Rasmussen University NUR 2180 Module 2 (pdf) | 2026/2027 |
Physical Assessment Q&A | Health Assessment
**1. A patient complains of diplopia. Which cranial nerve should the nurse
assess?**
A) Cranial nerve II (Optic)
B) Cranial nerve IV (Trochlear)
C) Cranial nerve VI (Abducens)
D) Cranial nerve VIII (Vestibulocochlear)
Correct Answer: C) Cranial nerve VI (Abducens)
Rationale: Diplopia, or double vision, is associated with dysfunction of cranial
nerve VI (abducens), which controls lateral eye movement. Cranial nerves III
and IV also control eye movement, but dysfunction of cranial nerve VI is a
classic cause of horizontal diplopia.
**2. Which test should the nurse perform to assess for diplopia?**
A) Snellen chart test
B) Six cardinal directions gaze test
C) Whisper test
D) Romberg test
Correct Answer: B) Six cardinal directions gaze test
Rationale: The six cardinal directions gaze test evaluates extraocular muscle
movement and can identify abnormalities that cause diplopia. The Snellen
chart (A) tests visual acuity. The whisper test (C) assesses hearing, and the
Romberg test (D) assesses balance.
,**3. A patient reports pain and crepitus in the jaw when chewing. How should
the nurse best assess this finding?**
A) Palpate the temporomandibular joint (TMJ)
B) Inspect the oral mucosa
C) Auscultate the carotid arteries
D) Test cranial nerve VII
Correct Answer: A) Palpate the temporomandibular joint (TMJ)
Rationale: TMJ assessment involves palpating the joint during jaw movement
to detect pain or crepitus. This is the most direct method to evaluate a
complaint of jaw pain with movement.
**4. What is the normal reflex grade for a deep tendon reflex?**
A) 0
B) 1+
C) 2+
D) 4+
Correct Answer: C) 2+
Rationale: A 2+ reflex is a normal response, indicating a brisk but expected
reaction. Grade 0 indicates no response, 1+ is diminished, 3+ is brisk, and
4+ is hyperactive with clonus.
**5. A client reports a headache. Which subjective data should the nurse
collect?**
A) Blood pressure reading
B) Pain level and location
,C) Pupil size
D) Heart rate
Correct Answer: B) Pain level and location
Rationale: Subjective data includes patient-reported information like pain
level, location, duration, and triggers for headaches. Blood pressure, pupil
size, and heart rate are objective data obtained by the examiner.
**6. When inspecting the head, what should the nurse primarily assess for?**
A) Symmetry and lumps
B) Breath sounds
C) Heart murmurs
D) Joint range of motion
Correct Answer: A) Symmetry and lumps
Rationale: Head inspection includes checking for symmetry, lumps, bumps,
bruising, and other abnormalities. Breath sounds (B) are assessed in the
respiratory exam, heart murmurs (C) in the cardiac exam, and joint range of
motion (D) in the musculoskeletal exam.
**7. A patient reports ear pain. Which structure should the nurse inspect
using an otoscope?**
A) Nasal mucosa
B) Tympanic membrane
C) Throat tonsils
D) Cornea
, Correct Answer: B) Tympanic membrane
Rationale: The otoscope is used to visualize the ear canal and tympanic
membrane for signs of infection or abnormality. Nasal mucosa (A) is assessed
with a nasal speculum, throat tonsils (C) with a tongue depressor, and the
cornea (D) with an ophthalmoscope or penlight.
**8. What is the correct order for assessing the abdomen?**
A) Palpate, auscultate, inspect, percuss
B) Inspect, auscultate, percuss, palpate
C) Auscultate, percuss, inspect, palpate
D) Palpate, inspect, auscultate, percuss
Correct Answer: B) Inspect, auscultate, percuss, palpate
Rationale: This order prevents palpation from altering bowel sounds,
ensuring accurate assessment. Inspection is always first, followed by
auscultation before percussion or palpation, which can stimulate peristalsis.
