NUR 2092 / NUR2092 Health Assessment |
ACTUAL FINAL EXAM | Questions &
Verified Answers | Latest Update –
Rasmussen College
1.
During a health-history interview, a 68-year-old woman states she experiences urine
leakage whenever she coughs or sneezes. Which response by the nurse is most
appropriate?
A. “That’s normal at your age; don’t worry about it.”
B. “How often does this occur, and does it affect your daily activities?”
C. “You probably need surgery to fix that problem.”
D. “Do you have a family history of kidney disease?”
Correct Answer: B
Rationale: Stress incontinence is common but never “normal”; further assessment of
frequency, volume, pads used, and impact on quality of life is required to plan care.
Option A dismisses the symptom and blocks communication. Option C prematurely
jumps to intervention before full assessment. Option D shifts focus to kidneys rather
than the lower urinary tract and pelvic-floor etiology.
2.
,When auscultating the apex of the heart, the nurse hears a loud, blowing pansystolic
murmur that radiates to the axilla. Which valve is most likely incompetent?
A. Aortic
B. Pulmonic
C. Mitral
D. Tricuspid
Correct Answer: C
Rationale: Mitral regurgitation produces a high-pitched pansystolic murmur best heard
at the apex and radiating to the left axilla. Aortic lesions (A) are heard at the right
second intercostal space and radiate to the neck. Pulmonic (B) murmurs are at the left
second interspace and do not radiate to the axilla. Tricuspid (D) murmurs are heard at
the left lower sternal border and radiate to the right of the sternum.
3.
A 22-year-old man presents with acute chest pain that worsens with inspiration and is
relieved when sitting up. A friction rub is heard. Which assessment finding is most
consistent with pericarditis?
A. Pain radiates to the right arm
B. Pain decreases with deep inspiration
C. Pain improves when supine
D. Pain is relieved by sitting up and leaning forward
Correct Answer: D
,Rationale: Pericarditic pain is positional; sitting up and leaning forward reduces
pericardial friction and pain. Radiation to the right arm (A) is more typical of biliary or
pleural issues. Pain worsens—not decreases—with deep inspiration (B). Supine position
(C) increases friction and pain.
4.
The nurse observes a patient’s respiratory pattern: 30-second apneic periods alternating
with 30-second periods of rapid, deep respirations. This pattern is documented as:
A. Kussmaul
B. Cheyne-Stokes
C. Biot’s
D. Apneustic
Correct Answer: B
Rationale: Cheyne-Stokes respiration is a cyclic crescendo-decrescendo pattern
followed by apnea, often seen in heart failure or neurologic injury. Kussmaul (A) is deep,
rapid breathing without apnea in metabolic acidosis. Biot’s (C) is irregular rate and
depth with sudden apneic spells. Apneustic (D) features prolonged inspiratory pauses.
5.
A 6-month-old infant is unable to track a colorful toy past midline. Which cranial nerve
should the nurse assess first?
A. CN II – Optic
B. CN III – Oculomotor
, C. CN IV – Trochlear
D. CN VI – Abducens
Correct Answer: A
Rationale: Inability to track (visual pursuit) first suggests a visual-field or acuity problem;
CN II integrity must be established before assessing extra-ocular muscles (CN III, IV, VI).
Options B, C, and D control eye movement but are secondary if vision is impaired.
6.
While testing light touch, the patient reports numbness over the lateral malleolus. Which
spinal dermatome is being tested?
A. L3
B. L4
C. L5
D. S1
Correct Answer: D
Rationale: The lateral malleolus corresponds to the S1 dermatome. L3 (A) is the medial
knee, L4 (B) is the medial malleolus, and L5 (C) is the dorsum of the foot.
7.
A 55-year-old woman of East-Asian descent mentions she avoids eye contact with
physicians as a sign of respect. Which action by the nurse is most culturally
appropriate?
