UR 101/ NUR101 Exam 1 – Health
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Assessment Review ACTUAL EXAM
2026/2027 | Health Assessment Review |
Verified Q&A | Pass Guaranteed - A+
Graded
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PART A – MULTIPLE CHOICE (Q1–60)
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* *Q1 (Health history – OLDCARTS):** A 45-year-old male presents with chest pain. During the
HPI, the nurse asks, "Does the pain radiate to your arm, jaw, or back?" Which OLDCARTS
component is the nurse assessing?
A. Character
B. Radiation
C. Aggravating factors
D. Severity
**[CORRECT]** B
*Rationale: The "R" in OLDCARTS stands for Radiation, which assesses whether pain spreads
to other areas of the body. Character (C) refers to the quality of pain (e.g., sharp, dull, burning).
Aggravating factors (A) identify what worsens the symptom. Severity (D) is typically measured
on a 0-10 scale. Clinical pearl: Radiation of chest pain to the left arm or jaw is a classic sign of
cardiac ischemia and requires immediate evaluation.*
* *Q2 (Communication – therapeutic techniques):** A patient states, "I'm so worried about my
surgery tomorrow." Which response demonstrates the therapeutic technique of reflection?
A. "Don't worry, you'll be fine. The surgeons here are excellent."
B. "You're feeling anxious about your upcoming surgery."
C. "Have you spoken to your doctor about your concerns?"
D. "I had surgery last year and everything went perfectly."
**[CORRECT]** B
*Rationale: Reflection mirrors the patient's feelings back to them, validating their emotional
state. Option A provides false reassurance, which is non-therapeutic. Option C changes the
subject rather than addressing the emotion. Option D shifts focus to the nurse's experience,
, hich is inappropriate. Clinical pearl: Reflection encourages patients to explore their feelings
w
further and builds therapeutic rapport.*
* *Q3 (Vital signs – blood pressure technique):** When assessing blood pressure, the nurse
hears the first Korotkoff sound. This sound corresponds to which pressure reading?
A. Diastolic blood pressure
B. Mean arterial pressure
C. Systolic blood pressure
D. Pulse pressure
**[CORRECT]** C
*Rationale: The first Korotkoff sound (Phase I) marks the onset of turbulent blood flow through
the compressed artery and corresponds to systolic blood pressure. Diastolic pressure (A) is
recorded when sounds disappear (Phase V) or muffle (Phase IV). Mean arterial pressure (B) is
calculated, not auscultated. Clinical pearl: In some patients (e.g., pregnancy, aortic
regurgitation), the Korotkoff sounds may not disappear; use Phase IV (muffling) for diastolic in
these cases.*
* *Q4 (Cultural assessment – LEARN model):** During a cultural assessment, the nurse explains
the treatment plan to a patient whose cultural beliefs may conflict with Western medicine.
According to the LEARN model, what is the nurse's next step?
A. Listen to the patient's perspective
B. Acknowledge the patient's cultural beliefs
C. Recommend a treatment plan
D. Negotiate a mutually acceptable plan
**[CORRECT]** D
*Rationale: The LEARN model sequence is Listen, Explain, Acknowledge, Recommend,
Negotiate. After recommending treatment (C), the nurse must negotiate (D) a plan that respects
the patient's cultural values while ensuring safe care. Listening (A) and explaining (B) occur
earlier in the sequence. Clinical pearl: Negotiation demonstrates cultural humility and increases
patient adherence to treatment plans.*
* *Q5 (Mental status – MMSE scoring):** A 78-year-old patient scores 22/30 on the Mini-Mental
State Examination (MMSE). How should the nurse interpret this result?
A. Normal cognitive function
B. Mild cognitive impairment
C. Moderate cognitive impairment
D. Severe cognitive impairment
**[CORRECT]** C
*Rationale: MMSE scores of 24-30 indicate normal cognition; 18-23 indicate moderate cognitive
impairment; 0-17 indicate severe impairment. A score of 22 falls within the moderate range. Mild
cognitive impairment is not specifically categorized on the MMSE; the Montreal Cognitive
Assessment (MoCA) is more sensitive for mild impairment. Clinical pearl: Always consider
education level and primary language when interpreting MMSE scores, as these factors affect
baseline performance.*
, * *Q6 (Pain assessment – PQRST):** A nurse is assessing a patient's abdominal pain using the
PQRST method. The patient states the pain started 2 hours ago after eating spicy food. Which
PQRST component has the patient described?