**9. A client reports shortness of breath. Which respiratory sound indicates
airway obstruction?**
A) Crackles
B) Wheezes
C) Rhonchi
D) Pleural rub
Correct Answer: B) Wheezes
Physical Assessment Q&A | Health Assessment
**1. A patient complains of diplopia. Which cranial nerve should the nurse
assess?**
A) Cranial nerve II (Optic)
B) Cranial nerve IV (Trochlear)
C) Cranial nerve VI (Abducens)
D) Cranial nerve VIII (Vestibulocochlear)
Correct Answer: C) Cranial nerve VI (Abducens)
Rationale: Diplopia, or double vision, is associated with dysfunction of cranial
nerve VI (abducens), which controls lateral eye movement. Cranial nerves III
and IV also control eye movement, but dysfunction of cranial nerve VI is a
classic cause of horizontal diplopia.
**2. Which test should the nurse perform to assess for diplopia?**
A) Snellen chart test
B) Six cardinal directions gaze test
C) Whisper test
D) Romberg test
Correct Answer: B) Six cardinal directions gaze test
Rationale: The six cardinal directions gaze test evaluates extraocular muscle
movement and can identify abnormalities that cause diplopia. The Snellen
chart (A) tests visual acuity. The whisper test (C) assesses hearing, and the
Romberg test (D) assesses balance.
,**3. A patient reports pain and crepitus in the jaw when chewing. How should
the nurse best assess this finding?**
A) Palpate the temporomandibular joint (TMJ)
B) Inspect the oral mucosa
C) Auscultate the carotid arteries
D) Test cranial nerve VII
Correct Answer: A) Palpate the temporomandibular joint (TMJ)
Rationale: TMJ assessment involves palpating the joint during jaw movement
to detect pain or crepitus. This is the most direct method to evaluate a
complaint of jaw pain with movement.
**4. What is the normal reflex grade for a deep tendon reflex?**
A) 0
B) 1+
C) 2+
D) 4+
Correct Answer: C) 2+
Rationale: A 2+ reflex is a normal response, indicating a brisk but expected
reaction. Grade 0 indicates no response, 1+ is diminished, 3+ is brisk, and
4+ is hyperactive with clonus.
**5. A client reports a headache. Which subjective data should the nurse
collect?**
A) Blood pressure reading
B) Pain level and location
,C) Pupil size
D) Heart rate
Correct Answer: B) Pain level and location
Rationale: Subjective data includes patient-reported information like pain
level, location, duration, and triggers for headaches. Blood pressure, pupil
size, and heart rate are objective data obtained by the examiner.
**6. When inspecting the head, what should the nurse primarily assess for?**
A) Symmetry and lumps
B) Breath sounds
C) Heart murmurs
D) Joint range of motion
Correct Answer: A) Symmetry and lumps
Rationale: Head inspection includes checking for symmetry, lumps, bumps,
bruising, and other abnormalities. Breath sounds (B) are assessed in the
respiratory exam, heart murmurs (C) in the cardiac exam, and joint range of
motion (D) in the musculoskeletal exam.
**7. A patient reports ear pain. Which structure should the nurse inspect
using an otoscope?**
A) Nasal mucosa
B) Tympanic membrane
C) Throat tonsils
D) Cornea
, Correct Answer: B) Tympanic membrane
Rationale: The otoscope is used to visualize the ear canal and tympanic
membrane for signs of infection or abnormality. Nasal mucosa (A) is assessed
with a nasal speculum, throat tonsils (C) with a tongue depressor, and the
cornea (D) with an ophthalmoscope or penlight.
**8. What is the correct order for assessing the abdomen?**
A) Palpate, auscultate, inspect, percuss
B) Inspect, auscultate, percuss, palpate
C) Auscultate, percuss, inspect, palpate
D) Palpate, inspect, auscultate, percuss
Correct Answer: B) Inspect, auscultate, percuss, palpate
Rationale: This order prevents palpation from altering bowel sounds,
ensuring accurate assessment. Inspection is always first, followed by
auscultation before percussion or palpation, which can stimulate peristalsis.
**9. A client reports shortness of breath. Which respiratory sound indicates
airway obstruction?**
A) Crackles
B) Wheezes
C) Rhonchi
D) Pleural rub
Correct Answer: B) Wheezes
