NRS 420 Exam 2 V1 | NRS 420 Health Assessment |
Actual Q&A with Rationale (NRS420 Exam 2) |
Grand Canyon University
1. When auscultating the heart, the nurse knows that the S1 sound is loudest at which
anatomical location?
A. The base of the heart
B. The second right intercostal space
C. The apex of the heart
D. The second left intercostal space
Correct Answer: C
Explanation: The S1 heart sound corresponds to the closure of the atrioventricular valves
(mitral and tricuspid) and marks the beginning of systole. It is traditionally loudest at the
apex, which is located at the fifth intercostal space at the left midclavicular line. This
contrasts with S2, which is heard loudest at the base of the heart.
2. A nurse is performing an abdominal assessment. In which order should the nurse perform
the physical examination techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
,D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: A
Explanation: The proper sequence for an abdominal assessment is inspection, followed by
auscultation, percussion, and finally palpation. Auscultation is performed before
percussion and palpation to avoid stimulating bowel sounds that were not originally
present. This sequence ensures the most accurate assessment of the patient’s bowel
activity.
3. Which of the following clinical findings are associated with a diagnosis of Chronic
Obstructive Pulmonary Disease (COPD)? (Select All That Apply)
A. Increased anteroposterior-to-transverse diameter (Barrel Chest)
B. Pursed-lip breathing
C. Clubbing of the fingernails
D. Use of accessory muscles during respiration
E. Tripod positioning
F. Enhanced tactile fremitus over the lower lobes
Correct Answer: A,B,C,D,E
Explanation: COPD patients often present with a ‘barrel chest’ due to air trapping and
hyperinflation of the lungs. Pursed-lip breathing and tripod positioning are compensatory
mechanisms used to improve gas exchange and ease the work of breathing. Tactile fremitus
, is actually decreased in COPD due to the presence of excess air which acts as a barrier to
vibration.
4. While assessing a patient’s lungs, the nurse notes a low-pitched, snoring sound that clears
with coughing. How should the nurse document this sound?
A. Fine crackles
B. Wheezes
C. Coarse crackles
D. Rhonchi (Sibilant wheeze)
Correct Answer: D
Explanation: Rhonchi are low-pitched, continuous sounds caused by secretions or
obstructions in the larger airways. They often resemble snoring and frequently clear or
change significantly after the patient coughs. This is a characteristic distinction from
crackles, which are discontinuous and do not typically clear with coughing.
5. The nurse is testing a patient’s cranial nerves. Which cranial nerves are responsible for
extraocular eye movements? (Select All That Apply)
A. Cranial Nerve II
B. Cranial Nerve III
C. Cranial Nerve IV
D. Cranial Nerve V
Actual Q&A with Rationale (NRS420 Exam 2) |
Grand Canyon University
1. When auscultating the heart, the nurse knows that the S1 sound is loudest at which
anatomical location?
A. The base of the heart
B. The second right intercostal space
C. The apex of the heart
D. The second left intercostal space
Correct Answer: C
Explanation: The S1 heart sound corresponds to the closure of the atrioventricular valves
(mitral and tricuspid) and marks the beginning of systole. It is traditionally loudest at the
apex, which is located at the fifth intercostal space at the left midclavicular line. This
contrasts with S2, which is heard loudest at the base of the heart.
2. A nurse is performing an abdominal assessment. In which order should the nurse perform
the physical examination techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
,D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: A
Explanation: The proper sequence for an abdominal assessment is inspection, followed by
auscultation, percussion, and finally palpation. Auscultation is performed before
percussion and palpation to avoid stimulating bowel sounds that were not originally
present. This sequence ensures the most accurate assessment of the patient’s bowel
activity.
3. Which of the following clinical findings are associated with a diagnosis of Chronic
Obstructive Pulmonary Disease (COPD)? (Select All That Apply)
A. Increased anteroposterior-to-transverse diameter (Barrel Chest)
B. Pursed-lip breathing
C. Clubbing of the fingernails
D. Use of accessory muscles during respiration
E. Tripod positioning
F. Enhanced tactile fremitus over the lower lobes
Correct Answer: A,B,C,D,E
Explanation: COPD patients often present with a ‘barrel chest’ due to air trapping and
hyperinflation of the lungs. Pursed-lip breathing and tripod positioning are compensatory
mechanisms used to improve gas exchange and ease the work of breathing. Tactile fremitus
, is actually decreased in COPD due to the presence of excess air which acts as a barrier to
vibration.
4. While assessing a patient’s lungs, the nurse notes a low-pitched, snoring sound that clears
with coughing. How should the nurse document this sound?
A. Fine crackles
B. Wheezes
C. Coarse crackles
D. Rhonchi (Sibilant wheeze)
Correct Answer: D
Explanation: Rhonchi are low-pitched, continuous sounds caused by secretions or
obstructions in the larger airways. They often resemble snoring and frequently clear or
change significantly after the patient coughs. This is a characteristic distinction from
crackles, which are discontinuous and do not typically clear with coughing.
5. The nurse is testing a patient’s cranial nerves. Which cranial nerves are responsible for
extraocular eye movements? (Select All That Apply)
A. Cranial Nerve II
B. Cranial Nerve III
C. Cranial Nerve IV
D. Cranial Nerve V
