NUR 2092 / NUR2092 Health Assessment | ACTUAL
FINAL EXAM | Questions & Verified Answers | Latest
Update – Rasmussen College
1. During the health-history interview, a 58-year-old male states, “I get heartburn whenever
I eat spicy food.” The student nurse documents this finding in which section of the health
history?
A. Chief complaint
B. Review of systems
C. History of present illness
D. Personal/social history
Correct Answer: B
Rationale: Heartburn that occurs with spicy food is a symptom related to a specific body system
(gastro-intestinal) and is therefore documented in the review of systems (ROS). The chief
complaint (A) is the single reason for the visit. History of present illness (C) describes details of
the primary concern. Personal/social history (D) includes habits such as smoking or alcohol use.
2. Which interview technique is most appropriate when the nurse suspects the patient is
withholding sensitive information?
A. Asking multiple rapid questions
B. Using confrontation to force disclosure
C. Employing therapeutic silence
,D. Redirecting to a different topic immediately
Correct Answer: C
Rationale: Therapeutic silence allows the patient time to organize thoughts and encourages
deeper disclosure without pressure. Rapid questioning (A) can overwhelm and inhibit sharing.
Confrontation (B) may damage rapport. Immediate redirection (D) signals disinterest and closes
further exploration.
3. Auscultation of the lungs reveals loud, high-pitched sounds over the right upper posterior
chest during both inspiration and expiration. Which term should the nurse use to chart
this finding?
A. Bronchial breath sounds
B. Broncho-vesicular breath sounds
C. Vesicular breath sounds
D. Tracheal breath sounds
Correct Answer: A
Rationale: Bronchial sounds are loud, high-pitched, and heard equally during inspiration and
expiration; they are normally heard only over the trachea but may indicate consolidation when
heard peripherally. Broncho-vesicular (B) are medium-pitched and equal. Vesicular (C) are soft
and heard mostly on inspiration. Tracheal (D) are heard only over the trachea itself.
4. The nurse notes a visible, palpable thrust at the 5th intercostal space at the mid-clavicular
line. This finding is best documented as:
A. Heave
B. Lift
,C. Apical impulse
D. Thrill
Correct Answer: C
Rationale: The normal point of maximal impulse (PMI) or apical impulse is felt at the 5th ICS
mid-clavicular line. A heave/lift (A,B) is a sustained outward movement of the chest wall and
indicates ventricular hypertrophy. A thrill (D) is a palpable vibration caused by turbulent blood
flow.
5. Which cranial nerve is assessed when the nurse asks the patient to smile, frown, and puff
out cheeks?
A. Facial (CN VII)
B. Trigeminal (CN V)
C. Glossopharyngeal (CN IX)
D. Hypoglossal (CN XII)
Correct Answer: A
Rationale: The facial nerve (CN VII) innervates muscles of facial expression. Trigeminal (B)
supplies sensation to the face and muscles of mastication. Glossopharyngeal (C) is tested with
gag reflex and taste. Hypoglossal (D) controls tongue movement.
6. A 22-year-old female denies pregnancy but has a 3-month history of amenorrhea,
bilateral milky breast discharge, and headaches. Which further assessment is priority?
A. Serum thyroid-stimulating hormone
B. Serum prolactin
, C. Urine human chorionic gonadotropin
D. Serum cortisol
Correct Answer: B
Rationale: Galactorrhea with amenorrhea and headaches suggests hyperprolactinemia, possibly
from a pituitary adenoma. Serum prolactin (B) is the priority test. TSH (A) can cause mild
hyperprolactinemia but is less likely to produce these symptoms. hCG (C) rules out pregnancy
but does not explain discharge. Cortisol (D) evaluates adrenal function, unrelated to this
presentation.
7. When assessing an 80-year-old client, the nurse notes increased anteroposterior chest
diameter and bilateral vesicular breath sounds that are faint. These findings are:
A. Expected age-related changes
B. Indicative of COPD exacerbation
C. Suggestive of pneumothorax
D. Evidence of pulmonary fibrosis
Correct Answer: A
Rationale: With aging, chest wall compliance decreases and airways may close prematurely,
resulting in a barrel-shaped chest and softer breath sounds. These are normal variants. COPD
exacerbation (B) would include decreased breath sounds, wheezes, or crackles. Pneumothorax
(C) presents with sudden sharp pain and absent breath sounds. Fibrosis (D) produces fine
crackles.
8. The nurse asks the patient to dorsiflex the foot against resistance. This maneuver tests
which spinal nerve root?