A. Provocation/Palliation
B. Quality
C. Region/Radiation
D. Timing
**[CORRECT]** A
*Rationale: The patient identified spicy food as the provoking factor for the pain, which
corresponds to Provocation/Palliation (P). Quality (B) describes the character of pain (e.g.,
burning, cramping). Region/Radiation (C) identifies location. Timing (D) refers to when the pain
started, how long it lasts, and whether it is constant or intermittent. Clinical pearl: OLDCARTS
and PQRST are complementary frameworks; PQRST's "P" combines OLDCARTS' Aggravating
and Alleviating factors.*
* *Q7 (Vital signs – orthostatic hypotension):** A nurse measures a patient's blood pressure
supine (120/80 mmHg) and standing (100/70 mmHg). What is the nurse's priority action?
A. Document the findings as normal variation
B. Assist the patient to a sitting position and reassess
C. Notify the provider immediately of orthostatic hypotension
D. Increase the patient's fluid intake
**[CORRECT]** B
*Rationale: Orthostatic hypotension is defined as a drop in SBP ≥20 mmHg or DBP ≥10 mmHg
upon standing. The nurse should first ensure patient safety by assisting them to sit (B) to
prevent falls, then reassess. While notification (C) is important, safety comes first.
Documentation (A) is incorrect as this is not normal. Clinical pearl: Orthostatic hypotension is
common in older adults, patients on antihypertensives, and those with volume depletion; always
assess before ambulation.*
* *Q8 (Health history – review of systems):** During the review of systems, a patient reports
unintentional weight loss of 15 pounds over 2 months, night sweats, and fatigue. Which body
system should the nurse focus on next?
A. Cardiovascular
B. Respiratory
C. Hematologic/Lymphatic
D. Musculoskeletal
**[CORRECT]** C
*Rationale: Unintentional weight loss, night sweats, and fatigue are classic "B symptoms"
associated with hematologic malignancies such as lymphoma. While these symptoms could
relate to other systems, the hematologic/lymphatic system (C) is the priority given this symptom
cluster. Clinical pearl: B symptoms (fever, drenching night sweats, unintentional weight loss
>10% body weight over 6 months) are prognostic indicators in lymphoma staging and require
prompt evaluation.*
N
Assessment Review ACTUAL EXAM
2026/2027 | Health Assessment Review |
Verified Q&A | Pass Guaranteed - A+
Graded
=======================================================================
=
========
PART A – MULTIPLE CHOICE (Q1–60)
========================================================================
========
* *Q1 (Health history – OLDCARTS):** A 45-year-old male presents with chest pain. During the
HPI, the nurse asks, "Does the pain radiate to your arm, jaw, or back?" Which OLDCARTS
component is the nurse assessing?
A. Character
B. Radiation
C. Aggravating factors
D. Severity
**[CORRECT]** B
*Rationale: The "R" in OLDCARTS stands for Radiation, which assesses whether pain spreads
to other areas of the body. Character (C) refers to the quality of pain (e.g., sharp, dull, burning).
Aggravating factors (A) identify what worsens the symptom. Severity (D) is typically measured
on a 0-10 scale. Clinical pearl: Radiation of chest pain to the left arm or jaw is a classic sign of
cardiac ischemia and requires immediate evaluation.*
* *Q2 (Communication – therapeutic techniques):** A patient states, "I'm so worried about my
surgery tomorrow." Which response demonstrates the therapeutic technique of reflection?
A. "Don't worry, you'll be fine. The surgeons here are excellent."
B. "You're feeling anxious about your upcoming surgery."
C. "Have you spoken to your doctor about your concerns?"
D. "I had surgery last year and everything went perfectly."
**[CORRECT]** B
*Rationale: Reflection mirrors the patient's feelings back to them, validating their emotional
state. Option A provides false reassurance, which is non-therapeutic. Option C changes the
subject rather than addressing the emotion. Option D shifts focus to the nurse's experience,
, hich is inappropriate. Clinical pearl: Reflection encourages patients to explore their feelings
w
further and builds therapeutic rapport.*
* *Q3 (Vital signs – blood pressure technique):** When assessing blood pressure, the nurse
hears the first Korotkoff sound. This sound corresponds to which pressure reading?
