UR 101/ NUR101 Exam 4 –
N
Health Assessment Guide| Fortis
(Latest 2026/ 2027 Update) 100%
Verified Questions & Answers |
Grade A
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PART A – MULTIPLE CHOICE (Q1–60)
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Q1 (Integrative physical exam – head-to-toe sequence):
A nurse is beginning a comprehensive head-to-toe physical examination on a newly admitted
68-year-old patient. According to standard health assessment protocols, which sequence should
the nurse follow to minimize patient discomfort and optimize efficiency?
A. General survey, vital signs, neurological, cardiovascular, thorax/lungs, abdomen,
musculoskeletal, skin, head/neck, genitourinary, rectal
B. General survey, vital signs, head/neck, thorax/lungs, cardiovascular, abdomen,
musculoskeletal, neurological, skin, genitourinary, rectal
C. General survey, vital signs, head/neck, cardiovascular, thorax/lungs, abdomen,
musculoskeletal, skin, neurological, genitourinary, rectal
D. General survey, vital signs, head/neck, thorax/lungs, cardiovascular, abdomen,
musculoskeletal, neurological, skin, genitourinary, rectal
[CORRECT] D
Rationale: The standard head-to-toe sequence follows a cephalocaudal and systematic
approach: general survey and vitals first, then head/neck, thorax/lungs, cardiovascular,
abdomen, musculoskeletal, neurological, skin, and finally genitourinary/rectal to minimize
repositioning and patient discomfort (Jarvis, 2024). Option A places neurological too early and
head/neck too late, violating the cephalocaudal principle. Option C places cardiovascular before
thorax/lungs, which is less efficient as lung auscultation is best done before cardiac auscultation
in the supine position. Option B places skin before neurological, but skin assessment is typically
integrated throughout or done after positioning changes; the sequence in D is the most widely
taught and clinically efficient.
Q2 (Clinical reasoning – diagnostic test selection):
, 55-year-old male presents with sudden-onset dyspnea, pleuritic chest pain, and tachycardia.
A
The nurse practitioner suspects pulmonary embolism (PE) and must select the most appropriate
initial diagnostic test. Which test has the highest sensitivity for ruling out PE in
low-to-intermediate risk patients?
A. D-dimer assay
B. CT pulmonary angiography (CTPA)
C. Ventilation-perfusion (V/Q) scan
D. Pulmonary angiography
[CORRECT] A
Rationale: The D-dimer assay has the highest sensitivity (approximately 95%) for ruling out PE
in patients with low-to-intermediate pretest probability when combined with clinical prediction
rules such as the Wells score or revised Geneva score (2026 ACCP guidelines). Option B,
CTPA, is the gold standard for confirming PE but involves radiation and contrast; it is not the
initial screening test. Option C, V/Q scan, is used when CTPA is contraindicated (e.g., renal
impairment, contrast allergy) but has lower specificity. Option D, pulmonary angiography, is
invasive and reserved for equivocal cases or when embolectomy is being considered.
Q3 (Special populations – bariatric assessment):
A nurse is preparing to measure blood pressure on a patient with a BMI of 48. The upper arm
circumference is 52 cm. Which action is most appropriate to obtain an accurate blood pressure
reading?
A. Use a standard adult cuff (12 × 26 cm) placed on the forearm
B. Use a large adult cuff (15 × 33 cm) placed on the upper arm
C. Use a thigh cuff (18 × 36 cm) placed on the upper arm
D. Use a wrist blood pressure monitor for convenience
[CORRECT] C
Rationale: For an upper arm circumference of 52 cm, a thigh cuff (18 × 36 cm) or an extra-large
adult cuff is required because the bladder width should cover 40% and the length 80% of the
arm circumference (AHA guidelines, 2026). Option A using a standard cuff on the forearm will
produce falsely elevated readings due to the smaller vessel diameter. Option B, a large adult
cuff, is insufficient for a 52 cm arm and will also yield falsely high readings. Option D, wrist
monitors, are less accurate in obese patients due to vessel distance from the heart and
positioning errors.
