30/08/2025
*Health Assessment – 2023 paper with Answers & Reasons*
Q1. Which action is the nurse performing when using the inspection technique during a health assessment?
* Answer: Looking for redness, swelling, or unusual shape.
* Reason: Inspection is the process of using the sense of sight to visually observe for both normal and abnormal findings.
Q2. A nurse gathers information about a patient’s health status systematically. What is this called?
* Answer: Health assessment
* Reason: A health assessment is the systematic collection of patient data. A medical diagnosis is a conclusion derived from this data, not the process itself.
Q3. While measuring leg edema, the nurse should measure at which sites?
* Answer: Forefoot, ankle, calf, and mid-thigh
* Reason: Measuring at these standard anatomical points ensures accuracy and consistency when monitoring the extent of swelling.
Q4. Which percussion note is normally heard over the lungs?
* Answer: Resonance
* Reason: Healthy, air-filled lung tissue produces a low-pitched, hollow sound called resonance upon percussion.
Q5. The nurse observes that the patient’s AP diameter equals the transverse diameter (1:1). What condition is this?
* Answer: Barrel chest
* Reason: A chest with an anterior-posterior (AP) to transverse diameter ratio of 1:1 gives it a rounded, barrel chest appearance, which is a classic sign of hyperinflation seen in COPD.
Q6. The nurse tests two-point discrimination. Which body part has the greatest ability?
* Answer: Fingertips
* Reason: The fingertips have a very high density of sensory receptors, giving them the greatest ability to distinguish between two close points.
Q7. Which statement best describes palpation during a physical exam?
* Answer: Using hands to feel texture, temperature, tenderness.
* Reason: Palpation is a hands-on technique that uses touch to assess physical characteristics like texture, temperature, moisture, and tenderness.
Q8. The nurse scores a newborn 9 on the APGAR test. What does this mean?
* Answer: Healthy newborn
* Reason: An APGAR score between 7 and 10 indicates a vigorous, healthy baby.
Q9. What is Dalry’s maneuver?
* Answer: Not a recognized term
* Reason: This term is likely a misprint. There is no standard medical maneuver by this name.
Q10. Which method is used to assess vibration sense?
* Answer: Tuning fork on a bony prominence
* Reason: A vibrating tuning fork (typically 128 Hz) placed on a bony prominence is the standard tool to test a patient's sense of vibration.
Q11. Which heart sound is produced by closure of the mitral and tricuspid valves?
* Answer: S1
* Reason: S1 (the first heart sound) is produced by the closure of the atrioventricular (AV) valves—the mitral and tricuspid valves—at the start of systole.
Q12. Which heart sound is produced by closure of the aortic and pulmonary valves?
* Answer: S2
* Reason: S2 (the second heart sound) is produced by the closure of the semilunar valves—the aortic and pulmonary valves—at the beginning of diastole.
Q13. Palpable vibration over the precordium is called?
* Answer: Thrill
* Reason: A thrill is a palpable vibration on the chest wall caused by turbulent blood flow, often associated with a loud heart murmur.
Q14. Extra heart sound after S2 (early diastole) is?
* Answer: S3 (ventricular gallop)
* Reason: An S3 heart sound is a low-pitched sound heard after S2 during early diastole, often due to rapid ventricular filling in conditions like heart failure.
Q15. Extra heart sound before S1 (late diastole) is?
* Answer: S4 (atrial gallop)
* Reason: An S4 heart sound is a low-pitched sound heard before S1 during late diastole. It's caused by the atria contracting against a stiff ventricle.
Q16. Where is the PMI normally located?
* Answer: 5th left intercostal space, midclavicular line
* Reason: The Point of Maximal Impulse (PMI) is normally located at the 5th left intercostal space, medial to the midclavicular line.
Q17. Displaced PMI laterally and downward indicates?
* Answer: Left ventricular hypertrophy/cardiomegaly
* Reason: An enlarged heart, specifically left ventricular hypertrophy, can push the PMI laterally and downward from its normal position.
Q18. High-pitched blowing systolic murmur at apex = ?
* Answer: Mitral regurgitation
* Reason: Mitral regurgitation is a high-pitched, blowing systolic murmur that is best heard at the apex and often radiates to the axilla.
Q19. Harsh systolic crescendo–decrescendo murmur at right 2nd ICS = ?
* Answer: Aortic stenosis
* Reason: Aortic stenosis is characterized by a harsh, crescendo-decrescendo systolic murmur best heard at the right 2nd intercostal space that radiates to the carotids.
Q20. Diastolic rumble with opening snap at apex = ?
* Answer: Mitral stenosis
* Reason: Mitral stenosis produces a low-pitched diastolic rumbling murmur with an audible opening snap.
