NUR 101 Exam 3 Health
Assessment Actual Exam
2026/2027 – 100% Verified |
Detailed Rationales – Pass
Guaranteed – A+ Graded
Section 1: General Survey, Vital Signs, & Pain Assessment
1. Question: The nurse is performing a general survey on a
newly admitted patient. Which component is NOT part of the
general survey?
a) Physical appearance and body structure
b) Mobility and gait
c) Behavior and mood
d) Auscultation of breath sounds
Answer: d) Auscultation of breath sounds
Rationale: The general survey is the initial visual assessment that
begins the moment the nurse meets the patient. It includes:
physical appearance (age, skin color, hygiene, grooming), body
structure (height, weight, posture), mobility (gait, range of
motion), and behavior (mood, affect, speech). Auscultation of
breath sounds is part of a focused physical exam.
2. Question: The nurse is assessing a patient's pain. Which of
the following is the most reliable indicator of pain intensity?
, a) The patient's facial expression
b) The patient's vital signs (heart rate, blood pressure)
c) The patient's self-report on a 0–10 pain scale
d) The patient's ability to move or ambulate
Answer: c) The patient's self-report on a 0–10 pain scale
Rationale: Pain is subjective. The patient's self-report is the single
most reliable indicator of pain intensity and quality. Vital signs
and behavioral cues can be unreliable (e.g., patients with chronic
pain may have normal vital signs despite severe pain). The nurse
should always ask the patient to rate their pain.
3. Question: The nurse is assessing a patient's blood pressure.
The patient is sitting with their legs crossed. What effect
does this have on the blood pressure reading?
a) It will cause a falsely low reading.
b) It will cause a falsely high reading.
c) It has no effect on the reading.
d) It will affect the diastolic reading only.
Answer: b) It will cause a falsely high reading.
Rationale: Crossing the legs can increase blood pressure readings
due to increased venous return and vasoconstriction. The nurse
should have the patient sit with feet flat on the floor and wait 1–2
minutes before measuring. The arm should be supported at the
level of the heart.
4. Question: A patient's oral temperature is 38.5°C (101.3°F).
This is classified as:
a) Hypothermia
b) Normal
, c) Fever (pyrexia)
d) Hyperthermia crisis
Answer: c) Fever (pyrexia)
Rationale: Normal oral temperature is 36°C–37.5°C (96.8°F–
99.5°F). A temperature >100.4°F (38°C) is considered a fever
(pyrexia). Hyperthermia crisis is >105.8°F (41°C).
Section 2: HEENT & Neurological Assessment
5. Question: The nurse is testing extraocular movements. The
patient is asked to move their eyes in six cardinal positions of
gaze. Which cranial nerves are being assessed?
a) CN I, II, III
b) CN III, IV, VI
c) CN V, VII, VIII
d) CN IX, X, XI
Answer: b) CN III, IV, VI
Rationale: Extraocular movements are controlled by CN III
(Oculomotor), CN IV (Trochlear), and CN VI (Abducens). CN III
controls most movements (up, down, inward); CN IV controls
downward and inward (superior oblique); CN VI controls lateral
movement (lateral rectus).
6. Question: The nurse is assessing a patient's hearing. The
nurse performs the Rinne test. Which result indicates normal
hearing?
a) Air conduction > bone conduction (2:1 ratio)
b) Bone conduction > air conduction
c) Air conduction = bone conduction
d) The patient cannot hear the tuning fork
, Answer: a) Air conduction > bone conduction (2:1 ratio)
Rationale: In the Rinne test, the tuning fork is placed on the
mastoid bone (bone conduction) and then in front of the ear (air
conduction). A normal finding is that air conduction is heard twice
as long as bone conduction (positive Rinne). If bone conduction >
air conduction, it suggests conductive hearing loss.
Section 3: Communication, Professionalism & Psychosocial
Concepts
7. Question: The nurse-patient relationship consists of three
phases. In which phase does the nurse and patient begin to
address the tasks outlined in the orientation phase, often
with regression preceding positive change?
a) Pre-interaction phase
b) Orientation phase
c) Working phase
d) Termination phase
Answer: c) Working phase
Rationale: The working phase is where the client and nurse work
together to address the identified tasks. Regression often
precedes positive change in this phase. The orientation phase is
"getting to know you" and begins with developing trust.