Q4 (Special populations – LGBTQ+ health assessment):
A 24-year-old transgender male patient (assigned female at birth, currently on testosterone
therapy) presents for a health assessment. Which statement by the nurse demonstrates
culturally competent, inclusive care?
A. "Since you are on testosterone, you no longer need cervical cancer screening."
B. "I see you are taking hormones; do you have any concerns about your current regimen or
fertility preservation?"
C. "Your anatomy is still female, so we will proceed with a standard female pelvic exam."
D. "Testosterone increases your risk of breast cancer, so we will skip the mammogram."
[CORRECT] B
Rationale: Culturally competent care for transgender patients involves open communication
about hormone therapy, fertility preservation, and individualized screening needs without making
, ssumptions (WPATH Standards of Care, Version 8, 2026). Option A is incorrect because
a
testosterone does not eliminate cervical cancer risk; screening guidelines still apply based on
anatomy and history. Option C uses stigmatizing language ("anatomy is still female") and
ignores the patient's gender identity. Option D is incorrect because testosterone actually
reduces breast cancer risk in transgender men, but screening decisions should be individualized
based on risk factors and remaining breast tissue.
Q5 (Environmental/occupational health – workplace exposure):
A nurse working in an occupational health clinic evaluates a 45-year-old construction worker
who reports chronic cough, dyspnea on exertion, and finger clubbing. He has worked with
drywall and insulation for 20 years. Which exposure is most likely responsible for these
findings?
A. Silica dust
B. Asbestos
C. Lead
D. Carbon monoxide
[CORRECT] B
Rationale: Asbestos exposure is strongly associated with construction work involving insulation
and drywall materials, and the triad of chronic cough, dyspnea, and finger clubbing suggests
asbestosis or mesothelioma (OSHA/NIOSH, 2026). Option A, silica dust, typically causes
silicosis with a different exposure profile (sandblasting, mining, stone cutting) and presents with
progressive massive fibrosis. Option C, lead, causes neurological and hematological symptoms
(abdominal colic, anemia, neuropathy) rather than pulmonary fibrosis. Option D, carbon
monoxide, causes acute toxicity (headache, confusion, cherry-red skin) rather than chronic
pulmonary disease.
Q6 (Mental health assessment – suicide risk):
A nurse is conducting a suicide risk assessment using the Columbia Suicide Severity Rating
Scale (C-SRS). The patient admits to having thoughts of killing himself but states he would not
act on them because of his children. How should the nurse classify this patient's risk?
A. No risk – passive thoughts without intent
B. Low risk – ideation without plan or intent
C. Moderate risk – ideation with intent but no plan
D. High risk – ideation with intent and specific plan
[CORRECT] C
Rationale: The C-SRS categorizes suicide risk based on ideation, intent, and plan; this patient
has active suicidal ideation with intent ("would act" is mitigated by protective factors, but intent
exists) but no specific plan described, placing him at moderate risk requiring safety planning and
close monitoring (C-SRS Screening Version, 2026). Option A is incorrect because the patient
has active, not passive, ideation. Option B is incorrect because the patient expresses intent, not
merely ideation. Option D requires a specific, actionable plan with means and opportunity, which
is not present in this scenario.
Q7 (Substance use assessment – screening tools):
A nurse in a primary care clinic uses the AUDIT-C to screen a 38-year-old female patient for
alcohol use. She scores 4 points (drinks 3-4 times per week, 2-3 drinks per occasion, never
binge drinks). What is the appropriate nursing action?
, . No further action needed – score is below threshold for all populations
A
B. Provide brief intervention and recommend abstinence
C. Conduct a full AUDIT assessment and provide brief counseling
D. Refer immediately to an addiction specialist
[CORRECT] C
Rationale: For women, an AUDIT-C score of 3 or higher indicates unhealthy alcohol use and
warrants a full AUDIT assessment and brief counseling (NIAAA/VA guidelines, 2026); this
patient scored 4. Option A is incorrect because the score exceeds the female threshold. Option
B is premature without a full assessment to determine dependence severity. Option D is
excessive for a moderate-risk score without evidence of severe alcohol use disorder; referral is
reserved for scores indicating dependence or failed brief intervention.
