NURS 190 PHYSICAL ASSESSMENT
WEEK 3 COMPREHENSIVE QUESTIONS
AND ANSWERS
1. When assessing a client for potential melanoma, the nurse uses the ABCDE mnemonic.
What does the ‘D’ represent in this assessment tool?
A. Depth of the lesion
B. Density of the pigmentation
C. Discoloration of the surrounding skin
D. Diameter greater than 6mm
Answer: D
Conceptual Explanation: In the ABCDE mnemonic for melanoma, D stands for Diameter. A
diameter greater than 6mm (the size of a pencil eraser) is a warning sign of malignancy.
2. A nurse notes a 1.5 cm fluid-filled, elevated lesion on a patient’s forearm. How should this
be documented?
A. Bulla
B. Pustule
C. Vesicle
,D. Papule
Answer: A
Conceptual Explanation: A bulla is a fluid-filled blister larger than 1 cm. A vesicle is fluid-
filled but smaller than 1 cm.
3. During a head and neck assessment, the nurse finds a palpable lymph node that is fixed,
hard, and non-tender. This finding is most suggestive of:
A. Acute infection
B. Malignancy
C. Chronic inflammation
D. Normal variation
Answer: B
Conceptual Explanation: Malignant lymph nodes are typically hard, fixed to underlying
structures, and non-tender. Infected nodes are usually soft, mobile, and tender.
4. Which cranial nerve is being tested when the nurse asks the patient to shrug their
shoulders against resistance?
A. Cranial Nerve VII (Facial)
B. Cranial Nerve X (Vagus)
C. Cranial Nerve XI (Spinal Accessory)
D. Cranial Nerve XII (Hypoglossal)
, Answer: C
Conceptual Explanation: Cranial Nerve XI (Spinal Accessory) innervates the trapezius and
sternocleidomastoid muscles; shrugging tests its motor function.
5. The nurse performs the Rinne test and finds that the patient hears the sound longer
through bone conduction than through air conduction (BC > AC). This indicates:
A. Conductive hearing loss
B. Sensorineural hearing loss
C. Normal hearing function
D. Tinnitus
Answer: A
Conceptual Explanation: In conductive hearing loss, bone conduction is heard longer than
or equal to air conduction. Normally, AC should be twice as long as BC.
6. When inspecting the tympanic membrane with an otoscope, which characteristic indicates
a healthy ear?
A. Pearly gray and translucent
B. Bulging and red in color
C. Yellow-amber with air bubbles
D. Opaque and white
Answer: A
WEEK 3 COMPREHENSIVE QUESTIONS
AND ANSWERS
1. When assessing a client for potential melanoma, the nurse uses the ABCDE mnemonic.
What does the ‘D’ represent in this assessment tool?
A. Depth of the lesion
B. Density of the pigmentation
C. Discoloration of the surrounding skin
D. Diameter greater than 6mm
Answer: D
Conceptual Explanation: In the ABCDE mnemonic for melanoma, D stands for Diameter. A
diameter greater than 6mm (the size of a pencil eraser) is a warning sign of malignancy.
2. A nurse notes a 1.5 cm fluid-filled, elevated lesion on a patient’s forearm. How should this
be documented?
A. Bulla
B. Pustule
C. Vesicle
,D. Papule
Answer: A
Conceptual Explanation: A bulla is a fluid-filled blister larger than 1 cm. A vesicle is fluid-
filled but smaller than 1 cm.
3. During a head and neck assessment, the nurse finds a palpable lymph node that is fixed,
hard, and non-tender. This finding is most suggestive of:
A. Acute infection
B. Malignancy
C. Chronic inflammation
D. Normal variation
Answer: B
Conceptual Explanation: Malignant lymph nodes are typically hard, fixed to underlying
structures, and non-tender. Infected nodes are usually soft, mobile, and tender.
4. Which cranial nerve is being tested when the nurse asks the patient to shrug their
shoulders against resistance?
A. Cranial Nerve VII (Facial)
B. Cranial Nerve X (Vagus)
C. Cranial Nerve XI (Spinal Accessory)
D. Cranial Nerve XII (Hypoglossal)
, Answer: C
Conceptual Explanation: Cranial Nerve XI (Spinal Accessory) innervates the trapezius and
sternocleidomastoid muscles; shrugging tests its motor function.
5. The nurse performs the Rinne test and finds that the patient hears the sound longer
through bone conduction than through air conduction (BC > AC). This indicates:
A. Conductive hearing loss
B. Sensorineural hearing loss
C. Normal hearing function
D. Tinnitus
Answer: A
Conceptual Explanation: In conductive hearing loss, bone conduction is heard longer than
or equal to air conduction. Normally, AC should be twice as long as BC.
6. When inspecting the tympanic membrane with an otoscope, which characteristic indicates
a healthy ear?
A. Pearly gray and translucent
B. Bulging and red in color
C. Yellow-amber with air bubbles
D. Opaque and white
Answer: A
