,NU 136 Exam 2 | Fundamentals of Nursing | Galen
College | Q & A | 2026 Edition (PDF)
1. Which of the following best describes the primary purpose of a comprehensive health assessment?
A) To establish a baseline for comparison and identify potential health problems
B) To provide data for medical diagnosis only
C) To satisfy hospital admission requirements
D) To determine the patient's financial eligibility for care
Correct Answer: To establish a baseline for comparison and identify potential health problems
Expert Rationale: A comprehensive health assessment establishes a baseline and identifies actual or
potential health problems. It is a continuous process, not just for admission. While it may inform medical
diagnoses, its purpose extends far beyond that to guide individualized nursing care.
2. In the context of the nursing process, which statement best describes the assessment phase?
A) Setting measurable goals for patient outcomes
B) Carrying out the planned nursing interventions
C) Collecting subjective and objective data systematically
D) Determining whether patient goals have been met
Correct Answer: Collecting subjective and objective data systematically
Expert Rationale: Assessment is the systematic collection of subjective (reported) and objective
(observable) data. Planning involves setting goals, implementation involves carrying out interventions,
and evaluation determines if goals were met. Assessment is the foundational first step of the nursing
process.
3. A nurse is preparing to perform a physical assessment on a newly admitted patient. What is the first
action the nurse should take?
A) Palpate the abdomen for tenderness
,B) Auscultate heart and lung sounds
C) Observe the patient's general appearance and behavior
D) Percuss the thorax for density
Correct Answer: Observe the patient's general appearance and behavior
Expert Rationale: The first step in assessment is observation—looking at the patient's general
appearance, gait, skin lesions, and behavior. Palpation, auscultation, and percussion follow in a
systematic sequence. Observation provides immediate data before any hands-on techniques are
employed.
4. Which assessment technique involves using the hands to feel for temperature, swelling, and abnormal
masses?
A) Inspection
B) Palpation
C) Percussion
D) Auscultation
Correct Answer: Palpation
Expert Rationale: Palpation uses the hands to assess temperature, texture, moisture, swelling, and
masses. Inspection is visual observation, percussion is tapping to assess density, and auscultation is
listening to sounds. Palpation requires proper technique, including using the flat part of the hand and
assessing depth of 1/2 to 3/4 inch.
5. What is the recommended depth for light palpation during a physical assessment?
A) 1/4 inch
B) 1/2 to 3/4 inch
C) 1 to 2 inches
D) 2 to 3 inches
, Correct Answer: 1/2 to 3/4 inch
Expert Rationale: Light palpation should be performed at a depth of 1/2 to 3/4 inch to assess surface
characteristics without causing discomfort or damaging internal organs. Deeper palpation may be
needed for certain assessments but should be performed with caution.
6. A nurse is assessing a patient and notes a lateral curvature of the spine. Which term correctly
describes this finding?
A) Kyphosis
B) Lordosis
C) Scoliosis
D) Osteoporosis
Correct Answer: Scoliosis
Expert Rationale: Scoliosis is a lateral curvature of the spine. Kyphosis is an exaggerated forward
curvature (hunchback), and lordosis is excessive inward curvature of the lower back. These spinal
deformities can affect mobility, breathing, and overall function.
7. Which of the following describes the consensual light reflex?
A) Constriction of the pupil in the eye directly stimulated by light
B) Constriction of the pupil in the eye opposite to the one stimulated
C) Dilation of both pupils in response to darkness
D) Lack of pupillary response to light stimulation
Correct Answer: Constriction of the pupil in the eye opposite to the one stimulated
Expert Rationale: The consensual light reflex is constriction of the pupil in the eye opposite to the one
directly stimulated by light. The direct reflex is constriction of the same pupil. Both reflexes indicate
intact brainstem function.
College | Q & A | 2026 Edition (PDF)
1. Which of the following best describes the primary purpose of a comprehensive health assessment?
A) To establish a baseline for comparison and identify potential health problems
B) To provide data for medical diagnosis only
C) To satisfy hospital admission requirements
D) To determine the patient's financial eligibility for care
Correct Answer: To establish a baseline for comparison and identify potential health problems
Expert Rationale: A comprehensive health assessment establishes a baseline and identifies actual or
potential health problems. It is a continuous process, not just for admission. While it may inform medical
diagnoses, its purpose extends far beyond that to guide individualized nursing care.
2. In the context of the nursing process, which statement best describes the assessment phase?
A) Setting measurable goals for patient outcomes
B) Carrying out the planned nursing interventions
C) Collecting subjective and objective data systematically
D) Determining whether patient goals have been met
Correct Answer: Collecting subjective and objective data systematically
Expert Rationale: Assessment is the systematic collection of subjective (reported) and objective
(observable) data. Planning involves setting goals, implementation involves carrying out interventions,
and evaluation determines if goals were met. Assessment is the foundational first step of the nursing
process.
3. A nurse is preparing to perform a physical assessment on a newly admitted patient. What is the first
action the nurse should take?
A) Palpate the abdomen for tenderness
,B) Auscultate heart and lung sounds
C) Observe the patient's general appearance and behavior
D) Percuss the thorax for density
Correct Answer: Observe the patient's general appearance and behavior
Expert Rationale: The first step in assessment is observation—looking at the patient's general
appearance, gait, skin lesions, and behavior. Palpation, auscultation, and percussion follow in a
systematic sequence. Observation provides immediate data before any hands-on techniques are
employed.
4. Which assessment technique involves using the hands to feel for temperature, swelling, and abnormal
masses?
A) Inspection
B) Palpation
C) Percussion
D) Auscultation
Correct Answer: Palpation
Expert Rationale: Palpation uses the hands to assess temperature, texture, moisture, swelling, and
masses. Inspection is visual observation, percussion is tapping to assess density, and auscultation is
listening to sounds. Palpation requires proper technique, including using the flat part of the hand and
assessing depth of 1/2 to 3/4 inch.
5. What is the recommended depth for light palpation during a physical assessment?
A) 1/4 inch
B) 1/2 to 3/4 inch
C) 1 to 2 inches
D) 2 to 3 inches
, Correct Answer: 1/2 to 3/4 inch
Expert Rationale: Light palpation should be performed at a depth of 1/2 to 3/4 inch to assess surface
characteristics without causing discomfort or damaging internal organs. Deeper palpation may be
needed for certain assessments but should be performed with caution.
6. A nurse is assessing a patient and notes a lateral curvature of the spine. Which term correctly
describes this finding?
A) Kyphosis
B) Lordosis
C) Scoliosis
D) Osteoporosis
Correct Answer: Scoliosis
Expert Rationale: Scoliosis is a lateral curvature of the spine. Kyphosis is an exaggerated forward
curvature (hunchback), and lordosis is excessive inward curvature of the lower back. These spinal
deformities can affect mobility, breathing, and overall function.
7. Which of the following describes the consensual light reflex?
A) Constriction of the pupil in the eye directly stimulated by light
B) Constriction of the pupil in the eye opposite to the one stimulated
C) Dilation of both pupils in response to darkness
D) Lack of pupillary response to light stimulation
Correct Answer: Constriction of the pupil in the eye opposite to the one stimulated
Expert Rationale: The consensual light reflex is constriction of the pupil in the eye opposite to the one
directly stimulated by light. The direct reflex is constriction of the same pupil. Both reflexes indicate
intact brainstem function.
