NUR 101/NUR101 Final Exam V3 | Health
Assessment Q&A with Rationale | Fortis College
1. When performing a physical assessment of the abdomen, in which order should the nurse
perform the examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: C
Explanation: Auscultation is performed before percussion and palpation because manual
manipulation of the abdomen can stimulate peristalsis and alter bowel sounds. Inspection
provides the initial visual data without disturbing the bowel. This specific sequence is
essential to ensure the accuracy of the gastrointestinal assessment.
2. A nurse is assessing a patient’s peripheral pulses and notes they are ‘weak and thready.’
How should the nurse document this finding on a scale of 0 to 4+?
A. 3+
B. 2+
C. 1+
D. 4+
,Correct Answer: C
Explanation: A pulse graded as 1+ is described as weak, thready, or diminished. A 2+
grade is considered normal or brisk, while 3+ and 4+ represent increased or bounding
pulses respectively. Consistent grading allows for accurate communication between
healthcare providers regarding the patient’s circulatory status.
3. During a respiratory assessment, the nurse hears high-pitched, musical sounds primarily
during expiration. How should the nurse document this sound?
A. Crackles
B. Rhonchi
C. Pleural friction rub
D. Wheezes
Correct Answer: D
Explanation: Wheezes are continuous, high-pitched musical sounds caused by air flowing
through narrowed or obstructed airways. Crackles are typically non-musical popping
sounds, and rhonchi are lower-pitched snoring sounds. Identifying the specific
characteristics of adventitious breath sounds helps in diagnosing underlying conditions
like asthma or COPD.
4. Which cranial nerve is the nurse assessing when asking the patient to shrug their shoulders
against resistance?
A. CN IX (Glossopharyngeal)
, B. CN X (Vagus)
C. CN XI (Spinal Accessory)
D. CN XII (Hypoglossal)
Correct Answer: C
Explanation: Cranial Nerve XI, the Spinal Accessory nerve, controls the trapezius and
sternocleidomastoid muscles. Testing shoulder shrugging and head turning against
resistance is the standard method for evaluating its motor function. Weakness or
asymmetry during this test may indicate nerve damage or muscular pathology.
5. The nurse is assessing a patient’s level of consciousness using the Glasgow Coma Scale
(GCS). What are the three components of this scale?
A. Orientation, memory, and cognitive ability
B. Pupillary response, blood pressure, and heart rate
C. Eye opening, motor response, and verbal response
D. Reflexes, gait, and balance
Correct Answer: C
Explanation: The Glasgow Coma Scale measures neurological status based on eye-opening,
verbal response, and motor response. The total score ranges from 3 to 15, with lower
scores indicating deeper levels of unconsciousness. It is a vital tool for monitoring patients
with potential or actual head injuries in a standardized way.
Assessment Q&A with Rationale | Fortis College
1. When performing a physical assessment of the abdomen, in which order should the nurse
perform the examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: C
Explanation: Auscultation is performed before percussion and palpation because manual
manipulation of the abdomen can stimulate peristalsis and alter bowel sounds. Inspection
provides the initial visual data without disturbing the bowel. This specific sequence is
essential to ensure the accuracy of the gastrointestinal assessment.
2. A nurse is assessing a patient’s peripheral pulses and notes they are ‘weak and thready.’
How should the nurse document this finding on a scale of 0 to 4+?
A. 3+
B. 2+
C. 1+
D. 4+
,Correct Answer: C
Explanation: A pulse graded as 1+ is described as weak, thready, or diminished. A 2+
grade is considered normal or brisk, while 3+ and 4+ represent increased or bounding
pulses respectively. Consistent grading allows for accurate communication between
healthcare providers regarding the patient’s circulatory status.
3. During a respiratory assessment, the nurse hears high-pitched, musical sounds primarily
during expiration. How should the nurse document this sound?
A. Crackles
B. Rhonchi
C. Pleural friction rub
D. Wheezes
Correct Answer: D
Explanation: Wheezes are continuous, high-pitched musical sounds caused by air flowing
through narrowed or obstructed airways. Crackles are typically non-musical popping
sounds, and rhonchi are lower-pitched snoring sounds. Identifying the specific
characteristics of adventitious breath sounds helps in diagnosing underlying conditions
like asthma or COPD.
4. Which cranial nerve is the nurse assessing when asking the patient to shrug their shoulders
against resistance?
A. CN IX (Glossopharyngeal)
, B. CN X (Vagus)
C. CN XI (Spinal Accessory)
D. CN XII (Hypoglossal)
Correct Answer: C
Explanation: Cranial Nerve XI, the Spinal Accessory nerve, controls the trapezius and
sternocleidomastoid muscles. Testing shoulder shrugging and head turning against
resistance is the standard method for evaluating its motor function. Weakness or
asymmetry during this test may indicate nerve damage or muscular pathology.
5. The nurse is assessing a patient’s level of consciousness using the Glasgow Coma Scale
(GCS). What are the three components of this scale?
A. Orientation, memory, and cognitive ability
B. Pupillary response, blood pressure, and heart rate
C. Eye opening, motor response, and verbal response
D. Reflexes, gait, and balance
Correct Answer: C
Explanation: The Glasgow Coma Scale measures neurological status based on eye-opening,
verbal response, and motor response. The total score ranges from 3 to 15, with lower
scores indicating deeper levels of unconsciousness. It is a vital tool for monitoring patients
with potential or actual head injuries in a standardized way.