Q8 (Nutritional assessment – eating disorders):
A nurse is assessing a 19-year-old female college student with a BMI of 16.5 who reports fear of
gaining weight, excessive exercise, and amenorrhea for 6 months. Which screening tool is most
appropriate to confirm an eating disorder?
A. Mini-Mental State Examination (MMSE)
B. SCOFF questionnaire
C. Patient Health Questionnaire-9 (PHQ-9)
D. CAGE questionnaire
[CORRECT] B
Rationale: The SCOFF questionnaire (Sick, Control, One stone, Fat, Food) is a validated
5-question screening tool specifically designed to detect anorexia and bulimia nervosa with high
sensitivity (84.6%) and specificity (89.6%) (Morgan et al., 2026 updates). Option A, MMSE,
screens for cognitive impairment. Option C, PHQ-9, screens for depression. Option D, CAGE,
screens for alcohol use disorder. The patient's BMI, amenorrhea, and behaviors are classic for
anorexia nervosa, making SCOFF the most appropriate tool.
Q9 (Genetic and genomic assessment – family pedigree):
A nurse is constructing a three-generation pedigree for a patient whose maternal grandmother
had breast cancer at age 42, mother had ovarian cancer at age 50, and the patient (female, age
32) is concerned about her risk. Which inheritance pattern is most likely if genetic testing
confirms a BRCA1 mutation?
A. Autosomal recessive
B. Autosomal dominant
C. X-linked dominant
D. Mitochondrial inheritance
[CORRECT] B
Rationale: BRCA1 and BRCA2 mutations follow an autosomal dominant inheritance pattern with
high penetrance; each first-degree relative has a 50% chance of inheriting the mutation (NCCN
Genetic/Familial High-Risk Assessment Guidelines, 2026). Option A, autosomal recessive,
requires two mutated alleles and is seen in conditions like cystic fibrosis. Option C, X-linked
dominant, affects males and females differently and is not the pattern for BRCA mutations.
Option D, mitochondrial inheritance, is maternal-only and associated with conditions like MELAS
syndrome.
Q10 (Integrative health assessment – complementary therapies):
N
Health Assessment Guide| Fortis
(Latest 2026/ 2027 Update) 100%
Verified Questions & Answers |
Grade A
=======================================================================
=
========
PART A – MULTIPLE CHOICE (Q1–60)
========================================================================
========
Q1 (Integrative physical exam – head-to-toe sequence):
A nurse is beginning a comprehensive head-to-toe physical examination on a newly admitted
68-year-old patient. According to standard health assessment protocols, which sequence should
the nurse follow to minimize patient discomfort and optimize efficiency?
A. General survey, vital signs, neurological, cardiovascular, thorax/lungs, abdomen,
musculoskeletal, skin, head/neck, genitourinary, rectal
B. General survey, vital signs, head/neck, thorax/lungs, cardiovascular, abdomen,
musculoskeletal, neurological, skin, genitourinary, rectal
C. General survey, vital signs, head/neck, cardiovascular, thorax/lungs, abdomen,
musculoskeletal, skin, neurological, genitourinary, rectal
D. General survey, vital signs, head/neck, thorax/lungs, cardiovascular, abdomen,
musculoskeletal, neurological, skin, genitourinary, rectal
[CORRECT] D
Rationale: The standard head-to-toe sequence follows a cephalocaudal and systematic
approach: general survey and vitals first, then head/neck, thorax/lungs, cardiovascular,
abdomen, musculoskeletal, neurological, skin, and finally genitourinary/rectal to minimize
repositioning and patient discomfort (Jarvis, 2024). Option A places neurological too early and
head/neck too late, violating the cephalocaudal principle. Option C places cardiovascular before
thorax/lungs, which is less efficient as lung auscultation is best done before cardiac auscultation
in the supine position. Option B places skin before neurological, but skin assessment is typically
integrated throughout or done after positioning changes; the sequence in D is the most widely
taught and clinically efficient.
Q2 (Clinical reasoning – diagnostic test selection):
, 55-year-old male presents with sudden-onset dyspnea, pleuritic chest pain, and tachycardia.
