NUR 2092/NUR2092 Exam 1 V2 | Health
Assessment Q&A with Rationale |
Rasmussen University
1. Which of the following data would be classified as subjective information?
A. Blood pressure reading of 120/80 mmHg
B. The presence of crackles during lung auscultation
C. A visible skin rash on the left forearm
D. The patient’s report of a sharp pain in the abdomen
Answer: D
Rationale: Subjective data consists of information provided by the patient that cannot be
directly observed by the nurse. A patient’s report of pain is a personal perception and is
therefore subjective. Objective data, conversely, includes measurable and observable signs
like blood pressure, rashes, and breath sounds.
2. In what order should the nurse perform the physical assessment techniques for a standard
physical exam (excluding the abdomen)?
A. Palpation, Inspection, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Inspection, Palpation, Percussion, Auscultation
D. Auscultation, Percussion, Palpation, Inspection
,Answer: C
Rationale: The standard sequence for physical assessment is Inspection, Palpation,
Percussion, and then Auscultation. Inspection always comes first to gather visual data
before touching the patient. Palpation and percussion follow, with auscultation usually
being the final step unless assessing the abdomen.
3. When using a stethoscope, what is the diaphragm primarily used for?
A. Listening to low-pitched heart murmurs
B. Listening to extra heart sounds like S3 or S4
C. Detecting bruits in the carotid artery
D. Listening to high-pitched sounds like breath and bowel sounds
Answer: D
Rationale: The diaphragm of the stethoscope is designed to pick up high-pitched sounds
such as normal heart sounds, breath sounds, and bowel sounds. The bell is used for soft,
low-pitched sounds like murmurs or bruits. It is important to press the diaphragm firmly
against the skin to create a seal.
4. Which part of the hand is most sensitive for assessing skin temperature?
A. The dorsal surface of the hand
B. The palmar surface of the hand
C. The fingertips
, D. The ulnar surface of the hand
Answer: A
Rationale: The dorsal surface, or back of the hand, is best for assessing temperature
because the skin is thinner than on the palms. Fingertips are better suited for fine tactile
discrimination and texture. Using the back of the hand provides a more accurate perception
of warmth or coolness.
5. What does the ‘P’ stand for in the PQRSTU mnemonic for pain assessment?
A. Pain level
B. Provocative or Palliative factors
C. Position of the patient
D. Previous history
Answer: B
Rationale: The ‘P’ in PQRSTU stands for Provocative or Palliative, which asks what makes
the pain worse or better. This helps the nurse understand the triggers and relief factors
associated with the patient’s discomfort. It is a critical component of a comprehensive pain
history.
6. A nurse is assessing a patient for orthostatic hypotension. Which finding would indicate
this condition?
A. A blood pressure reading of 140/90 mmHg while sitting
Assessment Q&A with Rationale |
Rasmussen University
1. Which of the following data would be classified as subjective information?
A. Blood pressure reading of 120/80 mmHg
B. The presence of crackles during lung auscultation
C. A visible skin rash on the left forearm
D. The patient’s report of a sharp pain in the abdomen
Answer: D
Rationale: Subjective data consists of information provided by the patient that cannot be
directly observed by the nurse. A patient’s report of pain is a personal perception and is
therefore subjective. Objective data, conversely, includes measurable and observable signs
like blood pressure, rashes, and breath sounds.
2. In what order should the nurse perform the physical assessment techniques for a standard
physical exam (excluding the abdomen)?
A. Palpation, Inspection, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Inspection, Palpation, Percussion, Auscultation
D. Auscultation, Percussion, Palpation, Inspection
,Answer: C
Rationale: The standard sequence for physical assessment is Inspection, Palpation,
Percussion, and then Auscultation. Inspection always comes first to gather visual data
before touching the patient. Palpation and percussion follow, with auscultation usually
being the final step unless assessing the abdomen.
3. When using a stethoscope, what is the diaphragm primarily used for?
A. Listening to low-pitched heart murmurs
B. Listening to extra heart sounds like S3 or S4
C. Detecting bruits in the carotid artery
D. Listening to high-pitched sounds like breath and bowel sounds
Answer: D
Rationale: The diaphragm of the stethoscope is designed to pick up high-pitched sounds
such as normal heart sounds, breath sounds, and bowel sounds. The bell is used for soft,
low-pitched sounds like murmurs or bruits. It is important to press the diaphragm firmly
against the skin to create a seal.
4. Which part of the hand is most sensitive for assessing skin temperature?
A. The dorsal surface of the hand
B. The palmar surface of the hand
C. The fingertips
, D. The ulnar surface of the hand
Answer: A
Rationale: The dorsal surface, or back of the hand, is best for assessing temperature
because the skin is thinner than on the palms. Fingertips are better suited for fine tactile
discrimination and texture. Using the back of the hand provides a more accurate perception
of warmth or coolness.
5. What does the ‘P’ stand for in the PQRSTU mnemonic for pain assessment?
A. Pain level
B. Provocative or Palliative factors
C. Position of the patient
D. Previous history
Answer: B
Rationale: The ‘P’ in PQRSTU stands for Provocative or Palliative, which asks what makes
the pain worse or better. This helps the nurse understand the triggers and relief factors
associated with the patient’s discomfort. It is a critical component of a comprehensive pain
history.
6. A nurse is assessing a patient for orthostatic hypotension. Which finding would indicate
this condition?
A. A blood pressure reading of 140/90 mmHg while sitting
