NUR 101/NUR101 Final Exam V1 | Health
Assessment Q&A with Rationale | Fortis College
1. A nurse is performing an abdominal assessment. Which sequence should the nurse follow
to ensure accurate findings?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: A
Explanation: In abdominal assessment, the sequence is altered to prevent false bowel
sound activity. Percussion and palpation can increase peristalsis, which would lead to an
inaccurate auscultation report. Therefore, the nurse must inspect first and then auscultate
before any physical manipulation occurs.
2. When assessing a patient’s radial pulse, the nurse notes the rhythm is irregular. What
should be the nurse’s next action?
A. Auscultate the apical pulse for one full minute.
B. Assess the carotid pulse for 30 seconds.
C. Count the radial pulse for a full minute.
D. Document the finding and notify the physician immediately.
,Correct Answer: A
Explanation: The apical pulse is the most accurate reflection of the heart’s rhythm and
rate. When a peripheral pulse is irregular, the nurse must assess the heart directly at the
apex for 60 seconds. This allows for the detection of pulse deficits or specific arrhythmias
that radial palpation might miss.
3. A patient presents with a ‘stabbing’ pain in the chest that worsens with deep inspiration.
Using the PQRST mnemonic, which component is the patient describing?
A. Provocation/Palliation
B. Severity
C. Region/Radiation
D. Quality
Correct Answer: D
Explanation: The word ‘stabbing’ refers to the Quality of the pain, describing how it feels
to the patient. Provocation would involve what makes it worse (deep inspiration), but the
specific descriptor ‘stabbing’ is the quality. Understanding the quality of pain helps
clinicians differentiate between pleural, muscular, or cardiac issues.
4. During a skin assessment, the nurse observes a lesion that is flat, non-palpable, and less
than 1 cm in diameter. How should this be documented?
A. Papule
B. Macule
, C. Plaque
D. Vesicle
Correct Answer: B
Explanation: A macule is a flat circumscribed area that is a change in the color of the skin;
it is less than 1 cm in diameter. A papule is elevated, whereas a vesicle contains fluid.
Accurate documentation of skin lesions is essential for tracking potential malignancies or
dermatological conditions.
5. A nurse is assessing the deep tendon reflexes (DTRs) of a patient and notes a normal,
average response. Which grade should the nurse assign?
A. 2+
B. 1+
C. 3+
D. 4+
Correct Answer: A
Explanation: Reflexes are graded on a scale of 0 to 4+, where 2+ is considered a normal or
average response. A grade of 1+ indicates a diminished or sluggish response, while 3+ is
brisker than average. 4+ indicates hyperactive reflexes with clonus, which is often
associated with upper motor neuron disease.
Assessment Q&A with Rationale | Fortis College
1. A nurse is performing an abdominal assessment. Which sequence should the nurse follow
to ensure accurate findings?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: A
Explanation: In abdominal assessment, the sequence is altered to prevent false bowel
sound activity. Percussion and palpation can increase peristalsis, which would lead to an
inaccurate auscultation report. Therefore, the nurse must inspect first and then auscultate
before any physical manipulation occurs.
2. When assessing a patient’s radial pulse, the nurse notes the rhythm is irregular. What
should be the nurse’s next action?
A. Auscultate the apical pulse for one full minute.
B. Assess the carotid pulse for 30 seconds.
C. Count the radial pulse for a full minute.
D. Document the finding and notify the physician immediately.
,Correct Answer: A
Explanation: The apical pulse is the most accurate reflection of the heart’s rhythm and
rate. When a peripheral pulse is irregular, the nurse must assess the heart directly at the
apex for 60 seconds. This allows for the detection of pulse deficits or specific arrhythmias
that radial palpation might miss.
3. A patient presents with a ‘stabbing’ pain in the chest that worsens with deep inspiration.
Using the PQRST mnemonic, which component is the patient describing?
A. Provocation/Palliation
B. Severity
C. Region/Radiation
D. Quality
Correct Answer: D
Explanation: The word ‘stabbing’ refers to the Quality of the pain, describing how it feels
to the patient. Provocation would involve what makes it worse (deep inspiration), but the
specific descriptor ‘stabbing’ is the quality. Understanding the quality of pain helps
clinicians differentiate between pleural, muscular, or cardiac issues.
4. During a skin assessment, the nurse observes a lesion that is flat, non-palpable, and less
than 1 cm in diameter. How should this be documented?
A. Papule
B. Macule
, C. Plaque
D. Vesicle
Correct Answer: B
Explanation: A macule is a flat circumscribed area that is a change in the color of the skin;
it is less than 1 cm in diameter. A papule is elevated, whereas a vesicle contains fluid.
Accurate documentation of skin lesions is essential for tracking potential malignancies or
dermatological conditions.
5. A nurse is assessing the deep tendon reflexes (DTRs) of a patient and notes a normal,
average response. Which grade should the nurse assign?
A. 2+
B. 1+
C. 3+
D. 4+
Correct Answer: A
Explanation: Reflexes are graded on a scale of 0 to 4+, where 2+ is considered a normal or
average response. A grade of 1+ indicates a diminished or sluggish response, while 3+ is
brisker than average. 4+ indicates hyperactive reflexes with clonus, which is often
associated with upper motor neuron disease.