A
The nurse practitioner suspects pulmonary embolism (PE) and must select the most appropriate
initial diagnostic test. Which test has the highest sensitivity for ruling out PE in
low-to-intermediate risk patients?
A. D-dimer assay
B. CT pulmonary angiography (CTPA)
C. Ventilation-perfusion (V/Q) scan
D. Pulmonary angiography
[CORRECT] A
Rationale: The D-dimer assay has the highest sensitivity (approximately 95%) for ruling out PE
in patients with low-to-intermediate pretest probability when combined with clinical prediction
rules such as the Wells score or revised Geneva score (2026 ACCP guidelines). Option B,
CTPA, is the gold standard for confirming PE but involves radiation and contrast; it is not the
initial screening test. Option C, V/Q scan, is used when CTPA is contraindicated (e.g., renal
impairment, contrast allergy) but has lower specificity. Option D, pulmonary angiography, is
invasive and reserved for equivocal cases or when embolectomy is being considered.
Q3 (Special populations – bariatric assessment):
A nurse is preparing to measure blood pressure on a patient with a BMI of 48. The upper arm
circumference is 52 cm. Which action is most appropriate to obtain an accurate blood pressure
reading?
A. Use a standard adult cuff (12 × 26 cm) placed on the forearm
B. Use a large adult cuff (15 × 33 cm) placed on the upper arm
C. Use a thigh cuff (18 × 36 cm) placed on the upper arm
D. Use a wrist blood pressure monitor for convenience
[CORRECT] C
Rationale: For an upper arm circumference of 52 cm, a thigh cuff (18 × 36 cm) or an extra-large
adult cuff is required because the bladder width should cover 40% and the length 80% of the
arm circumference (AHA guidelines, 2026). Option A using a standard cuff on the forearm will
produce falsely elevated readings due to the smaller vessel diameter. Option B, a large adult
cuff, is insufficient for a 52 cm arm and will also yield falsely high readings. Option D, wrist
monitors, are less accurate in obese patients due to vessel distance from the heart and
positioning errors.
Q4 (Special populations – LGBTQ+ health assessment):
A 24-year-old transgender male patient (assigned female at birth, currently on testosterone
therapy) presents for a health assessment. Which statement by the nurse demonstrates
culturally competent, inclusive care?
A. "Since you are on testosterone, you no longer need cervical cancer screening."
B. "I see you are taking hormones; do you have any concerns about your current regimen or
fertility preservation?"
C. "Your anatomy is still female, so we will proceed with a standard female pelvic exam."
D. "Testosterone increases your risk of breast cancer, so we will skip the mammogram."
[CORRECT] B
Rationale: Culturally competent care for transgender patients involves open communication
about hormone therapy, fertility preservation, and individualized screening needs without making
, ssumptions (WPATH Standards of Care, Version 8, 2026). Option A is incorrect because
a
testosterone does not eliminate cervical cancer risk; screening guidelines still apply based on
anatomy and history. Option C uses stigmatizing language ("anatomy is still female") and
ignores the patient's gender identity. Option D is incorrect because testosterone actually
reduces breast cancer risk in transgender men, but screening decisions should be individualized
based on risk factors and remaining breast tissue.
Q5 (Environmental/occupational health – workplace exposure):
A nurse working in an occupational health clinic evaluates a 45-year-old construction worker
who reports chronic cough, dyspnea on exertion, and finger clubbing. He has worked with
drywall and insulation for 20 years. Which exposure is most likely responsible for these
findings?
A. Silica dust
B. Asbestos
C. Lead
D. Carbon monoxide
[CORRECT] B
Rationale: Asbestos exposure is strongly associated with construction work involving insulation
and drywall materials, and the triad of chronic cough, dyspnea, and finger clubbing suggests
asbestosis or mesothelioma (OSHA/NIOSH, 2026). Option A, silica dust, typically causes
silicosis with a different exposure profile (sandblasting, mining, stone cutting) and presents with
progressive massive fibrosis. Option C, lead, causes neurological and hematological symptoms
(abdominal colic, anemia, neuropathy) rather than pulmonary fibrosis. Option D, carbon
monoxide, causes acute toxicity (headache, confusion, cherry-red skin) rather than chronic
pulmonary disease.
