Questions with Verified Answers & Detailed
Rationales | WCU Physical Assessment | Grade
A+
Section 1: General Survey & Assessment Techniques (Questions 1-40)
1. A nurse is preparing to give a handoff report using I-PASS. What does the "I" in I-
PASS stand for?
A) Information
B) Illness severity
C) Introduction
D) Intervention
Correct Answer: B
Rationale: The I-PASS mnemonic stands for Illness severity, Patient summary, Action list,
Situation awareness and contingency planning, and Synthesis by receiver. This
standardized handoff tool improves communication and patient safety .
, 2. Which of the following is a component of the general survey in a physical
assessment?
A) Blood pressure measurement
B) Assessment of level of consciousness
C) Auscultation of heart sounds
D) Palpation of the abdomen
Correct Answer: B
Rationale: The general survey includes observation of the patient's overall appearance,
level of consciousness, signs of distress, body type, posture, and hygiene. Blood pressure,
heart sounds, and abdominal palpation are focused assessments .
3. The nurse is assessing a patient's respiratory rate. Which finding should the nurse
document as abnormal?
A) Respiratory rate of 16 breaths/min in an adult
B) Respiratory rate of 12 breaths/min in an adult
C) Respiratory rate of 26 breaths/min in an adult
D) Respiratory rate of 18 breaths/min in an adult
Correct Answer: C
Rationale: The normal adult respiratory rate is 12-20 breaths per minute. A rate of 26
breaths/min indicates tachypnea, which may indicate respiratory distress, anxiety, fever, or
other underlying conditions .
, 4. The four basic techniques used in physical assessment are inspection, palpation,
percussion, and:
A) Auscultation
B) Evaluation
C) Documentation
D) Interpretation
Correct Answer: A
Rationale: The four fundamental techniques of the physical examination, performed in a
specific sequence for most body systems, are inspection, palpation, percussion, and
auscultation .
5. A nurse is assessing a patient's Glasgow Coma Scale (GCS) score. Which three
areas are evaluated?
A) Eye opening, verbal response, motor response
B) Heart rate, blood pressure, respiratory rate
C) Pupil size, reflex response, pain response
D) Orientation, memory, cognition
Correct Answer: A
, Rationale: The Glasgow Coma Scale evaluates three areas: eye opening (1-4), verbal
response (1-5), and motor response (1-6). The total score ranges from 3 to 15, with lower
scores indicating more severe impairment .
6. A nurse uses a goniometer during a physical assessment. What is the nurse
assessing?
A) The presence of edema
B) The degree of joint flexion and extension
C) The patient's height
D) The presence of a fungal infection
Correct Answer: B
Rationale: A goniometer is a specialized instrument designed to measure the angle of joints.
It is used to objectively assess the range of motion (flexion and extension) in joints like the
knee, elbow, or shoulder .
7. During an abdominal assessment, when should the nurse auscultate for bowel
sounds?
A) Before inspection and palpation
B) After palpation but before percussion
C) After percussion but before palpation
D) At any point during the exam, as it does not matter