NURS110 Introduction to Professional Nursing Assessment 2
2026 - WCU EXAM with Questions and Answers/Plus a
Rationale Updated 2026 A+/Instant Download PDF
EXAM COVERAGE
1. Advanced Health Assessment and Comprehensive Physical Examination Techniques
2. Clinical Judgement, Clinical Reasoning, and the Nursing Process
3. Pathophysiological Correlates and Diagnostic Findings Interpretation
4. Cultural Competence, Health Literacy, and Patient-Centered Interviewing
5. Lifespan Considerations: Pediatric, Adult, and Gerontological Assessments
6. Mental Status, Psychosocial, and Cognitive Function Evaluations
7. Documentation Standards, Communication, and Interprofessional Hand Offs
8. Evidence-Based Screening, Prevention, and Health Promotion Strategies
9. Acute and Critical Findings Recognition and Urgent Intervention Priorities
1. A nurse is assessing an adult client who presents with progressive shortness of breath, bilateral
lower extremity pitting edema, and jugular venous distention at 45 degrees. Which underlying
pathophysiological mechanism best explains these clinical assessment findings?
A. Primary left ventricular systolic dysfunction leading to systemic fluid depletion.
B. Right-sided heart failure resulting in systemic venous congestion and increased
hydrostatic pressure.
C. Acute hypovolemic shock secondary to massive capillary fluid leakage.
D. Chronic obstructive pulmonary disease causing isolated systemic vasoconstriction.
, CORRECT ANSWER : B
Rationale: Right-sided heart failure impairs the heart's ability to pump blood effectively into the
pulmonary circulation, causing blood to back up into the systemic venous system. This systemic
congestion manifests as elevated jugular venous pressure, hepatomegaly, and peripheral pitting
edema. Left ventricular failure primarily causes pulmonary congestion rather than systemic
venous pooling.
2. A nurse is conducting a comprehensive neurological assessment on a client admitted following a
traumatic brain injury. The client opens their eyes to verbal stimuli, makes incomprehensible
sounds, and localizes to pain. What is the client's Glasgow Coma Scale (GCS) score?
A. 10
B. 11
C. 13
D. 15
CORRECT ANSWER : B
Rationale: The Glasgow Coma Scale evaluates eye opening, verbal response, and motor
response. Opening eyes to verbal stimuli scores 3, making incomprehensible sounds scores 2,
and localizing to pain scores 5, resulting in a total score of 11. Accurate calculation is critical
for monitoring neurological trajectory and detecting acute intracranial changes.
3. During an abdominal assessment, a nurse performs deep palpation and notes a pulsating mass in
the periumbilical area accompanied by a bruit auscultated over the aorta. What is the nurse's
immediate priority action?
A. Percuss the lower quadrants to determine the exact liver span.
B. Stop palpating immediately and notify the primary healthcare provider to prevent
potential rupture.
C. Massage the area gently to encourage normal peristalsis and venous return.
D. Administer a prescribed oral laxative to relieve suspected gas distention.
CORRECT ANSWER : B
Rationale: A pulsating periumbilical mass accompanied by a bruit strongly indicates an
abdominal aortic aneurysm (AAA). Deep palpation is strictly contraindicated because manual
pressure can precipitate catastrophic rupture and fatal hemorrhage; immediate provider
notification is mandatory.
,4. A nurse is assessing an older adult client for suspected delirium versus dementia. Which
assessment finding specifically supports a diagnosis of delirium rather than dementia?
A. Insidious, slow onset of memory loss over several years.
B. Acute, fluctuating onset of altered consciousness, disorientation, and impaired attention
span.
C. Normal level of alertness with stable, progressive cognitive decline.
D. Intact immediate recall accompanied by chronic depressive symptoms.
CORRECT ANSWER : B
Rationale: Delirium is characterized by an acute, sudden onset and fluctuating course of
disorientation, inattention, and altered level of consciousness, frequently triggered by an
underlying medical condition or medication. Conversely, dementia presents with a slow,
insidious, and progressive cognitive decline.
