NURS 121L-B: Advanced Head-to-Toe Clinical Assessment - 2026
Update 2026 |WCU
1. During a neurological assessment, the nurse asks the patient to shrug their
shoulders against resistance. Which cranial nerve is being evaluated?
A. CN IX (Glossopharyngeal)
B. CN XI (Spinal Accessory)
C. CN X (Vagus)
D. CN XII (Hypoglossal)
Answer: B
Rationale: Cranial Nerve XI, the Spinal Accessory nerve, controls the trapezius and
sternocleidomastoid muscles; shrugging against resistance is the standard test.
2. While auscultating heart sounds, the nurse identifies a high-pitched, scratchy
sound loudest at the left lower sternal border. This finding is most likely:
A. A grade II systolic murmur
B. A pericardial friction rub
C. A physiological S3 sound
D. An atrial gallop
Answer: B
Rationale: A high-pitched, scratchy, or leathery sound is characteristic of a pericardial
friction rub, often heard best with the patient leaning forward.
,3. When assessing the abdomen, which sequence should the nurse follow to
avoid altering clinical findings?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Percussion, Auscultation, Palpation
C. Inspection, Palpation, Percussion, Auscultation
D. Auscultation, Inspection, Palpation, Percussion
Answer: A
Rationale: Auscultation is performed immediately after inspection because percussion and
palpation can stimulate peristalsis and alter bowel sounds.
4. A nurse observes a ‘swaying’ motion when the patient stands with feet
together and eyes closed. This is documented as a positive:
A. Babinski sign
B. Allen’s test
C. Romberg test
D. Phalen’s test
Answer: C
Rationale: The Romberg test assesses cerebellar function and proprioception; loss of
balance when eyes are closed constitutes a positive result.
5. What is the clinical significance of a patient presenting with an ankle-brachial
index (ABI) of 0.65?
A. Mild to moderate peripheral artery disease
B. Normal arterial blood flow
C. Severe limb ischemia
D. Venous insufficiency
Answer: A
Rationale: An ABI between 0.41 and 0.90 indicates mild to moderate peripheral artery
disease; a normal ABI is typically 1.0 to 1.4.
, 6. When assessing the lungs, the nurse hears low-pitched, snoring sounds that
clear after coughing. These are classified as:
A. Rhonchi
B. Fine crackles
C. Sibilant wheezes
D. Pleural friction rub
Answer: A
Rationale: Rhonchi (sonorous wheezes) are low-pitched sounds caused by secretions in
large airways and often improve or disappear after a patient coughs.
7. A 70-year-old patient exhibits a chest diameter that is equal in its
anteroposterior and transverse ratios. This is described as:
A. Barrel chest
B. Pectus carinatum
C. Pectus excavatum
D. Scoliosis
Answer: A
Rationale: A barrel chest features a 1:1 ratio and is typically associated with hyperinflation
of the lungs in chronic obstructive pulmonary disease (COPD).
8. The nurse is grading a patient’s pulse and finds it to be ‘full, brisk, and
expected.’ Which numerical grade is appropriate?
A. 1+
B. 4+
C. 3+
D. 2+
Answer: D
Rationale: On the standard 0-4 scale, 0 is absent, 1+ is diminished/weak, 2+ is
normal/brisk, and 3+ or 4+ indicate bounding pulses depending on the facility’s scale.
Update 2026 |WCU
1. During a neurological assessment, the nurse asks the patient to shrug their
shoulders against resistance. Which cranial nerve is being evaluated?
A. CN IX (Glossopharyngeal)
B. CN XI (Spinal Accessory)
C. CN X (Vagus)
D. CN XII (Hypoglossal)
Answer: B
Rationale: Cranial Nerve XI, the Spinal Accessory nerve, controls the trapezius and
sternocleidomastoid muscles; shrugging against resistance is the standard test.
2. While auscultating heart sounds, the nurse identifies a high-pitched, scratchy
sound loudest at the left lower sternal border. This finding is most likely:
A. A grade II systolic murmur
B. A pericardial friction rub
C. A physiological S3 sound
D. An atrial gallop
Answer: B
Rationale: A high-pitched, scratchy, or leathery sound is characteristic of a pericardial
friction rub, often heard best with the patient leaning forward.
,3. When assessing the abdomen, which sequence should the nurse follow to
avoid altering clinical findings?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Percussion, Auscultation, Palpation
C. Inspection, Palpation, Percussion, Auscultation
D. Auscultation, Inspection, Palpation, Percussion
Answer: A
Rationale: Auscultation is performed immediately after inspection because percussion and
palpation can stimulate peristalsis and alter bowel sounds.
4. A nurse observes a ‘swaying’ motion when the patient stands with feet
together and eyes closed. This is documented as a positive:
A. Babinski sign
B. Allen’s test
C. Romberg test
D. Phalen’s test
Answer: C
Rationale: The Romberg test assesses cerebellar function and proprioception; loss of
balance when eyes are closed constitutes a positive result.
5. What is the clinical significance of a patient presenting with an ankle-brachial
index (ABI) of 0.65?
A. Mild to moderate peripheral artery disease
B. Normal arterial blood flow
C. Severe limb ischemia
D. Venous insufficiency
Answer: A
Rationale: An ABI between 0.41 and 0.90 indicates mild to moderate peripheral artery
disease; a normal ABI is typically 1.0 to 1.4.
, 6. When assessing the lungs, the nurse hears low-pitched, snoring sounds that
clear after coughing. These are classified as:
A. Rhonchi
B. Fine crackles
C. Sibilant wheezes
D. Pleural friction rub
Answer: A
Rationale: Rhonchi (sonorous wheezes) are low-pitched sounds caused by secretions in
large airways and often improve or disappear after a patient coughs.
7. A 70-year-old patient exhibits a chest diameter that is equal in its
anteroposterior and transverse ratios. This is described as:
A. Barrel chest
B. Pectus carinatum
C. Pectus excavatum
D. Scoliosis
Answer: A
Rationale: A barrel chest features a 1:1 ratio and is typically associated with hyperinflation
of the lungs in chronic obstructive pulmonary disease (COPD).
8. The nurse is grading a patient’s pulse and finds it to be ‘full, brisk, and
expected.’ Which numerical grade is appropriate?
A. 1+
B. 4+
C. 3+
D. 2+
Answer: D
Rationale: On the standard 0-4 scale, 0 is absent, 1+ is diminished/weak, 2+ is
normal/brisk, and 3+ or 4+ indicate bounding pulses depending on the facility’s scale.