A. Diastolic blood pressure
B. Mean arterial pressure
C. Systolic blood pressure
D. Pulse pressure
**[CORRECT]** C
*Rationale: The first Korotkoff sound (Phase I) marks the onset of turbulent blood flow through
the compressed artery and corresponds to systolic blood pressure. Diastolic pressure (A) is
recorded when sounds disappear (Phase V) or muffle (Phase IV). Mean arterial pressure (B) is
calculated, not auscultated. Clinical pearl: In some patients (e.g., pregnancy, aortic
regurgitation), the Korotkoff sounds may not disappear; use Phase IV (muffling) for diastolic in
these cases.*
* *Q4 (Cultural assessment – LEARN model):** During a cultural assessment, the nurse explains
the treatment plan to a patient whose cultural beliefs may conflict with Western medicine.
According to the LEARN model, what is the nurse's next step?
A. Listen to the patient's perspective
B. Acknowledge the patient's cultural beliefs
C. Recommend a treatment plan
D. Negotiate a mutually acceptable plan
**[CORRECT]** D
*Rationale: The LEARN model sequence is Listen, Explain, Acknowledge, Recommend,
Negotiate. After recommending treatment (C), the nurse must negotiate (D) a plan that respects
the patient's cultural values while ensuring safe care. Listening (A) and explaining (B) occur
earlier in the sequence. Clinical pearl: Negotiation demonstrates cultural humility and increases
patient adherence to treatment plans.*
* *Q5 (Mental status – MMSE scoring):** A 78-year-old patient scores 22/30 on the Mini-Mental
State Examination (MMSE). How should the nurse interpret this result?
A. Normal cognitive function
B. Mild cognitive impairment
C. Moderate cognitive impairment
D. Severe cognitive impairment
**[CORRECT]** C
*Rationale: MMSE scores of 24-30 indicate normal cognition; 18-23 indicate moderate cognitive
impairment; 0-17 indicate severe impairment. A score of 22 falls within the moderate range. Mild
cognitive impairment is not specifically categorized on the MMSE; the Montreal Cognitive
Assessment (MoCA) is more sensitive for mild impairment. Clinical pearl: Always consider
education level and primary language when interpreting MMSE scores, as these factors affect
baseline performance.*
, * *Q6 (Pain assessment – PQRST):** A nurse is assessing a patient's abdominal pain using the
PQRST method. The patient states the pain started 2 hours ago after eating spicy food. Which
PQRST component has the patient described?
A. Provocation/Palliation
B. Quality
C. Region/Radiation
D. Timing
**[CORRECT]** A
*Rationale: The patient identified spicy food as the provoking factor for the pain, which
corresponds to Provocation/Palliation (P). Quality (B) describes the character of pain (e.g.,
burning, cramping). Region/Radiation (C) identifies location. Timing (D) refers to when the pain
started, how long it lasts, and whether it is constant or intermittent. Clinical pearl: OLDCARTS
and PQRST are complementary frameworks; PQRST's "P" combines OLDCARTS' Aggravating
and Alleviating factors.*
* *Q7 (Vital signs – orthostatic hypotension):** A nurse measures a patient's blood pressure
supine (120/80 mmHg) and standing (100/70 mmHg). What is the nurse's priority action?
A. Document the findings as normal variation
B. Assist the patient to a sitting position and reassess
C. Notify the provider immediately of orthostatic hypotension
D. Increase the patient's fluid intake
**[CORRECT]** B
*Rationale: Orthostatic hypotension is defined as a drop in SBP ≥20 mmHg or DBP ≥10 mmHg
upon standing. The nurse should first ensure patient safety by assisting them to sit (B) to
prevent falls, then reassess. While notification (C) is important, safety comes first.
Documentation (A) is incorrect as this is not normal. Clinical pearl: Orthostatic hypotension is
common in older adults, patients on antihypertensives, and those with volume depletion; always
assess before ambulation.*
* *Q8 (Health history – review of systems):** During the review of systems, a patient reports
unintentional weight loss of 15 pounds over 2 months, night sweats, and fatigue. Which body
system should the nurse focus on next?
A. Cardiovascular
B. Respiratory
C. Hematologic/Lymphatic
D. Musculoskeletal
**[CORRECT]** C
*Rationale: Unintentional weight loss, night sweats, and fatigue are classic "B symptoms"
associated with hematologic malignancies such as lymphoma. While these symptoms could
relate to other systems, the hematologic/lymphatic system (C) is the priority given this symptom
cluster. Clinical pearl: B symptoms (fever, drenching night sweats, unintentional weight loss
>10% body weight over 6 months) are prognostic indicators in lymphoma staging and require
prompt evaluation.*