5. A nurse is performing a respiratory assessment on a client experiencing an acute asthma
exacerbation. Which auscultatory finding should the nurse expect to hear?
A. Clear, resonant vesicular breath sounds throughout all lung fields.
B. High-pitched, musical expiratory wheezes caused by air rushing through narrowed
airways.
C. Coarse, bubbling crackles heard primarily during early inspiration.
D. Deep, grating pleural friction rubs localized to the lower lung bases.
CORRECT ANSWER : B
Rationale: Asthma involves bronchospasm, mucosal edema, and mucus hypersecretion, which
narrow the bronchial airways. As air flows through these constricted passages under pressure, it
produces high-pitched, musical expiratory wheezes.
6. A nurse is evaluating the nutritional status of a newly admitted client. Which diagnostic
laboratory value provides the most reliable indicator of chronic protein depletion over an
extended period?
A. Serum creatinine clearance
B. Serum albumin with a half-life of approximately 20 days
C. Serum prealbumin with a half-life of 2 days
, D. Complete blood count hemoglobin level
CORRECT ANSWER : B
Rationale: Serum albumin has a relatively long half-life of approximately 20 days, making it a
reliable clinical indicator of chronic nutritional status and long-term protein depletion.
Prealbumin has a much shorter half-life (2 days) and reflects acute, short-term nutritional
changes.
7. A nurse is assessing a client with suspected deep vein thrombosis (DVT) in the left calf. Which
clinical manifestation supports this assessment?
A. Cool, pale skin with absent distal pulses in the affected foot.
B. Unilateral calf swelling, localized tenderness, warmth, and erythema.
C. Bilateral symmetrical edema occurring strictly at the end of the day.
D. Sharp, shooting nerve pain radiating down the lateral aspect of the leg.
CORRECT ANSWER : B
Rationale: Deep vein thrombosis typically presents with unilateral localized findings caused by
venous outflow obstruction, including calf swelling, localized tenderness, warmth, and redness.
Arterial insufficiency presents with cool, pale skin and absent pulses, while bilateral edema
suggests systemic etiology.
8. A nurse is conducting a skin assessment on an immobile client and notes a non-blanching area of
erythema over the sacrum. The epidermis remains intact. How should the nurse stage this
pressure injury?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Stage 3 pressure injury
D. Unstageable pressure injury
CORRECT ANSWER : A
Rationale: A Stage 1 pressure injury is characterized by intact skin with non-blanching erythema
over a localized area, typically over a bony prominence. Stage 2 involves partial-thickness skin
loss with exposed dermis, while Stage 3 involves full-thickness tissue loss.
2026 - WCU EXAM with Questions and Answers/Plus a
Rationale Updated 2026 A+/Instant Download PDF
EXAM COVERAGE
1. Advanced Health Assessment and Comprehensive Physical Examination Techniques
2. Clinical Judgement, Clinical Reasoning, and the Nursing Process
3. Pathophysiological Correlates and Diagnostic Findings Interpretation
4. Cultural Competence, Health Literacy, and Patient-Centered Interviewing
5. Lifespan Considerations: Pediatric, Adult, and Gerontological Assessments
6. Mental Status, Psychosocial, and Cognitive Function Evaluations
7. Documentation Standards, Communication, and Interprofessional Hand Offs
8. Evidence-Based Screening, Prevention, and Health Promotion Strategies
9. Acute and Critical Findings Recognition and Urgent Intervention Priorities
1. A nurse is assessing an adult client who presents with progressive shortness of breath, bilateral
lower extremity pitting edema, and jugular venous distention at 45 degrees. Which underlying
pathophysiological mechanism best explains these clinical assessment findings?
A. Primary left ventricular systolic dysfunction leading to systemic fluid depletion.
B. Right-sided heart failure resulting in systemic venous congestion and increased
hydrostatic pressure.
