NSG 3160 HEALTH ASSESSMENT
COMPREHENSIVE FINAL EXAM
QUESTIONS AND ANSWERS
1. During a physical examination, the nurse notes a palpable vibration on the chest wall when
the patient speaks. Which term correctly identifies this finding?
A. Tactile fremitus
B. Adventitious breath sounds
C. Crepitus
D. Egophony
Answer: A
Conceptual Explanation: Tactile fremitus is a palpable vibration transmitted through the
bronchopulmonary system to the chest wall when the patient speaks.
2. A patient presents with a deep, rapid breathing pattern often associated with metabolic
acidosis. How should the nurse document this finding?
A. Cheyne-Stokes respirations
B. Biot’s respirations
C. Kussmaul respirations
,D. Hypoventilation
Answer: C
Conceptual Explanation: Kussmaul breathing is a deep and labored breathing pattern
often associated with severe metabolic acidosis, particularly diabetic ketoacidosis.
3. When assessing the cardiovascular system, the nurse hears a high-pitched, scratchy sound
at the left lower sternal border during both systole and diastole. This is indicative of:
A. Pericardial friction rub
B. Mitral regurgitation
C. Aortic stenosis
D. S3 gallop
Answer: A
Conceptual Explanation: A pericardial friction rub is a high-pitched, scratchy sound
caused by inflammation of the pericardial sac, heard throughout the cardiac cycle.
4. Which cranial nerve is being tested when the nurse asks the patient to shrug their
shoulders against resistance?
A. CN IX (Glossopharyngeal)
B. CN X (Vagus)
C. CN XI (Spinal Accessory)
D. CN XII (Hypoglossal)
, Answer: C
Conceptual Explanation: Cranial Nerve XI (Spinal Accessory) innervates the
sternocleidomastoid and trapezius muscles, responsible for shoulder shrugging.
5. During an abdominal assessment, the nurse performs the Murphy sign. A positive result
most likely indicates which condition?
A. Appendicitis
B. Cholecystitis
C. Splenomegaly
D. Ascites
Answer: B
Conceptual Explanation: A positive Murphy sign (pain and cessation of inspiration upon
palpation of the gallbladder area) is indicative of cholecystitis.
6. A nurse is assessing a patient for pitting edema. The indentation disappears rapidly but is
clearly visible. How should this be graded?
A. 1+
B. 2+
C. 3+
D. 4+
Answer: B
COMPREHENSIVE FINAL EXAM
QUESTIONS AND ANSWERS
1. During a physical examination, the nurse notes a palpable vibration on the chest wall when
the patient speaks. Which term correctly identifies this finding?
A. Tactile fremitus
B. Adventitious breath sounds
C. Crepitus
D. Egophony
Answer: A
Conceptual Explanation: Tactile fremitus is a palpable vibration transmitted through the
bronchopulmonary system to the chest wall when the patient speaks.
2. A patient presents with a deep, rapid breathing pattern often associated with metabolic
acidosis. How should the nurse document this finding?
A. Cheyne-Stokes respirations
B. Biot’s respirations
C. Kussmaul respirations
,D. Hypoventilation
Answer: C
Conceptual Explanation: Kussmaul breathing is a deep and labored breathing pattern
often associated with severe metabolic acidosis, particularly diabetic ketoacidosis.
3. When assessing the cardiovascular system, the nurse hears a high-pitched, scratchy sound
at the left lower sternal border during both systole and diastole. This is indicative of:
A. Pericardial friction rub
B. Mitral regurgitation
C. Aortic stenosis
D. S3 gallop
Answer: A
Conceptual Explanation: A pericardial friction rub is a high-pitched, scratchy sound
caused by inflammation of the pericardial sac, heard throughout the cardiac cycle.
4. Which cranial nerve is being tested when the nurse asks the patient to shrug their
shoulders against resistance?
A. CN IX (Glossopharyngeal)
B. CN X (Vagus)
C. CN XI (Spinal Accessory)
D. CN XII (Hypoglossal)
, Answer: C
Conceptual Explanation: Cranial Nerve XI (Spinal Accessory) innervates the
sternocleidomastoid and trapezius muscles, responsible for shoulder shrugging.
5. During an abdominal assessment, the nurse performs the Murphy sign. A positive result
most likely indicates which condition?
A. Appendicitis
B. Cholecystitis
C. Splenomegaly
D. Ascites
Answer: B
Conceptual Explanation: A positive Murphy sign (pain and cessation of inspiration upon
palpation of the gallbladder area) is indicative of cholecystitis.
6. A nurse is assessing a patient for pitting edema. The indentation disappears rapidly but is
clearly visible. How should this be graded?
A. 1+
B. 2+
C. 3+
D. 4+
Answer: B
