,NUR101 Health Assessment Exam 4 Study
Guide & 150 Practice Questions Fortis College
2026/2027
1. A nurse is beginning a comprehensive head-to-toe physical examination on a newly admitted
68-year-old patient. According to standard health assessment protocols, which sequence should
the nurse follow to minimize patient discomfort and optimize efficiency?
A. General survey, vital signs, neurological, cardiovascular, thorax/lungs, abdomen,
musculoskeletal, skin, head/neck, genitourinary, rectal
B. General survey, vital signs, head/neck, thorax/lungs, cardiovascular, abdomen,
musculoskeletal, neurological, skin, genitourinary, rectal
C. General survey, vital signs, head/neck, cardiovascular, thorax/lungs, abdomen,
musculoskeletal, skin, neurological, genitourinary, rectal
D. General survey, vital signs, head/neck, thorax/lungs, cardiovascular, abdomen,
musculoskeletal, neurological, skin, genitourinary, rectal
Correct Answer: D. General survey, vital signs, head/neck, thorax/lungs, cardiovascular,
abdomen, musculoskeletal, neurological, skin, genitourinary, rectal
Rationale: The standard head-to-toe sequence follows a cephalocaudal and systematic
approach: general survey and vitals first, then head/neck, thorax/lungs, cardiovascular,
abdomen, musculoskeletal, neurological, skin, and finally genitourinary/rectal to minimize
repositioning and patient discomfort. Option A places neurological too early and head/neck too
late, violating the cephalocaudal principle. Option C places cardiovascular before thorax/lungs,
which is less efficient.
,2. A nurse is performing a comprehensive assessment on a patient with a suspected pulmonary
embolism. Which initial diagnostic test has the highest sensitivity for ruling out PE in low- to
intermediate-risk patients?
A. D-dimer assay
B. CT pulmonary angiography (CTPA)
C. Ventilation-perfusion (V/Q) scan
D. Pulmonary angiography
Correct Answer: A. D-dimer assay
Rationale: The D-dimer assay has the highest sensitivity (approximately 95%) for ruling out PE in
patients with low- to intermediate pretest probability when combined with clinical prediction
rules such as the Wells score. CTPA is the gold standard for confirming PE but is not the initial
screening test. V/Q scan is used when CTPA is contraindicated. Pulmonary angiography is
invasive and reserved for equivocal cases.
3. A nurse is preparing to measure blood pressure on a patient with a BMI of 48. The upper arm
circumference is 52 cm. Which action is most appropriate to obtain an accurate blood pressure
reading?
A. Use a standard adult cuff (12 × 26 cm) placed on the forearm
, B. Use a large adult cuff (15 × 33 cm) placed on the upper arm
C. Use a thigh cuff (18 × 36 cm) placed on the upper arm
D. Use a standard adult cuff (12 × 26 cm) placed on the upper arm
Correct Answer: C. Use a thigh cuff (18 × 36 cm) placed on the upper arm
Rationale: For a patient with an upper arm circumference greater than 41 cm, a thigh cuff (18 ×
36 cm) is required for accurate measurement. Using a cuff that is too small results in falsely
elevated readings. A standard or large adult cuff would be too small for this patient.
4. A nurse is documenting a patient's head-to-toe assessment findings. Which format organizes
data by subjective, objective, assessment, and plan?
A. SOAP
B. SBAR
C. DAR
D. PIE
Correct Answer: A. SOAP
Guide & 150 Practice Questions Fortis College
2026/2027
1. A nurse is beginning a comprehensive head-to-toe physical examination on a newly admitted
68-year-old patient. According to standard health assessment protocols, which sequence should
the nurse follow to minimize patient discomfort and optimize efficiency?
A. General survey, vital signs, neurological, cardiovascular, thorax/lungs, abdomen,
musculoskeletal, skin, head/neck, genitourinary, rectal
B. General survey, vital signs, head/neck, thorax/lungs, cardiovascular, abdomen,
musculoskeletal, neurological, skin, genitourinary, rectal
C. General survey, vital signs, head/neck, cardiovascular, thorax/lungs, abdomen,
musculoskeletal, skin, neurological, genitourinary, rectal
D. General survey, vital signs, head/neck, thorax/lungs, cardiovascular, abdomen,
musculoskeletal, neurological, skin, genitourinary, rectal
Correct Answer: D. General survey, vital signs, head/neck, thorax/lungs, cardiovascular,
abdomen, musculoskeletal, neurological, skin, genitourinary, rectal
Rationale: The standard head-to-toe sequence follows a cephalocaudal and systematic
approach: general survey and vitals first, then head/neck, thorax/lungs, cardiovascular,
abdomen, musculoskeletal, neurological, skin, and finally genitourinary/rectal to minimize
repositioning and patient discomfort. Option A places neurological too early and head/neck too
late, violating the cephalocaudal principle. Option C places cardiovascular before thorax/lungs,
which is less efficient.
,2. A nurse is performing a comprehensive assessment on a patient with a suspected pulmonary
embolism. Which initial diagnostic test has the highest sensitivity for ruling out PE in low- to
intermediate-risk patients?
A. D-dimer assay
B. CT pulmonary angiography (CTPA)
C. Ventilation-perfusion (V/Q) scan
D. Pulmonary angiography
Correct Answer: A. D-dimer assay
Rationale: The D-dimer assay has the highest sensitivity (approximately 95%) for ruling out PE in
patients with low- to intermediate pretest probability when combined with clinical prediction
rules such as the Wells score. CTPA is the gold standard for confirming PE but is not the initial
screening test. V/Q scan is used when CTPA is contraindicated. Pulmonary angiography is
invasive and reserved for equivocal cases.
3. A nurse is preparing to measure blood pressure on a patient with a BMI of 48. The upper arm
circumference is 52 cm. Which action is most appropriate to obtain an accurate blood pressure
reading?
A. Use a standard adult cuff (12 × 26 cm) placed on the forearm
, B. Use a large adult cuff (15 × 33 cm) placed on the upper arm
C. Use a thigh cuff (18 × 36 cm) placed on the upper arm
D. Use a standard adult cuff (12 × 26 cm) placed on the upper arm
Correct Answer: C. Use a thigh cuff (18 × 36 cm) placed on the upper arm
Rationale: For a patient with an upper arm circumference greater than 41 cm, a thigh cuff (18 ×
36 cm) is required for accurate measurement. Using a cuff that is too small results in falsely
elevated readings. A standard or large adult cuff would be too small for this patient.
4. A nurse is documenting a patient's head-to-toe assessment findings. Which format organizes
data by subjective, objective, assessment, and plan?
A. SOAP
B. SBAR
C. DAR
D. PIE
Correct Answer: A. SOAP
