NUR 6001/NUR6001 Exam 2 V2 | Advanced
Health Assessment Q&A with Rationale |
William Paterson University
1. A 65-year-old patient presents with a third heart sound (S3). What does this finding most
likely indicate in an adult of this age?
A. Normal physiological finding
B. Ventricular gallop associated with heart failure
C. Atrial gallop associated with hypertension
D. Closing of the aortic valve
Answer: B
Rationale: The S3 heart sound is often referred to as a ventricular gallop and occurs during
the early phase of diastole. In older adults, it is a significant clinical indicator of decreased
ventricular compliance or fluid volume overload. This finding is frequently associated with
conditions such as congestive heart failure.
2. When auscultating the lungs of a patient with lobar pneumonia, the nurse practitioner
notes increased tactile fremitus. What is the physiological basis for this finding?
A. Air trapping in the alveoli
B. Fluid in the pleural space
C. Obstruction of the bronchus
,D. Consolidation of lung tissue
Answer: D
Rationale: Tactile fremitus refers to the palpable vibrations transmitted through the
bronchopulmonary system to the chest wall. Consolidation, such as that found in
pneumonia, conducts sound vibrations more effectively than air-filled lung tissue.
Consequently, the vibrations feel stronger over the affected area during palpation.
3. A patient exhibits a positive Murphy’s sign during a physical examination. This finding is
most suggestive of which condition?
A. Acute appendicitis
B. Splenomegaly
C. Acute cholecystitis
D. Nephrolithiasis
Answer: C
Rationale: Murphy’s sign is assessed by asking the patient to inhale while the examiner
applies pressure under the right costal margin. A positive sign occurs when the patient
abruptly stops inhaling due to pain as the inflamed gallbladder contacts the examiner’s
hand. This is a classic clinical indicator for acute cholecystitis.
4. Which cranial nerve is being assessed when the provider asks the patient to shrug their
shoulders against resistance?
A. Cranial Nerve X (Vagus)
, B. Cranial Nerve XI (Spinal Accessory)
C. Cranial Nerve XII (Hypoglossal)
D. Cranial Nerve IX (Glossopharyngeal)
Answer: B
Rationale: Cranial Nerve XI, the Spinal Accessory nerve, innervates the trapezius and
sternocleidomastoid muscles. Shrugging the shoulders tests the strength and symmetry of
the trapezius muscles. This assessment helps identify potential nerve damage or muscular
weakness in the neck and shoulder region.
5. During an abdominal assessment, the nurse practitioner performs the Rovsing sign. What
constitutes a positive Rovsing sign?
A. Pain in the right lower quadrant during left-sided pressure
B. Pain upon quick withdrawal of pressure in the right lower quadrant
C. Pain when the patient straightens the right leg
D. Pain during internal rotation of the right hip
Answer: A
Rationale: Rovsing sign is a test for peritoneal irritation often associated with appendicitis.
It involves applying deep pressure to the left lower quadrant of the abdomen. If this action
elicits pain in the right lower quadrant, the test is considered positive.
Health Assessment Q&A with Rationale |
William Paterson University
1. A 65-year-old patient presents with a third heart sound (S3). What does this finding most
likely indicate in an adult of this age?
A. Normal physiological finding
B. Ventricular gallop associated with heart failure
C. Atrial gallop associated with hypertension
D. Closing of the aortic valve
Answer: B
Rationale: The S3 heart sound is often referred to as a ventricular gallop and occurs during
the early phase of diastole. In older adults, it is a significant clinical indicator of decreased
ventricular compliance or fluid volume overload. This finding is frequently associated with
conditions such as congestive heart failure.
2. When auscultating the lungs of a patient with lobar pneumonia, the nurse practitioner
notes increased tactile fremitus. What is the physiological basis for this finding?
A. Air trapping in the alveoli
B. Fluid in the pleural space
C. Obstruction of the bronchus
,D. Consolidation of lung tissue
Answer: D
Rationale: Tactile fremitus refers to the palpable vibrations transmitted through the
bronchopulmonary system to the chest wall. Consolidation, such as that found in
pneumonia, conducts sound vibrations more effectively than air-filled lung tissue.
Consequently, the vibrations feel stronger over the affected area during palpation.
3. A patient exhibits a positive Murphy’s sign during a physical examination. This finding is
most suggestive of which condition?
A. Acute appendicitis
B. Splenomegaly
C. Acute cholecystitis
D. Nephrolithiasis
Answer: C
Rationale: Murphy’s sign is assessed by asking the patient to inhale while the examiner
applies pressure under the right costal margin. A positive sign occurs when the patient
abruptly stops inhaling due to pain as the inflamed gallbladder contacts the examiner’s
hand. This is a classic clinical indicator for acute cholecystitis.
4. Which cranial nerve is being assessed when the provider asks the patient to shrug their
shoulders against resistance?
A. Cranial Nerve X (Vagus)
, B. Cranial Nerve XI (Spinal Accessory)
C. Cranial Nerve XII (Hypoglossal)
D. Cranial Nerve IX (Glossopharyngeal)
Answer: B
Rationale: Cranial Nerve XI, the Spinal Accessory nerve, innervates the trapezius and
sternocleidomastoid muscles. Shrugging the shoulders tests the strength and symmetry of
the trapezius muscles. This assessment helps identify potential nerve damage or muscular
weakness in the neck and shoulder region.
5. During an abdominal assessment, the nurse practitioner performs the Rovsing sign. What
constitutes a positive Rovsing sign?
A. Pain in the right lower quadrant during left-sided pressure
B. Pain upon quick withdrawal of pressure in the right lower quadrant
C. Pain when the patient straightens the right leg
D. Pain during internal rotation of the right hip
Answer: A
Rationale: Rovsing sign is a test for peritoneal irritation often associated with appendicitis.
It involves applying deep pressure to the left lower quadrant of the abdomen. If this action
elicits pain in the right lower quadrant, the test is considered positive.
