©SIRJOEL EXAM SOLUTIONS
10/11/2024 1:41 PM
NUR 218 Exam 2 Questions 100% Solved.
Objective data can be gathered from the patient during which aspects of the physical assessment
process? (Select all that apply.)
a. Patient interview
b. Health history
c. General survey
d. Physical examination
e. Laboratory testing - answer✔a, b, c, d, e
Objective data consist of observed information or signs that can be collected during all stages of
the physical assessment process. Even while the patient is answering questions, providing
subjective data or symptom information, the nurse observes for physical signs of abnormalities
or impairment.
Which sequence best identifies the order in which the nurse should complete an abdominal
assessment?
, ©SIRJOEL EXAM SOLUTIONS
10/11/2024 1:41 PM
a. Inspection, palpation, percussion, auscultation
b. Auscultation, inspection, palpation, percussion
c. Auscultation, palpation, percussion, inspection
d. Inspection, auscultation, palpation, percussion - answer✔Inspection, auscultation, palpation,
percussion
Assessment of the abdominal cavity requires auscultation to immediately follow inspection,
before palpation or percussion, to avoid stimulating the bowel and eliciting inaccurate
assessment results
During examination of a patient's neck with the bell of the stethoscope, the nurse identifies a
carotid bruit. When are bruits audible in the neck?
a. When jugular vein distention is present
b. During normal examination of the neck
c. When the carotid artery is partially occluded
d. With complete occlusion of both carotid arteries - answer✔When the carotid artery is partially
occluded
, ©SIRJOEL EXAM SOLUTIONS
10/11/2024 1:41 PM
A bruit indicates blood flow turbulence and occurs with partial occlusion of a carotid artery by
atherosclerosis. Bruits are not associated with jugular vein distention and are an abnormal
assessment finding. Bruits will not be heard if the artery is 100% occluded or if the artery blood
flow is normal, without partial obstruction.
A nurse is preparing to auscultate a patient's chest. In which area should the nurse listen to
evaluate the patient's aortic valve?
a. Second right intercostal space
b. Third left intercostal space
c. Fifth right intercostal space
d. Fifth left intercostal space along the midclavicular line - answer✔Second right intercostal
space
The second intercostal space on the right is the auscultation point for the aortic valve. The
ventricles and pulmonic valve are located on the left. The point of maximal impulse (PMI) over
the mitral valve is located between the left fourth and fifth intercostal spaces.
Which assessment finding would be most important to document in a patient with known liver
disease who has a distended, taut abdomen?
a. Abdominal girth
, ©SIRJOEL EXAM SOLUTIONS
10/11/2024 1:41 PM
b. Dentition condition
c. Benign cardiac murmurs
d. Daily ambulatory distance - answer✔Abdominal girth
Increasing abdominal girth may be due to ascites, which is potentially life-threatening and could
cause respiratory arrest if the ascitic fluid is not drained. Dentition condition and benign
murmurs are not directly associated with liver disease. The patient's condition may affect
ambulatory distance; however, it is not the most important assessment finding listed.
The nurse notes the presence of ptosis when assessing an adult patient's eyes. Which potential
cause would be considered of most concern, requiring further evaluation as soon as possible?
a. Loss of skin elasticity
b. Levator muscle weakness
c. Congenital ocular abnormality
d. Oculomotor cranial nerve III paralysis - answer✔Oculomotor cranial nerve III paralysis
Oculomotor nerve paralysis may indicate the presence of a larger neurologic problem that
requires further investigation as soon as possible. Loss of skin elasticity and muscle weakness
may be due to aging, and congenital ptosis does not require immediate attention in an adult.
10/11/2024 1:41 PM
NUR 218 Exam 2 Questions 100% Solved.
Objective data can be gathered from the patient during which aspects of the physical assessment
process? (Select all that apply.)
a. Patient interview
b. Health history
c. General survey
d. Physical examination
e. Laboratory testing - answer✔a, b, c, d, e
Objective data consist of observed information or signs that can be collected during all stages of
the physical assessment process. Even while the patient is answering questions, providing
subjective data or symptom information, the nurse observes for physical signs of abnormalities
or impairment.
Which sequence best identifies the order in which the nurse should complete an abdominal
assessment?
, ©SIRJOEL EXAM SOLUTIONS
10/11/2024 1:41 PM
a. Inspection, palpation, percussion, auscultation
b. Auscultation, inspection, palpation, percussion
c. Auscultation, palpation, percussion, inspection
d. Inspection, auscultation, palpation, percussion - answer✔Inspection, auscultation, palpation,
percussion
Assessment of the abdominal cavity requires auscultation to immediately follow inspection,
before palpation or percussion, to avoid stimulating the bowel and eliciting inaccurate
assessment results
During examination of a patient's neck with the bell of the stethoscope, the nurse identifies a
carotid bruit. When are bruits audible in the neck?
a. When jugular vein distention is present
b. During normal examination of the neck
c. When the carotid artery is partially occluded
d. With complete occlusion of both carotid arteries - answer✔When the carotid artery is partially
occluded
, ©SIRJOEL EXAM SOLUTIONS
10/11/2024 1:41 PM
A bruit indicates blood flow turbulence and occurs with partial occlusion of a carotid artery by
atherosclerosis. Bruits are not associated with jugular vein distention and are an abnormal
assessment finding. Bruits will not be heard if the artery is 100% occluded or if the artery blood
flow is normal, without partial obstruction.
A nurse is preparing to auscultate a patient's chest. In which area should the nurse listen to
evaluate the patient's aortic valve?
a. Second right intercostal space
b. Third left intercostal space
c. Fifth right intercostal space
d. Fifth left intercostal space along the midclavicular line - answer✔Second right intercostal
space
The second intercostal space on the right is the auscultation point for the aortic valve. The
ventricles and pulmonic valve are located on the left. The point of maximal impulse (PMI) over
the mitral valve is located between the left fourth and fifth intercostal spaces.
Which assessment finding would be most important to document in a patient with known liver
disease who has a distended, taut abdomen?
a. Abdominal girth
, ©SIRJOEL EXAM SOLUTIONS
10/11/2024 1:41 PM
b. Dentition condition
c. Benign cardiac murmurs
d. Daily ambulatory distance - answer✔Abdominal girth
Increasing abdominal girth may be due to ascites, which is potentially life-threatening and could
cause respiratory arrest if the ascitic fluid is not drained. Dentition condition and benign
murmurs are not directly associated with liver disease. The patient's condition may affect
ambulatory distance; however, it is not the most important assessment finding listed.
The nurse notes the presence of ptosis when assessing an adult patient's eyes. Which potential
cause would be considered of most concern, requiring further evaluation as soon as possible?
a. Loss of skin elasticity
b. Levator muscle weakness
c. Congenital ocular abnormality
d. Oculomotor cranial nerve III paralysis - answer✔Oculomotor cranial nerve III paralysis
Oculomotor nerve paralysis may indicate the presence of a larger neurologic problem that
requires further investigation as soon as possible. Loss of skin elasticity and muscle weakness
may be due to aging, and congenital ptosis does not require immediate attention in an adult.
