C. Increased sebaceous gland activity
D. Decreased incidence of skin tears
Correct Answer: B
Rationale:
Older adults typically have decreased skin elasticity due to loss of collagen and elastin.
Skin turgor (A) may be decreased. Sebaceous gland activity (C) decreases, leading to dry
skin. The incidence of skin tears (D) increases due to fragile skin.
, Question 7. A patient presents with a lesion on the skin that is asymmetric, has
irregular borders, is multi-colored, and has a diameter greater than 6 mm. These
findings are concerning for:
A. Basal cell carcinoma
B. Squamous cell carcinoma
C. Melanoma
D. Actinic keratosis
Correct Answer: C
Rationale:
The ABCD criteria (Asymmetry, Border irregularity, Color variation, Diameter >6 mm) are
used to identify suspicious lesions for melanoma. Basal cell carcinoma (A) typically
presents as a pearly nodule. Squamous cell carcinoma (B) presents as a rough, scaly
patch. Actinic keratosis (D) is a precancerous lesion.
Question 8. When assessing the head and neck, which of the following is a normal
finding?
A. Tracheal deviation to one side
B. Thyroid gland is not palpable
C. Jugular venous distention at 45 degrees
D. Lymph nodes are firm and fixed
Correct Answer: B
Rationale:
A normal thyroid gland is typically not palpable. Tracheal deviation (A) is abnormal.
Jugular venous distention at 45 degrees (C) may indicate heart failure. Firm and fixed
lymph nodes (D) may indicate malignancy.
Question 9. A patient is diagnosed with conjunctivitis. Which of the following
findings would suggest a bacterial cause?
A. Watery discharge
B. Itching
C. Purulent discharge
D. Bilateral involvement
Correct Answer: C
Health Assessment | UTA
Question 1. A 65-year-old male presents with complaints of chest pain that
radiates to his left arm and jaw. He is diaphoretic and nauseated. Which of the
following is the most appropriate initial action?
A. Obtain a detailed dietary history
B. Perform a focused cardiovascular assessment and obtain an ECG
C. Administer an antacid and reassess in 30 minutes
D. Schedule an outpatient stress test
Correct Answer: B
Rationale:
The patient's presentation is classic for acute coronary syndrome (ACS). The most
appropriate initial action is to perform a focused cardiovascular assessment and obtain
an ECG immediately to evaluate for ischemia or infarction. A dietary history (A) is not
urgent. Administering an antacid (C) delays critical treatment. Scheduling an outpatient
stress test (D) is inappropriate for an acute presentation.
Question 2. During auscultation of the heart, the "lub" sound (S1) is best heard at
which location?
A. The base of the heart (aortic area)
B. The apex of the heart (mitral area)
C. The left sternal border (pulmonic area)
D. Erb's point
Correct Answer: B
Rationale:
S1, the first heart sound, is caused by closure of the mitral and tricuspid valves. It is best
heard at the apex (mitral area) using the bell of the stethoscope. The base (A) is where
S2 is best heard. The left sternal border (C) is the pulmonic area. Erb's point (D) is a
secondary aortic area.
,Question 3. A patient presents with a blood pressure of 150/95 mmHg. According
to the American College of Cardiology/American Heart Association, this is
classified as:
A. Normal
B. Elevated
C. Stage 1 hypertension
D. Stage 2 hypertension
Correct Answer: C
Rationale:
According to ACC/AHA guidelines, Stage 1 hypertension is defined as systolic 130-139
mmHg or diastolic 80-89 mmHg. Wait, that's for Stage 1. Actually, Stage 2 is ≥140/90.
So 150/95 is Stage 2. Let me correct: ACC/AHA 2017: Normal <120/80, Elevated 120-
129/<80, Stage 1 130-139 or 80-89, Stage 2 ≥140 or ≥90. So 150/95 is Stage 2
hypertension. The correct answer should be D. I'll change options: A. Normal, B.
Elevated, C. Stage 1, D. Stage 2. Correct is D. Let me redo question.
Question 3. A patient presents with a blood pressure of 150/95 mmHg. According
to the American College of Cardiology/American Heart Association, this is
classified as:
A. Normal
B. Elevated
C. Stage 1 hypertension
D. Stage 2 hypertension
Correct Answer: D
Rationale:
According to the 2017 ACC/AHA guidelines, Stage 2 hypertension is defined as a systolic
blood pressure ≥140 mmHg or a diastolic blood pressure ≥90 mmHg. A reading of
150/95 mmHg falls into this category. Normal (A) is <120/80. Elevated (B) is 120-
129/<80. Stage 1 (C) is 130-139 or 80-89.
Question 4. Which of the following is the correct technique for palpating the radial
pulse?
A. Use the thumb to palpate the pulse
B. Use the index and middle fingers to palpate the pulse
,C. Use the palm of the hand to palpate the pulse
D. Use the little finger to palpate the pulse
Correct Answer: B
Rationale:
The radial pulse is best palpated using the index and middle fingers, which are most
sensitive to tactile stimuli. The thumb (A) has its own pulse and should not be used. The
palm (C) is not sensitive enough. The little finger (D) is not standard.
Question 5. A nurse is assessing a patient's respiratory rate. Which of the following
is the correct procedure?
A. Inform the patient that you are counting their breaths
B. Count the breaths for 15 seconds and multiply by 4
C. Count the breaths for a full 60 seconds if the rhythm is irregular
D. Count the breaths for 30 seconds and multiply by 2
Correct Answer: C
Rationale:
If the respiratory rhythm is irregular, it is best to count for a full 60 seconds to obtain an
accurate rate. Informing the patient (A) may cause them to alter their breathing.
Counting for 15 seconds (B) or 30 seconds (D) is acceptable for regular rhythms but less
accurate for irregular ones.
Question 6. Which of the following is a normal finding when assessing the skin of
an older adult?
A. Increased skin turgor
B. Decreased skin elasticity
C. Increased sebaceous gland activity
D. Decreased incidence of skin tears
Correct Answer: B
Rationale:
Older adults typically have decreased skin elasticity due to loss of collagen and elastin.
Skin turgor (A) may be decreased. Sebaceous gland activity (C) decreases, leading to dry
skin. The incidence of skin tears (D) increases due to fragile skin.
, Question 7. A patient presents with a lesion on the skin that is asymmetric, has
irregular borders, is multi-colored, and has a diameter greater than 6 mm. These
findings are concerning for:
A. Basal cell carcinoma
B. Squamous cell carcinoma
C. Melanoma
D. Actinic keratosis
Correct Answer: C
Rationale:
The ABCD criteria (Asymmetry, Border irregularity, Color variation, Diameter >6 mm) are
used to identify suspicious lesions for melanoma. Basal cell carcinoma (A) typically
presents as a pearly nodule. Squamous cell carcinoma (B) presents as a rough, scaly
patch. Actinic keratosis (D) is a precancerous lesion.
Question 8. When assessing the head and neck, which of the following is a normal
finding?
A. Tracheal deviation to one side
B. Thyroid gland is not palpable
C. Jugular venous distention at 45 degrees
D. Lymph nodes are firm and fixed
Correct Answer: B
Rationale:
A normal thyroid gland is typically not palpable. Tracheal deviation (A) is abnormal.
Jugular venous distention at 45 degrees (C) may indicate heart failure. Firm and fixed
lymph nodes (D) may indicate malignancy.
Question 9. A patient is diagnosed with conjunctivitis. Which of the following
findings would suggest a bacterial cause?
A. Watery discharge
B. Itching
C. Purulent discharge
D. Bilateral involvement
Correct Answer: C
