UR 101/ NUR101 Exam 2 – Health
N
Assessment Guide ACTUAL EXAM
2026/2027 | Health Assessment Guide
| Verified Q&A | Pass Guaranteed - A+
Graded
ligned with: Jarvis Physical Examination & Health Assessment (9th Ed.), Weber & Kelley
A
Health Assessment in Nursing (6th Ed.), ATI Health Assessment 2026, and NCLEX-RN Test
Plan 2026/2027
=======================================================================
=
========
PART A - MULTIPLE CHOICE (Q1-60)
========================================================================
========
* *Q1 (Physical Assessment Techniques - Auscultation):** A nursing student is preparing to
auscultate a patient's heart sounds. The instructor reminds the student that the bell of the
stethoscope is best used for which type of sounds?
. High-pitched sounds such as S1 and S2
A
B. Low-pitched sounds such as S3 and S4
C. High-pitched sounds such as bronchial breath sounds
D. Low-pitched sounds such as vesicular breath sounds
* *[CORRECT]** B
*Rationale: According to Jarvis (9th Ed.), the bell of the stethoscope is designed to detect
low-pitched sounds such as S3, S4 gallops, and murmurs by applying light pressure to the chest
wall. The diaphragm detects high-pitched sounds like S1, S2, and normal breath sounds when
firm pressure is applied. Students frequently confuse the bell and diaphragm functions. Clinical
pearl for Fortis students: 'BELL = Best for Extra Low-pitched sounds (S3, S4, murmurs);
DIAPHRAGM = Detects High-pitched sounds (S1, S2, normal breath sounds)' - apply LIGHT
pressure with the bell, FIRM pressure with the diaphragm.*
,* *Q2 (Physical Assessment Techniques - Percussion):** A nurse percusses the chest and hears
a hyperresonant sound over the left lower lobe. This finding is most consistent with:
. Normal lung tissue
A
B. Pneumothorax
C. Consolidation
D. Pleural effusion
* *[CORRECT]** B
*Rationale: Hyperresonance (a booming sound louder than normal resonance) is heard over
air-filled spaces such as pneumothorax or emphysema, indicating excessive air in the pleural
space or alveoli (Jarvis, 9th Ed.). Normal lung tissue produces resonance; consolidation
produces dullness; pleural effusion produces flatness. Students often confuse percussion
sounds. Clinical pearl for Fortis students: 'Tympany = Too much air (stomach, intestine);
Hyperresonance = Hyper air (pneumothorax, emphysema); Resonance = Right (normal lung);
Dullness = Disease (consolidation, tumor); Flatness = Fluid (pleural effusion, muscle)' -
remember the 5 percussion sounds from most air to least air.*
* *Q3 (Physical Assessment Techniques - Palpation):** A nurse is assessing a patient's
abdomen and palpates a pulsatile mass in the midline above the umbilicus. What is the nurse's
most appropriate immediate action?
. Apply firm pressure to determine the size of the mass
A
B. Auscultate for bruits over the mass
C. Do not palpate further and notify the provider immediately
D. Percuss the mass to determine density
* *[CORRECT]** C
*Rationale: A pulsatile midline abdominal mass above the umbilicus is highly suggestive of an
abdominal aortic aneurysm (AAA), and further palpation could precipitate rupture, which is a
surgical emergency with a mortality rate exceeding 50% (Jarvis, 9th Ed.). Auscultation and
percussion are also contraindicated as they may increase intra-abdominal pressure. Students
often want to 'complete' the assessment, but patient safety takes priority. Clinical pearl for Fortis
students: 'Pulsatile + Midline + Above Umbilicus = STOP and CALL' - this is one of the few
times you intentionally STOP your assessment to prevent catastrophic rupture.*
* *Q4 (Skin, Hair, Nails - Lesions):** A patient presents with a 5-mm raised, solid lesion on the
forearm. The nurse documents this finding as a:
. Macule
A
B. Papule
C. Vesicle
D. Pustule
,* *[CORRECT]** B
*Rationale: A papule is defined as a solid, elevated lesion less than 1 cm in diameter (Jarvis, 9th
Ed.). A macule is flat and non-palpable (<1 cm); a vesicle is a fluid-filled blister (<1 cm); a
pustule contains pus. Students often confuse primary skin lesions. Clinical pearl for Fortis
students: 'Macule = Mark (flat, discolored); Papule = Palpable (raised, solid); Vesicle = Volume
of fluid (small blister); Pustule = Pus-filled; Nodule = Noticeable (larger, deeper); Tumor =
Tremendous (>2 cm)' - size and consistency are the key differentiators.*
* *Q5 (Skin, Hair, Nails - Turgor):** A nurse assesses skin turgor by pinching the skin over the
sternum and notes that the skin remains tented for 3 seconds. This finding is most consistent
with:
. Normal hydration status
A
B. Dehydration
C. Edema
D. Hyperthyroidism
* *[CORRECT]** B
*Rationale: Poor skin turgor (skin tenting lasting >2 seconds) is a classic sign of dehydration,
particularly in older adults and infants, indicating decreased interstitial fluid volume (Jarvis, 9th
Ed.). Normal turgor returns immediately; edema presents as swelling, not tenting;
hyperthyroidism causes warm, moist skin. Students sometimes confuse turgor with other skin
findings. Clinical pearl for Fortis students: 'Tenting = Thirsty (dehydration); Immediate return =
Ideal hydration; Check over sternum or clavicle in adults (not forearm, which may have
decreased elasticity with aging) - poor turgor in infants indicates significant fluid deficit.*
* *Q6 (Skin, Hair, Nails - Clubbing):** A nurse is assessing a patient's fingers and notes that the
angle between the nail bed and the proximal nail fold is 180 degrees. The nurse recognizes this
finding as indicative of which condition?
