NUR 101/ NUR101 Exam 1 –
Health Assessment Guide
ACTUAL EXAM 2026/2027 |
Health Assessment Guide |
Verified Q&A | Pass Guaranteed -
A+ Graded
ART A – MULTIPLE CHOICE (Q1-75)
P
Q1. A 68-year-old patient states, "I've been having chest pain for 3 days." Which component of
the health history does this represent?
A. Past medical history
B. Chief complaint
C. Review of systems
D. Social history
[CORRECT] B
Rationale: The chief complaint is the patient's own words describing the reason for seeking
care, typically documented in quotation marks. It should be brief and in the patient's language,
not medical terminology. Past medical history would include previous diagnoses, while review of
systems is a head-to-toe symptom checklist. Social history covers lifestyle factors.
Q2. When obtaining a history of present illness, the nurse asks, "What does the pain feel like?"
This question addresses which OLDCARTS element?
A. Onset
B. Location
C. Character
D. Severity
[CORRECT] C
Rationale: The "Character" element of OLDCARTS asks about the quality of the symptom
(sharp, dull, burning, pressure). Onset asks when it started, location asks where it is, and
severity asks about intensity (often using a 0-10 scale). Understanding character helps
differentiate potential causes of symptoms.
Q3. A nurse is interviewing a patient who begins crying when discussing a recent divorce.
Which response demonstrates therapeutic communication?
, . "Don't cry, things will get better soon."
A
B. "You should focus on your health right now."
C. "This seems really difficult for you."
D. "Let's talk about something else."
[CORRECT] C
Rationale: Reflecting feelings ("This seems really difficult for you") is a therapeutic technique
that validates the patient's emotions without minimizing or changing the subject. False
reassurance (A), giving advice (B), and changing the subject (D) are non-therapeutic responses
that may make the patient feel unheard or dismissed.
Q4. Which statement about the CAGE questionnaire is correct?
A. It screens for depression
B. A score of 1 or more indicates alcohol use disorder
C. It assesses anxiety levels
D. Two or more positive responses suggest need for further evaluation
[CORRECT] D
Rationale: The CAGE questionnaire screens for alcohol misuse. Two or more positive
responses indicate high suspicion of alcohol use disorder and warrant further assessment. It
does not diagnose but identifies patients who may need additional screening. The PHQ-2/9
screens for depression, and GAD-7 screens for anxiety.
Q5. A patient with dementia is unable to rate their pain on a 0-10 scale. Which pain assessment
tool is most appropriate?
A. Numeric Rating Scale
B. Wong-Baker FACES Scale
C. FLACC Scale
D. PAINAD Scale
[CORRECT] D
Rationale: The PAINAD (Pain Assessment in Advanced Dementia) scale is specifically validated
for patients with dementia who cannot self-report pain. It assesses breathing, vocalization, facial
expression, body language, and consolability. FLACC is for preverbal children, Wong-Baker
FACES requires cognitive ability to associate faces with feelings, and NRS requires numerical
understanding.
Q6. Which vital sign measurement technique is correct?
A. Blood pressure cuff should cover 100% of arm circumference
B. The apical pulse is auscultated at the 5th intercostal space, midclavicular line
C. Rectal temperature is contraindicated in all children
D. Orthostatic vital signs are measured only in the standing position
[CORRECT] B
Rationale: The apical pulse is best heard at the 5th intercostal space, midclavicular line (apex of
the heart) using a stethoscope. The BP cuff bladder should cover 80% of arm circumference
(not 100%). Rectal temperature is safe in infants but contraindicated with diarrhea, rectal
surgery, or bleeding disorders. Orthostatic vitals require measurement in supine, sitting, AND
standing positions.
Q7. A patient's BMI is calculated at 31.2. How is this classified?
A. Overweight
, . Obese Class I
B
C. Obese Class II
D. Normal
[CORRECT] B
Rationale: A BMI of 31.2 falls within the Obese Class I range (30-34.9). Overweight is 25-29.9,
Obese Class II is 35-39.9, and normal is 18.5-24.9. BMI is a screening tool but does not account
for muscle mass or body composition, so additional assessment (waist circumference, body fat
percentage) may be needed for comprehensive evaluation.