FINAL EXAM | Questions & Verified Answers | Latest
Update – Rasmussen College
1. During the health-history interview, a 58-year-old male states, “I get heartburn whenever
I eat spicy food.” The student nurse documents this finding in which section of the health
history?
A. Chief complaint
B. Review of systems
C. History of present illness
D. Personal/social history
Correct Answer: B
Rationale: Heartburn that occurs with spicy food is a symptom related to a specific body system
(gastro-intestinal) and is therefore documented in the review of systems (ROS). The chief
complaint (A) is the single reason for the visit. History of present illness (C) describes details of
the primary concern. Personal/social history (D) includes habits such as smoking or alcohol use.
2. Which interview technique is most appropriate when the nurse suspects the patient is
withholding sensitive information?
A. Asking multiple rapid questions
B. Using confrontation to force disclosure
C. Employing therapeutic silence
,D. Redirecting to a different topic immediately
Correct Answer: C
Rationale: Therapeutic silence allows the patient time to organize thoughts and encourages
deeper disclosure without pressure. Rapid questioning (A) can overwhelm and inhibit sharing.
Confrontation (B) may damage rapport. Immediate redirection (D) signals disinterest and closes
further exploration.
3. Auscultation of the lungs reveals loud, high-pitched sounds over the right upper posterior
chest during both inspiration and expiration. Which term should the nurse use to chart
this finding?
A. Bronchial breath sounds
B. Broncho-vesicular breath sounds
C. Vesicular breath sounds
D. Tracheal breath sounds
Correct Answer: A
Rationale: Bronchial sounds are loud, high-pitched, and heard equally during inspiration and
expiration; they are normally heard only over the trachea but may indicate consolidation when
heard peripherally. Broncho-vesicular (B) are medium-pitched and equal. Vesicular (C) are soft
and heard mostly on inspiration. Tracheal (D) are heard only over the trachea itself.
4. The nurse notes a visible, palpable thrust at the 5th intercostal space at the mid-clavicular
line. This finding is best documented as:
A. Heave
B. Lift
,C. Apical impulse
D. Thrill
Correct Answer: C
Rationale: The normal point of maximal impulse (PMI) or apical impulse is felt at the 5th ICS
mid-clavicular line. A heave/lift (A,B) is a sustained outward movement of the chest wall and
indicates ventricular hypertrophy. A thrill (D) is a palpable vibration caused by turbulent blood
flow.
5. Which cranial nerve is assessed when the nurse asks the patient to smile, frown, and puff
out cheeks?
A. Facial (CN VII)
B. Trigeminal (CN V)
C. Glossopharyngeal (CN IX)
D. Hypoglossal (CN XII)
Correct Answer: A
Rationale: The facial nerve (CN VII) innervates muscles of facial expression. Trigeminal (B)
supplies sensation to the face and muscles of mastication. Glossopharyngeal (C) is tested with
gag reflex and taste. Hypoglossal (D) controls tongue movement.
6. A 22-year-old female denies pregnancy but has a 3-month history of amenorrhea,
bilateral milky breast discharge, and headaches. Which further assessment is priority?
A. Serum thyroid-stimulating hormone
B. Serum prolactin
, C. Urine human chorionic gonadotropin
D. Serum cortisol
Correct Answer: B
Rationale: Galactorrhea with amenorrhea and headaches suggests hyperprolactinemia, possibly
from a pituitary adenoma. Serum prolactin (B) is the priority test. TSH (A) can cause mild
hyperprolactinemia but is less likely to produce these symptoms. hCG (C) rules out pregnancy
but does not explain discharge. Cortisol (D) evaluates adrenal function, unrelated to this
presentation.
7. When assessing an 80-year-old client, the nurse notes increased anteroposterior chest
diameter and bilateral vesicular breath sounds that are faint. These findings are:
A. Expected age-related changes
B. Indicative of COPD exacerbation
C. Suggestive of pneumothorax
D. Evidence of pulmonary fibrosis
Correct Answer: A
Rationale: With aging, chest wall compliance decreases and airways may close prematurely,
resulting in a barrel-shaped chest and softer breath sounds. These are normal variants. COPD
exacerbation (B) would include decreased breath sounds, wheezes, or crackles. Pneumothorax
(C) presents with sudden sharp pain and absent breath sounds. Fibrosis (D) produces fine
crackles.
8. The nurse asks the patient to dorsiflex the foot against resistance. This maneuver tests
which spinal nerve root?