Q21. Pulse site checked during adult CPR?
* Answer: Carotid artery
* Reason: The carotid artery is a central and reliable site to check for a pulse during CPR in adults.
Q22. Which artery is used for blood pressure measurement?
* Answer: Brachial artery
* Reason: The brachial artery in the upper arm is the standard site for blood pressure measurement.
Q23. Pulse palpated at wrist, thumb side?
* Answer: Radial pulse
* Reason: The radial pulse is palpated on the lateral aspect of the wrist, on the thumb side.
Q24. Best pulse in infants during CPR?
* Answer: Brachial artery
* Reason: The brachial artery is easier to feel in infants than the carotid artery.
Q25. Pulse palpated in the groin?
* Answer: Femoral pulse
* Reason: The femoral pulse is located in the groin area, inferior to the inguinal ligament.
Q26. Pulse behind the knee?
* Answer: Popliteal artery
* Reason: The popliteal artery is deep in the popliteal fossa, behind the knee.
Q27. Pulse on dorsum of foot?
* Answer: Dorsalis pedis artery
* Reason: The dorsalis pedis artery is located on the top of the foot.
Q28. Pulse behind medial malleolus?
* Answer: Posterior tibial artery
* Reason: The posterior tibial artery is a key pulse point for assessing peripheral circulation, located just behind the medial malleolus.
Q29. BP difference >10 mmHg between arms suggests?
* Answer: Arterial obstruction (subclavian stenosis, aortic dissection)
* Reason: A systolic BP difference of more than 10 mmHg between arms can be a sign of arterial obstruction.
Q30. Which Korotkoff sound indicates systolic BP?
* Answer: Phase I (first tapping sound)
* Reason: The first tapping sound, Korotkoff Phase I, indicates the systolic blood pressure.
Q31. Which Korotkoff sound indicates diastolic BP?
* Answer: Phase V (disappearance of sound)
* Reason: The point at which the sounds completely disappear, Korotkoff Phase V, indicates the diastolic blood pressure in adults.
Q32. Which cranial nerve tests smell?
* Answer: CN I – Olfactory nerve
* Reason: The olfactory nerve (CN I) is responsible for the sense of smell.
Q33. Which cranial nerve controls vision?
* Answer: CN II – Optic nerve
* Reason: The optic nerve (CN II) is responsible for transmitting visual information.
Q34. Which cranial nerves control eye movements?
* Answer: CN III (Oculomotor), IV (Trochlear), VI (Abducens)
* Reason: These three nerves work together to control eye movements.
Q35. Which cranial nerve tests facial sensation?
* Answer: CN V – Trigeminal
* Reason: The trigeminal nerve (CN V) is responsible for sensation in the face.
Q36. Which cranial nerve tests facial movements?
* Answer: CN VII – Facial nerve
* Reason: The facial nerve (CN VII) controls the muscles of facial expression.
Q37. Which cranial nerve tests hearing and balance?
* Answer: CN VIII – Vestibulocochlear
* Reason: The vestibulocochlear nerve (CN VIII) has two divisions: one for hearing and one for balance.
Q38. Which cranial nerves test gag reflex?
* Answer: CN IX (Glossopharyngeal) & CN X (Vagus)
* Reason: These two nerves work together to mediate the gag and swallowing reflexes.
Q39. Which cranial nerve tests tongue movement?
* Answer: CN XII – Hypoglossal
* Reason: The hypoglossal nerve (CN XII) controls the muscles of the tongue, which are essential for speech and swallowing.
Q40. Which cranial nerve tests shoulder shrug/head turn?
* Answer: CN XI – Accessory nerve
* Reason: The accessory nerve (CN XI) innervates the muscles responsible for these movements.
Q41. Which lobe of brain controls personality & motor function?
* Answer: Frontal lobe
* Reason: The frontal lobe is responsible for higher-level functions including personality and voluntary motor control.
Q42. Which lobe controls hearing?
* Answer: Temporal lobe
* Reason: The temporal lobe houses the primary auditory cortex.
Q43. Which lobe controls vision?
* Answer: Occipital lobe
* Reason: The occipital lobe is the brain's visual processing center.
Q44. Which lobe processes sensory input (touch, pain)?
* Answer: Parietal lobe
* Reason: The parietal lobe contains the primary somatosensory cortex, which processes touch and pain.
Q45. Which test checks cerebellar coordination?
* Answer: Finger-to-nose / Heel-to-shin test
* Reason: These are standard tests used to assess fine motor coordination and balance.
Q46. Positive Romberg’s test suggests?