Q8. During a mental status exam, the nurse observes that the patient rapidly shifts topics during
conversation, but the topics are loosely connected. This describes:
A. Tangential thought process
B. Flight of ideas
C. Circumstantial thought process
D. Loose associations
[CORRECT] B
Rationale: Flight of ideas is characterized by rapid shifting between topics that are loosely
connected, often seen in mania. Tangential thought never returns to the original topic.
Circumstantial thought eventually returns to the point with excessive detail. Loose associations
have no logical connection between ideas, seen in schizophrenia.
Q9. Which factor would NOT typically cause a falsely elevated blood pressure reading?
A. Cuff too small for the arm
B. Arm positioned above heart level
C. Recent cigarette smoking
D. White coat syndrome
[CORRECT] B
Rationale: An arm positioned ABOVE heart level would cause a falsely LOW blood pressure
reading due to reduced hydrostatic pressure. A cuff that is too small yields falsely high readings.
Recent smoking and white coat syndrome (anxiety in clinical settings) both elevate blood
pressure. Proper technique requires the arm at heart level.
Q10. The LEARN model for cultural competence includes all of the following EXCEPT:
A. Listen to the patient's perspective
B. Explain your medical perspective
C. Advise the patient on the correct treatment
D. Negotiate a mutually acceptable plan
[CORRECT] C
Rationale: The LEARN model stands for Listen, Explain, Acknowledge, Recommend, and
Negotiate. It does NOT include "Advise" because cultural competence emphasizes collaboration
and mutual decision-making rather than the provider dictating treatment. The negotiation step
ensures the plan respects the patient's cultural beliefs and preferences.
Q11. A nurse is assessing a patient who states, "I hear voices telling me to hurt myself." This is
an example of:
A. Delusion
B. Hallucination
C. Illusion
, . Obsession
D
[CORRECT] B
Rationale: Hallucinations are false sensory perceptions without external stimuli. Auditory
hallucinations are the most common type in psychiatric disorders. Delusions are fixed false
beliefs (not sensory). Illusions are misinterpretations of real stimuli. Obsessions are recurrent
intrusive thoughts that the patient recognizes as their own.
Q12. Normal respiratory rate for a healthy adult at rest is:
A. 8-12 breaths per minute
B. 12-20 breaths per minute
C. 20-30 breaths per minute
D. 30-40 breaths per minute
[CORRECT] B
Rationale: Normal adult respiratory rate is 12-20 breaths per minute. Tachypnea is >20, and
bradypnea is <12. Children have higher normal rates (20-30 for toddlers, 30-60 for infants).
Respiratory rate should be counted for a full minute when irregular.
Q13. Which technique demonstrates active listening?
A. Finishing the patient's sentences to save time
B. Nodding and maintaining eye contact while the patient speaks
C. Planning your next question while the patient is talking
D. Interrupting to correct medical misinformation
[CORRECT] B
Rationale: Active listening involves giving full attention through verbal and nonverbal cues such
as nodding, eye contact, and verbal acknowledgment. Finishing sentences, planning responses,
and interrupting are barriers to effective communication. Active listening builds rapport and
ensures accurate information gathering.
Q14. The FICA spiritual assessment tool includes all of the following EXCEPT:
A. Faith and belief
B. Importance and influence
C. Community
D. Attendance at religious services
[CORRECT] D
Rationale: FICA stands for Faith/belief, Importance/influence, Community, and Address in care.
It does NOT specifically ask about attendance at religious services. Spiritual assessment
focuses on what gives life meaning, how beliefs influence health decisions, support systems,
and how to incorporate spirituality into the care plan.
Q15. A patient has the following vital signs: BP 110/70 mmHg supine, BP 90/60 mmHg
standing, HR 88 bpm supine, HR 112 bpm standing. These findings indicate:
A. Normal variation
B. Orthostatic hypotension
C. Hypertensive crisis
D. Bradycardia
[CORRECT] B
Rationale: Orthostatic hypotension is diagnosed when systolic BP drops ≥20 mmHg OR
diastolic BP drops ≥10 mmHg OR heart rate increases ≥20 bpm when moving from supine to
Health Assessment Guide
ACTUAL EXAM 2026/2027 |
Health Assessment Guide |
Verified Q&A | Pass Guaranteed -
A+ Graded
ART A – MULTIPLE CHOICE (Q1-75)
P
Q1. A 68-year-old patient states, "I've been having chest pain for 3 days." Which component of
the health history does this represent?