Q6 (Mental health assessment – suicide risk):
A nurse is conducting a suicide risk assessment using the Columbia Suicide Severity Rating
Scale (C-SRS). The patient admits to having thoughts of killing himself but states he would not
act on them because of his children. How should the nurse classify this patient's risk?
A. No risk – passive thoughts without intent
B. Low risk – ideation without plan or intent
C. Moderate risk – ideation with intent but no plan
D. High risk – ideation with intent and specific plan
[CORRECT] C
Rationale: The C-SRS categorizes suicide risk based on ideation, intent, and plan; this patient
has active suicidal ideation with intent ("would act" is mitigated by protective factors, but intent
exists) but no specific plan described, placing him at moderate risk requiring safety planning and
close monitoring (C-SRS Screening Version, 2026). Option A is incorrect because the patient
has active, not passive, ideation. Option B is incorrect because the patient expresses intent, not
merely ideation. Option D requires a specific, actionable plan with means and opportunity, which
is not present in this scenario.
Q7 (Substance use assessment – screening tools):
A nurse in a primary care clinic uses the AUDIT-C to screen a 38-year-old female patient for
alcohol use. She scores 4 points (drinks 3-4 times per week, 2-3 drinks per occasion, never
binge drinks). What is the appropriate nursing action?
, . No further action needed – score is below threshold for all populations
A
B. Provide brief intervention and recommend abstinence
C. Conduct a full AUDIT assessment and provide brief counseling
D. Refer immediately to an addiction specialist
[CORRECT] C
Rationale: For women, an AUDIT-C score of 3 or higher indicates unhealthy alcohol use and
warrants a full AUDIT assessment and brief counseling (NIAAA/VA guidelines, 2026); this
patient scored 4. Option A is incorrect because the score exceeds the female threshold. Option
B is premature without a full assessment to determine dependence severity. Option D is
excessive for a moderate-risk score without evidence of severe alcohol use disorder; referral is
reserved for scores indicating dependence or failed brief intervention.
Q8 (Nutritional assessment – eating disorders):
A nurse is assessing a 19-year-old female college student with a BMI of 16.5 who reports fear of
gaining weight, excessive exercise, and amenorrhea for 6 months. Which screening tool is most
appropriate to confirm an eating disorder?
A. Mini-Mental State Examination (MMSE)
B. SCOFF questionnaire
C. Patient Health Questionnaire-9 (PHQ-9)
D. CAGE questionnaire
[CORRECT] B
Rationale: The SCOFF questionnaire (Sick, Control, One stone, Fat, Food) is a validated
5-question screening tool specifically designed to detect anorexia and bulimia nervosa with high
sensitivity (84.6%) and specificity (89.6%) (Morgan et al., 2026 updates). Option A, MMSE,
screens for cognitive impairment. Option C, PHQ-9, screens for depression. Option D, CAGE,
screens for alcohol use disorder. The patient's BMI, amenorrhea, and behaviors are classic for
anorexia nervosa, making SCOFF the most appropriate tool.
Q9 (Genetic and genomic assessment – family pedigree):
A nurse is constructing a three-generation pedigree for a patient whose maternal grandmother
had breast cancer at age 42, mother had ovarian cancer at age 50, and the patient (female, age
32) is concerned about her risk. Which inheritance pattern is most likely if genetic testing
confirms a BRCA1 mutation?
A. Autosomal recessive
B. Autosomal dominant
C. X-linked dominant
D. Mitochondrial inheritance
[CORRECT] B
Rationale: BRCA1 and BRCA2 mutations follow an autosomal dominant inheritance pattern with
high penetrance; each first-degree relative has a 50% chance of inheriting the mutation (NCCN
Genetic/Familial High-Risk Assessment Guidelines, 2026). Option A, autosomal recessive,
requires two mutated alleles and is seen in conditions like cystic fibrosis. Option C, X-linked
dominant, affects males and females differently and is not the pattern for BRCA mutations.
Option D, mitochondrial inheritance, is maternal-only and associated with conditions like MELAS
syndrome.
Q10 (Integrative health assessment – complementary therapies):
