NUR 2092/NUR2092 Final Exam V2 |
Health Assessment Q&A with Rationale |
Rasmussen University
1. During an abdominal assessment, in which order should the nurse perform the
examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Palpation, Percussion, Auscultation, Inspection
D. Inspection, Auscultation, Percussion, Palpation
Correct Answer: D
Expert Explanation: In abdominal assessment, the order is modified to Inspection,
Auscultation, Percussion, and then Palpation. This sequence is used because palpation and
percussion can alter bowel sounds and lead to an inaccurate assessment. The nurse must
listen to the natural state of the abdomen before physically manipulating the tissues.
2. When assessing a patient’s pupillary response, the nurse notes that both pupils constrict
when light is shone into one eye. What is the term for this finding in the non-illuminated eye?
A. Direct light reflex
C. Consensual light reflex
B. Accommodation reflex
,D. Corneal reflex
Correct Answer: C
Expert Explanation: The consensual light reflex is the simultaneous constriction of the
pupil in the eye that is not receiving the light stimulus. This occurs because the optic nerve
of the stimulated eye sends signals that eventually reach both oculomotor nerves. A lack of
this response can indicate neurological damage or issues with the cranial nerves.
3. The nurse is assessing a patient for tactile fremitus. Which part of the hand is most
sensitive to vibrations?
A. The fingertips
B. The dorsal surface of the hand
C. The ulnar surface of the hand or base of fingers
D. The center of the palm
Correct Answer: C
Expert Explanation: Tactile fremitus is best assessed using the ulnar surface of the hand
or the ball of the hand because these areas are most sensitive to vibrations. The nurse
should ask the patient to repeat phrases like ninety-nine while moving the hands down the
back. This technique helps identify areas of lung consolidation or pleural effusion.
4. A patient presents with a ‘swishing’ sound heard over the carotid artery during
auscultation. What does this finding most likely indicate?
A. A normal find for an older adult
, B. A thrill suggesting valvular disease
C. High cardiac output
D. A bruit suggesting turbulent blood flow
Correct Answer: D
Expert Explanation: A bruit is a blowing or swishing sound that indicates turbulent blood
flow within a narrowed vessel. This is often found in patients with atherosclerosis of the
carotid arteries. It is important to have the patient hold their breath briefly during
auscultation to ensure breath sounds do not mask the bruit.
5. Where is the apical pulse located in a healthy adult?
A. Second intercostal space, right sternal border
B. Fifth intercostal space, left midclavicular line
C. Fourth intercostal space, left sternal border
D. Fifth intercostal space, left axillary line
Correct Answer: B
Expert Explanation: The apical pulse, also known as the point of maximal impulse (PMI),
is normally located at the fifth intercostal space at the midclavicular line. This location
allows the nurse to listen directly over the mitral valve area. Assessing this pulse for one
full minute is the standard practice for patients on cardiac medications.
Health Assessment Q&A with Rationale |
Rasmussen University
1. During an abdominal assessment, in which order should the nurse perform the
examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Palpation, Percussion, Auscultation, Inspection
D. Inspection, Auscultation, Percussion, Palpation
Correct Answer: D
Expert Explanation: In abdominal assessment, the order is modified to Inspection,
Auscultation, Percussion, and then Palpation. This sequence is used because palpation and
percussion can alter bowel sounds and lead to an inaccurate assessment. The nurse must
listen to the natural state of the abdomen before physically manipulating the tissues.
2. When assessing a patient’s pupillary response, the nurse notes that both pupils constrict
when light is shone into one eye. What is the term for this finding in the non-illuminated eye?
A. Direct light reflex
C. Consensual light reflex
B. Accommodation reflex
,D. Corneal reflex
Correct Answer: C
Expert Explanation: The consensual light reflex is the simultaneous constriction of the
pupil in the eye that is not receiving the light stimulus. This occurs because the optic nerve
of the stimulated eye sends signals that eventually reach both oculomotor nerves. A lack of
this response can indicate neurological damage or issues with the cranial nerves.
3. The nurse is assessing a patient for tactile fremitus. Which part of the hand is most
sensitive to vibrations?
A. The fingertips
B. The dorsal surface of the hand
C. The ulnar surface of the hand or base of fingers
D. The center of the palm
Correct Answer: C
Expert Explanation: Tactile fremitus is best assessed using the ulnar surface of the hand
or the ball of the hand because these areas are most sensitive to vibrations. The nurse
should ask the patient to repeat phrases like ninety-nine while moving the hands down the
back. This technique helps identify areas of lung consolidation or pleural effusion.
4. A patient presents with a ‘swishing’ sound heard over the carotid artery during
auscultation. What does this finding most likely indicate?
A. A normal find for an older adult
, B. A thrill suggesting valvular disease
C. High cardiac output
D. A bruit suggesting turbulent blood flow
Correct Answer: D
Expert Explanation: A bruit is a blowing or swishing sound that indicates turbulent blood
flow within a narrowed vessel. This is often found in patients with atherosclerosis of the
carotid arteries. It is important to have the patient hold their breath briefly during
auscultation to ensure breath sounds do not mask the bruit.
5. Where is the apical pulse located in a healthy adult?
A. Second intercostal space, right sternal border
B. Fifth intercostal space, left midclavicular line
C. Fourth intercostal space, left sternal border
D. Fifth intercostal space, left axillary line
Correct Answer: B
Expert Explanation: The apical pulse, also known as the point of maximal impulse (PMI),
is normally located at the fifth intercostal space at the midclavicular line. This location
allows the nurse to listen directly over the mitral valve area. Assessing this pulse for one
full minute is the standard practice for patients on cardiac medications.