A. Past medical history
B. Chief complaint
C. Review of systems
D. Social history
[CORRECT] B
Rationale: The chief complaint is the patient's own words describing the reason for seeking
care, typically documented in quotation marks. It should be brief and in the patient's language,
not medical terminology. Past medical history would include previous diagnoses, while review of
systems is a head-to-toe symptom checklist. Social history covers lifestyle factors.
Q2. When obtaining a history of present illness, the nurse asks, "What does the pain feel like?"
This question addresses which OLDCARTS element?
A. Onset
B. Location
C. Character
D. Severity
[CORRECT] C
Rationale: The "Character" element of OLDCARTS asks about the quality of the symptom
(sharp, dull, burning, pressure). Onset asks when it started, location asks where it is, and
severity asks about intensity (often using a 0-10 scale). Understanding character helps
differentiate potential causes of symptoms.
Q3. A nurse is interviewing a patient who begins crying when discussing a recent divorce.
Which response demonstrates therapeutic communication?
, . "Don't cry, things will get better soon."
A
B. "You should focus on your health right now."
C. "This seems really difficult for you."
D. "Let's talk about something else."
[CORRECT] C
Rationale: Reflecting feelings ("This seems really difficult for you") is a therapeutic technique
that validates the patient's emotions without minimizing or changing the subject. False
reassurance (A), giving advice (B), and changing the subject (D) are non-therapeutic responses
that may make the patient feel unheard or dismissed.
Q4. Which statement about the CAGE questionnaire is correct?
A. It screens for depression
B. A score of 1 or more indicates alcohol use disorder
C. It assesses anxiety levels
D. Two or more positive responses suggest need for further evaluation
[CORRECT] D
Rationale: The CAGE questionnaire screens for alcohol misuse. Two or more positive
responses indicate high suspicion of alcohol use disorder and warrant further assessment. It
does not diagnose but identifies patients who may need additional screening. The PHQ-2/9
screens for depression, and GAD-7 screens for anxiety.
Q5. A patient with dementia is unable to rate their pain on a 0-10 scale. Which pain assessment
tool is most appropriate?
A. Numeric Rating Scale
B. Wong-Baker FACES Scale
C. FLACC Scale
D. PAINAD Scale
[CORRECT] D
Rationale: The PAINAD (Pain Assessment in Advanced Dementia) scale is specifically validated
for patients with dementia who cannot self-report pain. It assesses breathing, vocalization, facial
expression, body language, and consolability. FLACC is for preverbal children, Wong-Baker
FACES requires cognitive ability to associate faces with feelings, and NRS requires numerical
understanding.
Q6. Which vital sign measurement technique is correct?
A. Blood pressure cuff should cover 100% of arm circumference
B. The apical pulse is auscultated at the 5th intercostal space, midclavicular line
C. Rectal temperature is contraindicated in all children
D. Orthostatic vital signs are measured only in the standing position
[CORRECT] B
Rationale: The apical pulse is best heard at the 5th intercostal space, midclavicular line (apex of
the heart) using a stethoscope. The BP cuff bladder should cover 80% of arm circumference
(not 100%). Rectal temperature is safe in infants but contraindicated with diarrhea, rectal
surgery, or bleeding disorders. Orthostatic vitals require measurement in supine, sitting, AND
standing positions.
Q7. A patient's BMI is calculated at 31.2. How is this classified?
A. Overweight
, . Obese Class I
B
C. Obese Class II
D. Normal
[CORRECT] B
Rationale: A BMI of 31.2 falls within the Obese Class I range (30-34.9). Overweight is 25-29.9,
Obese Class II is 35-39.9, and normal is 18.5-24.9. BMI is a screening tool but does not account
for muscle mass or body composition, so additional assessment (waist circumference, body fat
percentage) may be needed for comprehensive evaluation.
