NSG 3160 EXAM 2: ADVANCED HEALTH
ASSESSMENT QUESTIONS AND
ANSWERS AND EXPLANATIONS
1. During a respiratory assessment, the nurse notes increased tactile fremitus over the right
lower lobe. Which condition is most likely associated with this finding?
A. Pneumothorax
B. Pleural effusion
C. Pneumonia with consolidation
D. Bronchial obstruction
Answer: C
Conceptual Explanation: Tactile fremitus increases with consolidation (e.g., pneumonia)
because sound travels better through solid/fluid-filled tissue than air-filled tissue.
2. Which heart sound is specifically associated with the rapid filling phase of the ventricles
and is often an early sign of heart failure in older adults?
A. S1
B. S2
,C. S3
D. S4
Answer: C
Conceptual Explanation: S3 (ventricular gallop) occurs during the rapid filling phase of
diastole and is a clinical indicator of fluid volume overload or heart failure.
3. A patient presents with a ‘brownish’ discoloration of the skin around the ankles and
significant lower extremity edema. These findings are characteristic of:
A. Chronic arterial insufficiency
B. Chronic venous insufficiency
C. Raynaud’s phenomenon
D. Peripheral artery disease
Answer: B
Conceptual Explanation: Hemosiderin staining (brownish tint) and edema are hallmark
signs of chronic venous insufficiency caused by blood pooling and RBC breakdown.
4. When assessing the abdomen, what is the correct sequence of techniques to ensure
accurate findings?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Percussion, Palpation, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
, D. Inspection, Auscultation, Percussion, Palpation
Answer: D
Conceptual Explanation: Auscultation follows inspection to prevent bowel sounds from
being altered by percussion or palpation.
5. The nurse notes a high-pitched, musical sound heard primarily during expiration while
auscultating a patient with asthma. This is documented as:
A. Stridor
B. Wheezing
C. Crackles
D. Pleural friction rub
Answer: B
Conceptual Explanation: Wheezing is caused by air flowing through narrowed or
obstructed airways, common in asthma.
6. A Grade IV heart murmur is uniquely identified by the presence of which finding?
A. A sound heard in all four valvular areas
B. A very faint sound heard only with effort
C. A sound heard with the stethoscope off the chest
D. A palpable thrill
ASSESSMENT QUESTIONS AND
ANSWERS AND EXPLANATIONS
1. During a respiratory assessment, the nurse notes increased tactile fremitus over the right
lower lobe. Which condition is most likely associated with this finding?
A. Pneumothorax
B. Pleural effusion
C. Pneumonia with consolidation
D. Bronchial obstruction
Answer: C
Conceptual Explanation: Tactile fremitus increases with consolidation (e.g., pneumonia)
because sound travels better through solid/fluid-filled tissue than air-filled tissue.
2. Which heart sound is specifically associated with the rapid filling phase of the ventricles
and is often an early sign of heart failure in older adults?
A. S1
B. S2
,C. S3
D. S4
Answer: C
Conceptual Explanation: S3 (ventricular gallop) occurs during the rapid filling phase of
diastole and is a clinical indicator of fluid volume overload or heart failure.
3. A patient presents with a ‘brownish’ discoloration of the skin around the ankles and
significant lower extremity edema. These findings are characteristic of:
A. Chronic arterial insufficiency
B. Chronic venous insufficiency
C. Raynaud’s phenomenon
D. Peripheral artery disease
Answer: B
Conceptual Explanation: Hemosiderin staining (brownish tint) and edema are hallmark
signs of chronic venous insufficiency caused by blood pooling and RBC breakdown.
4. When assessing the abdomen, what is the correct sequence of techniques to ensure
accurate findings?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Percussion, Palpation, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
, D. Inspection, Auscultation, Percussion, Palpation
Answer: D
Conceptual Explanation: Auscultation follows inspection to prevent bowel sounds from
being altered by percussion or palpation.
5. The nurse notes a high-pitched, musical sound heard primarily during expiration while
auscultating a patient with asthma. This is documented as:
A. Stridor
B. Wheezing
C. Crackles
D. Pleural friction rub
Answer: B
Conceptual Explanation: Wheezing is caused by air flowing through narrowed or
obstructed airways, common in asthma.
6. A Grade IV heart murmur is uniquely identified by the presence of which finding?
A. A sound heard in all four valvular areas
B. A very faint sound heard only with effort
C. A sound heard with the stethoscope off the chest
D. A palpable thrill