. Iron deficiency anemia
A
B. Chronic hypoxia
C. Liver cirrhosis
D. Rheumatoid arthritis
* *[CORRECT]** B
*Rationale: Clubbing (loss of the normal 160-degree nail bed angle, resulting in a straight or
convex angle of 180 degrees or greater) is associated with chronic hypoxic conditions such as
cystic fibrosis, lung cancer, congenital heart disease, and inflammatory bowel disease (Jarvis,
9th Ed.). Iron deficiency causes koilonychia (spoon nails); cirrhosis causes Terry's nails;
rheumatoid arthritis causes nail pitting. Students often confuse nail findings. Clinical pearl for
Fortis students: 'Clubbing = Chronic hypoxia (COPD, CF, lung cancer, CHD); Koilonychia =
Kinky iron deficiency (spoon nails); Terry's nails = Terrible liver (cirrhosis); Beau's lines = Bad
, illness (systemic stress); Pitting = Psoriasis' - the Lovibond angle >180 degrees defines
clubbing.*
* *Q7 (Skin, Hair, Nails - Capillary Refill):** A nurse assesses capillary refill in a patient's toes
and notes a refill time of 5 seconds. The patient's feet are cool and pale. These findings are
most consistent with:
. Normal peripheral circulation
A
B. Arterial insufficiency
C. Venous insufficiency
D. Lymphedema
* *[CORRECT]** B
*Rationale: Delayed capillary refill (>2 seconds) with cool, pale extremities indicates arterial
insufficiency (peripheral artery disease), as reduced arterial blood flow delays the return of color
after blanching (Jarvis, 9th Ed.). Venous insufficiency presents with warm, edematous
extremities and normal capillary refill; lymphedema presents with non-pitting edema. Students
often confuse arterial and venous findings. Clinical pearl for Fortis students: 'Arterial = All the
bad signs (cool, pale, hairless, delayed cap refill, pulses diminished, pain with elevation);
Venous = Very swollen (warm, edematous, brown discoloration, normal cap refill, pain when
dependent)' - the 6 P's of acute arterial occlusion are Pain, Pallor, Pulselessness, Paresthesia,
Paralysis, and Poikilothermia.*
* *Q8 (Head and Neck - Lymph Nodes):** During assessment of the head and neck, a nurse
palpates a firm, fixed, non-tender lymph node in the left supraclavicular area. The nurse
recognizes this finding as potentially indicative of:
. Active viral infection
A
B. Metastatic abdominal malignancy (Virchow's node)
C. Recent streptococcal pharyngitis
D. Allergic rhinitis
* *[CORRECT]** B
*Rationale: A firm, fixed, non-tender supraclavicular lymph node (particularly on the left, known
as Virchow's node or Troisier's sign) is highly suggestive of metastatic abdominal malignancy,
especially gastric cancer, as the thoracic duct drains into the left subclavian vein (Jarvis, 9th
Ed.). Viral infections and streptococcal pharyngitis produce tender, mobile nodes; allergic rhinitis
may cause small, mobile posterior cervical nodes. Students often overlook the significance of
supraclavicular nodes. Clinical pearl for Fortis students: 'Left supraclavicular = Left thoracic duct
= Look for abdominal cancer (Virchow's node); Right supraclavicular = Right lymphatic duct =
Look for thoracic cancer; Fixed + Firm + Non-tender = Fear (malignancy); Mobile + Tender =
Mild (infection)' - always examine lymph nodes for size, mobility, tenderness, consistency, and
warmth.*
N
Assessment Guide ACTUAL EXAM
2026/2027 | Health Assessment Guide
| Verified Q&A | Pass Guaranteed - A+
Graded
ligned with: Jarvis Physical Examination & Health Assessment (9th Ed.), Weber & Kelley
A
Health Assessment in Nursing (6th Ed.), ATI Health Assessment 2026, and NCLEX-RN Test
Plan 2026/2027
=======================================================================
=
========
PART A - MULTIPLE CHOICE (Q1-60)
========================================================================
========
* *Q1 (Physical Assessment Techniques - Auscultation):** A nursing student is preparing to
auscultate a patient's heart sounds. The instructor reminds the student that the bell of the
stethoscope is best used for which type of sounds?