Q8. During a mental status exam, the nurse observes that the patient rapidly shifts topics during
conversation, but the topics are loosely connected. This describes:
A. Tangential thought process
B. Flight of ideas
C. Circumstantial thought process
D. Loose associations
[CORRECT] B
Rationale: Flight of ideas is characterized by rapid shifting between topics that are loosely
connected, often seen in mania. Tangential thought never returns to the original topic.
Circumstantial thought eventually returns to the point with excessive detail. Loose associations
have no logical connection between ideas, seen in schizophrenia.
Q9. Which factor would NOT typically cause a falsely elevated blood pressure reading?
A. Cuff too small for the arm
B. Arm positioned above heart level
C. Recent cigarette smoking
D. White coat syndrome
[CORRECT] B
Rationale: An arm positioned ABOVE heart level would cause a falsely LOW blood pressure
reading due to reduced hydrostatic pressure. A cuff that is too small yields falsely high readings.
Recent smoking and white coat syndrome (anxiety in clinical settings) both elevate blood
pressure. Proper technique requires the arm at heart level.
Q10. The LEARN model for cultural competence includes all of the following EXCEPT:
A. Listen to the patient's perspective
B. Explain your medical perspective
C. Advise the patient on the correct treatment
D. Negotiate a mutually acceptable plan
[CORRECT] C
Rationale: The LEARN model stands for Listen, Explain, Acknowledge, Recommend, and
Negotiate. It does NOT include "Advise" because cultural competence emphasizes collaboration
and mutual decision-making rather than the provider dictating treatment. The negotiation step
ensures the plan respects the patient's cultural beliefs and preferences.
Q11. A nurse is assessing a patient who states, "I hear voices telling me to hurt myself." This is
an example of:
A. Delusion
B. Hallucination
C. Illusion
, . Obsession
D
[CORRECT] B
Rationale: Hallucinations are false sensory perceptions without external stimuli. Auditory
hallucinations are the most common type in psychiatric disorders. Delusions are fixed false
beliefs (not sensory). Illusions are misinterpretations of real stimuli. Obsessions are recurrent
intrusive thoughts that the patient recognizes as their own.
Q12. Normal respiratory rate for a healthy adult at rest is:
A. 8-12 breaths per minute
B. 12-20 breaths per minute
C. 20-30 breaths per minute
D. 30-40 breaths per minute
[CORRECT] B
Rationale: Normal adult respiratory rate is 12-20 breaths per minute. Tachypnea is >20, and
bradypnea is <12. Children have higher normal rates (20-30 for toddlers, 30-60 for infants).
Respiratory rate should be counted for a full minute when irregular.
Q13. Which technique demonstrates active listening?
A. Finishing the patient's sentences to save time
B. Nodding and maintaining eye contact while the patient speaks
C. Planning your next question while the patient is talking
D. Interrupting to correct medical misinformation
[CORRECT] B
Rationale: Active listening involves giving full attention through verbal and nonverbal cues such
as nodding, eye contact, and verbal acknowledgment. Finishing sentences, planning responses,
and interrupting are barriers to effective communication. Active listening builds rapport and
ensures accurate information gathering.
Q14. The FICA spiritual assessment tool includes all of the following EXCEPT:
A. Faith and belief
B. Importance and influence
C. Community
D. Attendance at religious services
[CORRECT] D
Rationale: FICA stands for Faith/belief, Importance/influence, Community, and Address in care.
It does NOT specifically ask about attendance at religious services. Spiritual assessment
focuses on what gives life meaning, how beliefs influence health decisions, support systems,
and how to incorporate spirituality into the care plan.
Q15. A patient has the following vital signs: BP 110/70 mmHg supine, BP 90/60 mmHg
standing, HR 88 bpm supine, HR 112 bpm standing. These findings indicate:
A. Normal variation
B. Orthostatic hypotension
C. Hypertensive crisis
D. Bradycardia
[CORRECT] B
Rationale: Orthostatic hypotension is diagnosed when systolic BP drops ≥20 mmHg OR
diastolic BP drops ≥10 mmHg OR heart rate increases ≥20 bpm when moving from supine to
