NSG 3160 Exam 2 V1 | NSG 3160 Health
Assessment | Actual Q&A with Rationale (NSG3160
Exam 2) | Galen
1. A nurse is evaluating a patient with chronic obstructive pulmonary disease (COPD). Which
of the following physical assessment findings are characteristic of this condition? (Select All
That Apply)
A. Barrel chest appearance
B. Use of accessory muscles during respiration
C. Increased tactile fremitus
D. Pursed-lip breathing
E. Clubbing of the fingernails
F. Hyperresonance upon percussion
Correct Answer: A, B, D, E, F
Explanation: Patients with COPD typically exhibit a barrel chest due to chronic air
trapping and hyperinflation of the lungs. The use of accessory muscles and pursed-lip
breathing are compensatory mechanisms to facilitate gas exchange under respiratory
distress. Hyperresonance is expected on percussion because of the increased volume of
trapped air, whereas tactile fremitus would actually be decreased, not increased.
,2. When auscultating the heart, where is the S2 sound typically heard the loudest?
A. At the base of the heart
B. At the apex of the heart
C. Along the left lower sternal border
D. At the fourth intercostal space
Correct Answer: A
Explanation: The S2 heart sound represents the closure of the semilunar valves, which
include the aortic and pulmonic valves. This sound is generally loudest at the base of the
heart, located at the second intercostal space. In contrast, the S1 sound is loudest at the
apex due to the closure of the atrioventricular valves.
3. Which assessment technique is correct for a nurse to use when palpating the liver?
A. Light palpation in the left upper quadrant
B. Deep palpation in the right upper quadrant during expiration
C. Deep palpation in the right upper quadrant as the patient inhales
D. Bimanual palpation in the umbilical region
Correct Answer: C
Explanation: Palpation of the liver is performed in the right upper quadrant because that
is where the organ is anatomically located. As the patient takes a deep breath, the
diaphragm pushes the liver downward, making it easier for the nurse to feel the liver edge.
, Using deep palpation during inspiration allows the nurse to identify the consistency and
size of the liver border.
4. A patient presents with a suspected umbilical hernia. Which physical examination finding
would support this diagnosis?
A. Dullness to percussion in the left lower quadrant
B. Rebound tenderness in the right lower quadrant
C. Absent bowel sounds in all four quadrants
D. A protrusion that increases in size when the patient coughs
Correct Answer: D
Explanation: An umbilical hernia is a protrusion of the intestine through a weakness in the
abdominal wall at the umbilicus. Increased intra-abdominal pressure, such as that caused
by coughing or straining, makes the protrusion more prominent. This sign is a classic
finding used by clinicians to differentiate a hernia from other abdominal masses.
5. During a breast examination, the nurse notes a mass in the upper outer quadrant of the
right breast. Why is this area significant?
A. It contains the largest concentration of fat tissue.
B. It is the site of the most frequent breast cancer occurrences.
C. It is the only area that drains to the axillary nodes.
D. It is the most sensitive area to hormonal changes.
Assessment | Actual Q&A with Rationale (NSG3160
Exam 2) | Galen
1. A nurse is evaluating a patient with chronic obstructive pulmonary disease (COPD). Which
of the following physical assessment findings are characteristic of this condition? (Select All
That Apply)
A. Barrel chest appearance
B. Use of accessory muscles during respiration
C. Increased tactile fremitus
D. Pursed-lip breathing
E. Clubbing of the fingernails
F. Hyperresonance upon percussion
Correct Answer: A, B, D, E, F
Explanation: Patients with COPD typically exhibit a barrel chest due to chronic air
trapping and hyperinflation of the lungs. The use of accessory muscles and pursed-lip
breathing are compensatory mechanisms to facilitate gas exchange under respiratory
distress. Hyperresonance is expected on percussion because of the increased volume of
trapped air, whereas tactile fremitus would actually be decreased, not increased.
,2. When auscultating the heart, where is the S2 sound typically heard the loudest?
A. At the base of the heart
B. At the apex of the heart
C. Along the left lower sternal border
D. At the fourth intercostal space
Correct Answer: A
Explanation: The S2 heart sound represents the closure of the semilunar valves, which
include the aortic and pulmonic valves. This sound is generally loudest at the base of the
heart, located at the second intercostal space. In contrast, the S1 sound is loudest at the
apex due to the closure of the atrioventricular valves.
3. Which assessment technique is correct for a nurse to use when palpating the liver?
A. Light palpation in the left upper quadrant
B. Deep palpation in the right upper quadrant during expiration
C. Deep palpation in the right upper quadrant as the patient inhales
D. Bimanual palpation in the umbilical region
Correct Answer: C
Explanation: Palpation of the liver is performed in the right upper quadrant because that
is where the organ is anatomically located. As the patient takes a deep breath, the
diaphragm pushes the liver downward, making it easier for the nurse to feel the liver edge.
, Using deep palpation during inspiration allows the nurse to identify the consistency and
size of the liver border.
4. A patient presents with a suspected umbilical hernia. Which physical examination finding
would support this diagnosis?
A. Dullness to percussion in the left lower quadrant
B. Rebound tenderness in the right lower quadrant
C. Absent bowel sounds in all four quadrants
D. A protrusion that increases in size when the patient coughs
Correct Answer: D
Explanation: An umbilical hernia is a protrusion of the intestine through a weakness in the
abdominal wall at the umbilicus. Increased intra-abdominal pressure, such as that caused
by coughing or straining, makes the protrusion more prominent. This sign is a classic
finding used by clinicians to differentiate a hernia from other abdominal masses.
5. During a breast examination, the nurse notes a mass in the upper outer quadrant of the
right breast. Why is this area significant?
A. It contains the largest concentration of fat tissue.
B. It is the site of the most frequent breast cancer occurrences.
C. It is the only area that drains to the axillary nodes.
D. It is the most sensitive area to hormonal changes.