. High-pitched sounds such as S1 and S2
A
B. Low-pitched sounds such as S3 and S4
C. High-pitched sounds such as bronchial breath sounds
D. Low-pitched sounds such as vesicular breath sounds
* *[CORRECT]** B
*Rationale: According to Jarvis (9th Ed.), the bell of the stethoscope is designed to detect
low-pitched sounds such as S3, S4 gallops, and murmurs by applying light pressure to the chest
wall. The diaphragm detects high-pitched sounds like S1, S2, and normal breath sounds when
firm pressure is applied. Students frequently confuse the bell and diaphragm functions. Clinical
pearl for Fortis students: 'BELL = Best for Extra Low-pitched sounds (S3, S4, murmurs);
DIAPHRAGM = Detects High-pitched sounds (S1, S2, normal breath sounds)' - apply LIGHT
pressure with the bell, FIRM pressure with the diaphragm.*
,* *Q2 (Physical Assessment Techniques - Percussion):** A nurse percusses the chest and hears
a hyperresonant sound over the left lower lobe. This finding is most consistent with:
. Normal lung tissue
A
B. Pneumothorax
C. Consolidation
D. Pleural effusion
* *[CORRECT]** B
*Rationale: Hyperresonance (a booming sound louder than normal resonance) is heard over
air-filled spaces such as pneumothorax or emphysema, indicating excessive air in the pleural
space or alveoli (Jarvis, 9th Ed.). Normal lung tissue produces resonance; consolidation
produces dullness; pleural effusion produces flatness. Students often confuse percussion
sounds. Clinical pearl for Fortis students: 'Tympany = Too much air (stomach, intestine);
Hyperresonance = Hyper air (pneumothorax, emphysema); Resonance = Right (normal lung);
Dullness = Disease (consolidation, tumor); Flatness = Fluid (pleural effusion, muscle)' -
remember the 5 percussion sounds from most air to least air.*
* *Q3 (Physical Assessment Techniques - Palpation):** A nurse is assessing a patient's
abdomen and palpates a pulsatile mass in the midline above the umbilicus. What is the nurse's
most appropriate immediate action?
. Apply firm pressure to determine the size of the mass
A
B. Auscultate for bruits over the mass
C. Do not palpate further and notify the provider immediately
D. Percuss the mass to determine density
* *[CORRECT]** C
*Rationale: A pulsatile midline abdominal mass above the umbilicus is highly suggestive of an
abdominal aortic aneurysm (AAA), and further palpation could precipitate rupture, which is a
surgical emergency with a mortality rate exceeding 50% (Jarvis, 9th Ed.). Auscultation and
percussion are also contraindicated as they may increase intra-abdominal pressure. Students
often want to 'complete' the assessment, but patient safety takes priority. Clinical pearl for Fortis
students: 'Pulsatile + Midline + Above Umbilicus = STOP and CALL' - this is one of the few
times you intentionally STOP your assessment to prevent catastrophic rupture.*
* *Q4 (Skin, Hair, Nails - Lesions):** A patient presents with a 5-mm raised, solid lesion on the
forearm. The nurse documents this finding as a:
. Macule
A
B. Papule
C. Vesicle
D. Pustule
,* *[CORRECT]** B
*Rationale: A papule is defined as a solid, elevated lesion less than 1 cm in diameter (Jarvis, 9th
Ed.). A macule is flat and non-palpable (<1 cm); a vesicle is a fluid-filled blister (<1 cm); a
pustule contains pus. Students often confuse primary skin lesions. Clinical pearl for Fortis
students: 'Macule = Mark (flat, discolored); Papule = Palpable (raised, solid); Vesicle = Volume
of fluid (small blister); Pustule = Pus-filled; Nodule = Noticeable (larger, deeper); Tumor =
Tremendous (>2 cm)' - size and consistency are the key differentiators.*
* *Q5 (Skin, Hair, Nails - Turgor):** A nurse assesses skin turgor by pinching the skin over the
sternum and notes that the skin remains tented for 3 seconds. This finding is most consistent
with:
. Normal hydration status
A
B. Dehydration
C. Edema
D. Hyperthyroidism
* *[CORRECT]** B
*Rationale: Poor skin turgor (skin tenting lasting >2 seconds) is a classic sign of dehydration,
particularly in older adults and infants, indicating decreased interstitial fluid volume (Jarvis, 9th
Ed.). Normal turgor returns immediately; edema presents as swelling, not tenting;
hyperthyroidism causes warm, moist skin. Students sometimes confuse turgor with other skin
findings. Clinical pearl for Fortis students: 'Tenting = Thirsty (dehydration); Immediate return =
Ideal hydration; Check over sternum or clavicle in adults (not forearm, which may have
decreased elasticity with aging) - poor turgor in infants indicates significant fluid deficit.*
* *Q6 (Skin, Hair, Nails - Clubbing):** A nurse is assessing a patient's fingers and notes that the
angle between the nail bed and the proximal nail fold is 180 degrees. The nurse recognizes this
finding as indicative of which condition?