A. Insist she maintain eye contact to ensure understanding
ACTUAL FINAL EXAM | Questions &
Verified Answers | Latest Update –
Rasmussen College
1.
During a health-history interview, a 68-year-old woman states she experiences urine
leakage whenever she coughs or sneezes. Which response by the nurse is most
appropriate?
A. “That’s normal at your age; don’t worry about it.”
B. “How often does this occur, and does it affect your daily activities?”
C. “You probably need surgery to fix that problem.”
D. “Do you have a family history of kidney disease?”
Correct Answer: B
Rationale: Stress incontinence is common but never “normal”; further assessment of
frequency, volume, pads used, and impact on quality of life is required to plan care.
Option A dismisses the symptom and blocks communication. Option C prematurely
jumps to intervention before full assessment. Option D shifts focus to kidneys rather
than the lower urinary tract and pelvic-floor etiology.
2.
,When auscultating the apex of the heart, the nurse hears a loud, blowing pansystolic
murmur that radiates to the axilla. Which valve is most likely incompetent?
A. Aortic
B. Pulmonic
C. Mitral
D. Tricuspid
Correct Answer: C
Rationale: Mitral regurgitation produces a high-pitched pansystolic murmur best heard
at the apex and radiating to the left axilla. Aortic lesions (A) are heard at the right
second intercostal space and radiate to the neck. Pulmonic (B) murmurs are at the left
second interspace and do not radiate to the axilla. Tricuspid (D) murmurs are heard at
the left lower sternal border and radiate to the right of the sternum.
3.
A 22-year-old man presents with acute chest pain that worsens with inspiration and is
relieved when sitting up. A friction rub is heard. Which assessment finding is most
consistent with pericarditis?
A. Pain radiates to the right arm
B. Pain decreases with deep inspiration
C. Pain improves when supine
D. Pain is relieved by sitting up and leaning forward
Correct Answer: D
,Rationale: Pericarditic pain is positional; sitting up and leaning forward reduces
pericardial friction and pain. Radiation to the right arm (A) is more typical of biliary or
pleural issues. Pain worsens—not decreases—with deep inspiration (B). Supine position
(C) increases friction and pain.
4.
The nurse observes a patient’s respiratory pattern: 30-second apneic periods alternating
with 30-second periods of rapid, deep respirations. This pattern is documented as:
A. Kussmaul
B. Cheyne-Stokes
C. Biot’s
D. Apneustic
Correct Answer: B
Rationale: Cheyne-Stokes respiration is a cyclic crescendo-decrescendo pattern
followed by apnea, often seen in heart failure or neurologic injury. Kussmaul (A) is deep,
rapid breathing without apnea in metabolic acidosis. Biot’s (C) is irregular rate and
depth with sudden apneic spells. Apneustic (D) features prolonged inspiratory pauses.
5.
A 6-month-old infant is unable to track a colorful toy past midline. Which cranial nerve
should the nurse assess first?
A. CN II – Optic
B. CN III – Oculomotor
, C. CN IV – Trochlear
D. CN VI – Abducens
Correct Answer: A
Rationale: Inability to track (visual pursuit) first suggests a visual-field or acuity problem;
CN II integrity must be established before assessing extra-ocular muscles (CN III, IV, VI).
Options B, C, and D control eye movement but are secondary if vision is impaired.
6.
While testing light touch, the patient reports numbness over the lateral malleolus. Which
spinal dermatome is being tested?
A. L3
B. L4
C. L5
D. S1
Correct Answer: D
Rationale: The lateral malleolus corresponds to the S1 dermatome. L3 (A) is the medial
knee, L4 (B) is the medial malleolus, and L5 (C) is the dorsum of the foot.
7.
A 55-year-old woman of East-Asian descent mentions she avoids eye contact with
physicians as a sign of respect. Which action by the nurse is most culturally
appropriate?
A. Insist she maintain eye contact to ensure understanding