8. Question: According to the ANA Code of Ethics, which of the
following is a key principle for developing self-awareness in a
nurse?
a) Using close-ended questions to obtain specific data
b) Avoiding the use of stereotypes and nonjudgmental
acceptance
c) Focusing on the nurse's own emotional needs during the
Assessment Actual Exam
2026/2027 – 100% Verified |
Detailed Rationales – Pass
Guaranteed – A+ Graded
Section 1: General Survey, Vital Signs, & Pain Assessment
1. Question: The nurse is performing a general survey on a
newly admitted patient. Which component is NOT part of the
general survey?
a) Physical appearance and body structure
b) Mobility and gait
c) Behavior and mood
d) Auscultation of breath sounds
Answer: d) Auscultation of breath sounds
Rationale: The general survey is the initial visual assessment that
begins the moment the nurse meets the patient. It includes:
physical appearance (age, skin color, hygiene, grooming), body
structure (height, weight, posture), mobility (gait, range of
motion), and behavior (mood, affect, speech). Auscultation of
breath sounds is part of a focused physical exam.
2. Question: The nurse is assessing a patient's pain. Which of
the following is the most reliable indicator of pain intensity?
, a) The patient's facial expression
b) The patient's vital signs (heart rate, blood pressure)
c) The patient's self-report on a 0–10 pain scale
d) The patient's ability to move or ambulate
Answer: c) The patient's self-report on a 0–10 pain scale
Rationale: Pain is subjective. The patient's self-report is the single
most reliable indicator of pain intensity and quality. Vital signs
and behavioral cues can be unreliable (e.g., patients with chronic
pain may have normal vital signs despite severe pain). The nurse
should always ask the patient to rate their pain.
3. Question: The nurse is assessing a patient's blood pressure.
The patient is sitting with their legs crossed. What effect
does this have on the blood pressure reading?
a) It will cause a falsely low reading.
b) It will cause a falsely high reading.
c) It has no effect on the reading.
d) It will affect the diastolic reading only.
Answer: b) It will cause a falsely high reading.
Rationale: Crossing the legs can increase blood pressure readings
due to increased venous return and vasoconstriction. The nurse
should have the patient sit with feet flat on the floor and wait 1–2
minutes before measuring. The arm should be supported at the
level of the heart.
4. Question: A patient's oral temperature is 38.5°C (101.3°F).
This is classified as:
a) Hypothermia
b) Normal
, c) Fever (pyrexia)
d) Hyperthermia crisis
Answer: c) Fever (pyrexia)
Rationale: Normal oral temperature is 36°C–37.5°C (96.8°F–
99.5°F). A temperature >100.4°F (38°C) is considered a fever
(pyrexia). Hyperthermia crisis is >105.8°F (41°C).
Section 2: HEENT & Neurological Assessment
5. Question: The nurse is testing extraocular movements. The
patient is asked to move their eyes in six cardinal positions of
gaze. Which cranial nerves are being assessed?
a) CN I, II, III
b) CN III, IV, VI
c) CN V, VII, VIII
d) CN IX, X, XI
Answer: b) CN III, IV, VI
Rationale: Extraocular movements are controlled by CN III
(Oculomotor), CN IV (Trochlear), and CN VI (Abducens). CN III
controls most movements (up, down, inward); CN IV controls
downward and inward (superior oblique); CN VI controls lateral
movement (lateral rectus).
6. Question: The nurse is assessing a patient's hearing. The
nurse performs the Rinne test. Which result indicates normal
hearing?
a) Air conduction > bone conduction (2:1 ratio)
b) Bone conduction > air conduction
c) Air conduction = bone conduction
d) The patient cannot hear the tuning fork
, Answer: a) Air conduction > bone conduction (2:1 ratio)
Rationale: In the Rinne test, the tuning fork is placed on the
mastoid bone (bone conduction) and then in front of the ear (air
conduction). A normal finding is that air conduction is heard twice
as long as bone conduction (positive Rinne). If bone conduction >
air conduction, it suggests conductive hearing loss.
Section 3: Communication, Professionalism & Psychosocial
Concepts
7. Question: The nurse-patient relationship consists of three
phases. In which phase does the nurse and patient begin to
address the tasks outlined in the orientation phase, often
with regression preceding positive change?
a) Pre-interaction phase
b) Orientation phase
c) Working phase
d) Termination phase
Answer: c) Working phase
Rationale: The working phase is where the client and nurse work
together to address the identified tasks. Regression often
precedes positive change in this phase. The orientation phase is
"getting to know you" and begins with developing trust.
8. Question: According to the ANA Code of Ethics, which of the
following is a key principle for developing self-awareness in a
nurse?
a) Using close-ended questions to obtain specific data
b) Avoiding the use of stereotypes and nonjudgmental
acceptance
c) Focusing on the nurse's own emotional needs during the