. Iron deficiency anemia
A
B. Chronic hypoxia
C. Liver cirrhosis
D. Rheumatoid arthritis
* *[CORRECT]** B
*Rationale: Clubbing (loss of the normal 160-degree nail bed angle, resulting in a straight or
convex angle of 180 degrees or greater) is associated with chronic hypoxic conditions such as
cystic fibrosis, lung cancer, congenital heart disease, and inflammatory bowel disease (Jarvis,
9th Ed.). Iron deficiency causes koilonychia (spoon nails); cirrhosis causes Terry's nails;
rheumatoid arthritis causes nail pitting. Students often confuse nail findings. Clinical pearl for
Fortis students: 'Clubbing = Chronic hypoxia (COPD, CF, lung cancer, CHD); Koilonychia =
Kinky iron deficiency (spoon nails); Terry's nails = Terrible liver (cirrhosis); Beau's lines = Bad
, illness (systemic stress); Pitting = Psoriasis' - the Lovibond angle >180 degrees defines
clubbing.*
* *Q7 (Skin, Hair, Nails - Capillary Refill):** A nurse assesses capillary refill in a patient's toes
and notes a refill time of 5 seconds. The patient's feet are cool and pale. These findings are
most consistent with:
. Normal peripheral circulation
A
B. Arterial insufficiency
C. Venous insufficiency
D. Lymphedema
* *[CORRECT]** B
*Rationale: Delayed capillary refill (>2 seconds) with cool, pale extremities indicates arterial
insufficiency (peripheral artery disease), as reduced arterial blood flow delays the return of color
after blanching (Jarvis, 9th Ed.). Venous insufficiency presents with warm, edematous
extremities and normal capillary refill; lymphedema presents with non-pitting edema. Students
often confuse arterial and venous findings. Clinical pearl for Fortis students: 'Arterial = All the
bad signs (cool, pale, hairless, delayed cap refill, pulses diminished, pain with elevation);
Venous = Very swollen (warm, edematous, brown discoloration, normal cap refill, pain when
dependent)' - the 6 P's of acute arterial occlusion are Pain, Pallor, Pulselessness, Paresthesia,
Paralysis, and Poikilothermia.*
* *Q8 (Head and Neck - Lymph Nodes):** During assessment of the head and neck, a nurse
palpates a firm, fixed, non-tender lymph node in the left supraclavicular area. The nurse
recognizes this finding as potentially indicative of:
. Active viral infection
A
B. Metastatic abdominal malignancy (Virchow's node)
C. Recent streptococcal pharyngitis
D. Allergic rhinitis
* *[CORRECT]** B
*Rationale: A firm, fixed, non-tender supraclavicular lymph node (particularly on the left, known
as Virchow's node or Troisier's sign) is highly suggestive of metastatic abdominal malignancy,
especially gastric cancer, as the thoracic duct drains into the left subclavian vein (Jarvis, 9th
Ed.). Viral infections and streptococcal pharyngitis produce tender, mobile nodes; allergic rhinitis
may cause small, mobile posterior cervical nodes. Students often overlook the significance of
supraclavicular nodes. Clinical pearl for Fortis students: 'Left supraclavicular = Left thoracic duct
= Look for abdominal cancer (Virchow's node); Right supraclavicular = Right lymphatic duct =
Look for thoracic cancer; Fixed + Firm + Non-tender = Fear (malignancy); Mobile + Tender =
Mild (infection)' - always examine lymph nodes for size, mobility, tenderness, consistency, and
warmth.*