* Answer: Impaired proprioception or vestibular dysfunction
* Reason: A positive Romberg's test (loss of balance when eyes are closed) indicates a problem with either the sense of position or the balance system.
Q47. Deep tendon reflexes are graded from?
* Answer: 0 to 4+
* Reason: Deep tendon reflexes are graded on a scale from 0 (absent) to 4+ (hyperactive). A score of 2+ is normal.
Q48. Babinski’s sign in adults indicates?
* Answer: Upper motor neuron lesion
* Reason: A positive Babinski's sign in an adult is a sign of an upper motor neuron lesion.
Q49. Glasgow Coma Scale minimum & maximum score?
* Answer: 3 (worst) to 15 (best)
* Reason: The Glasgow Coma Scale (GCS) ranges from 3 (deep coma) to 15 (fully conscious).
Q50. Normal pupil reaction to light?
* Answer: Direct & consensual constriction
* Reason: A normal pupil response is for both the directly illuminated pupil and the opposite pupil to constrict simultaneously.
Q51. Term for unequal pupils?
* Answer: Anisocoria
* Reason: Anisocoria is the medical term for pupils of unequal size.
Q52. Yellow sclera indicates?
* Answer: Jaundice
* Reason: Yellowing of the sclera is a key sign of jaundice, caused by an accumulation of bilirubin.
Q53. Clubbing of fingers suggests?
* Answer: Chronic hypoxia (e.g., lung disease, cyanotic heart disease)
* Reason: Clubbing is a sign of long-term oxygen deficiency.
Q54. Cyanosis indicates?
* Answer: Low oxygen saturation
* Reason: Cyanosis is a bluish discoloration of the skin that indicates a low oxygen level in the blood.
Q55. Capillary refill time >2 seconds indicates?
* Answer: Poor peripheral perfusion
* Reason: A capillary refill time greater than two seconds suggests that blood flow to the extremities is sluggish.
Q56. Which sound is heard over the stomach during percussion?
* Answer: Tympany
* Reason: Tympany is a high-pitched, drum-like sound produced by percussing over a hollow, air-filled organ like the stomach or intestines.
Q57. Dullness on abdominal percussion suggests?
* Answer: Fluid, mass, or organ (e.g., liver, ascites)
* Reason: Dullness is a flat, short sound heard on percussion over a dense structure.
Q58. Ascites is confirmed by which test?
* Answer: Shifting dullness / Fluid wave test
* Reason: These tests are used to detect the presence of free fluid in the peritoneal cavity, which is characteristic of ascites.
Q59. Murphy’s sign indicates?
* Answer: Cholecystitis
* Reason: A positive Murphy's sign (pain on inspiration when palpating the right upper quadrant) is highly suggestive of acute cholecystitis.
Q60. McBurney’s point tenderness indicates?
* Answer: Appendicitis
* Reason: McBurney's point tenderness is a classic sign of appendicitis.
Q61. Rebound tenderness is a sign of?
* Answer: Peritonitis
* Reason: Rebound tenderness is pain that occurs upon the sudden release of pressure from the abdomen, a key indicator of peritoneal inflammation.
Q62. Costovertebral angle tenderness suggests?
* Answer: Kidney infection (pyelonephritis)
* Reason: Costovertebral angle (CVA) tenderness is a common sign of a kidney infection.
Q63. Grey-Turner sign indicates?
* Answer: Hemorrhagic pancreatitis / retroperitoneal bleed
* Reason: Grey-Turner sign is bruising in the flank area, which suggests retroperitoneal bleeding.
Q64. Cullen’s sign indicates?
* Answer: Hemorrhagic pancreatitis / intraperitoneal bleed
* Reason: Cullen's sign is bruising around the belly button, which suggests an intra-abdominal bleed.
Q65. Hyperactive bowel sounds suggest?
* Answer: Diarrhea, gastroenteritis, early obstruction
* Reason: Hyperactive bowel sounds indicate increased intestinal motility.
Q66. Absent bowel sounds suggest?
* Answer: Ileus or late bowel obstruction
* Reason: Absent bowel sounds indicate a lack of peristaltic activity.
Q67. Normal bowel sounds frequency?
* Answer: 5–30 per minute
* Reason: Normal bowel sounds are typically heard at a frequency of 5 to 30 clicks or gurgles per minute.
Q68. Term for difficulty swallowing?
* Answer: Dysphagia
* Reason: Dysphagia is the medical term for difficulty swallowing.
Q69. Term for painful swallowing?
* Answer: Odynophagia
* Reason: Odynophagia is the medical term for painful swallowing.
Q70. Term for vomiting blood?
* Answer: Hematemesis
* Reason: Hematemesis is the act of vomiting blood.