C. Acute hypovolemic shock secondary to massive capillary fluid leakage.
D. Chronic obstructive pulmonary disease causing isolated systemic vasoconstriction.
, CORRECT ANSWER : B
Rationale: Right-sided heart failure impairs the heart's ability to pump blood effectively into the
pulmonary circulation, causing blood to back up into the systemic venous system. This systemic
congestion manifests as elevated jugular venous pressure, hepatomegaly, and peripheral pitting
edema. Left ventricular failure primarily causes pulmonary congestion rather than systemic
venous pooling.
2. A nurse is conducting a comprehensive neurological assessment on a client admitted following a
traumatic brain injury. The client opens their eyes to verbal stimuli, makes incomprehensible
sounds, and localizes to pain. What is the client's Glasgow Coma Scale (GCS) score?
A. 10
B. 11
C. 13
D. 15
CORRECT ANSWER : B
Rationale: The Glasgow Coma Scale evaluates eye opening, verbal response, and motor
response. Opening eyes to verbal stimuli scores 3, making incomprehensible sounds scores 2,
and localizing to pain scores 5, resulting in a total score of 11. Accurate calculation is critical
for monitoring neurological trajectory and detecting acute intracranial changes.
3. During an abdominal assessment, a nurse performs deep palpation and notes a pulsating mass in
the periumbilical area accompanied by a bruit auscultated over the aorta. What is the nurse's
immediate priority action?
A. Percuss the lower quadrants to determine the exact liver span.
B. Stop palpating immediately and notify the primary healthcare provider to prevent
potential rupture.
C. Massage the area gently to encourage normal peristalsis and venous return.
D. Administer a prescribed oral laxative to relieve suspected gas distention.
CORRECT ANSWER : B
Rationale: A pulsating periumbilical mass accompanied by a bruit strongly indicates an
abdominal aortic aneurysm (AAA). Deep palpation is strictly contraindicated because manual
pressure can precipitate catastrophic rupture and fatal hemorrhage; immediate provider
notification is mandatory.
,4. A nurse is assessing an older adult client for suspected delirium versus dementia. Which
assessment finding specifically supports a diagnosis of delirium rather than dementia?
A. Insidious, slow onset of memory loss over several years.
B. Acute, fluctuating onset of altered consciousness, disorientation, and impaired attention
span.
C. Normal level of alertness with stable, progressive cognitive decline.
D. Intact immediate recall accompanied by chronic depressive symptoms.
CORRECT ANSWER : B
Rationale: Delirium is characterized by an acute, sudden onset and fluctuating course of
disorientation, inattention, and altered level of consciousness, frequently triggered by an
underlying medical condition or medication. Conversely, dementia presents with a slow,
insidious, and progressive cognitive decline.
5. A nurse is performing a respiratory assessment on a client experiencing an acute asthma
exacerbation. Which auscultatory finding should the nurse expect to hear?
A. Clear, resonant vesicular breath sounds throughout all lung fields.
B. High-pitched, musical expiratory wheezes caused by air rushing through narrowed
airways.
C. Coarse, bubbling crackles heard primarily during early inspiration.
D. Deep, grating pleural friction rubs localized to the lower lung bases.
CORRECT ANSWER : B
Rationale: Asthma involves bronchospasm, mucosal edema, and mucus hypersecretion, which
narrow the bronchial airways. As air flows through these constricted passages under pressure, it
produces high-pitched, musical expiratory wheezes.
6. A nurse is evaluating the nutritional status of a newly admitted client. Which diagnostic
laboratory value provides the most reliable indicator of chronic protein depletion over an
extended period?
A. Serum creatinine clearance
B. Serum albumin with a half-life of approximately 20 days
C. Serum prealbumin with a half-life of 2 days
, D. Complete blood count hemoglobin level
CORRECT ANSWER : B
Rationale: Serum albumin has a relatively long half-life of approximately 20 days, making it a
reliable clinical indicator of chronic nutritional status and long-term protein depletion.
Prealbumin has a much shorter half-life (2 days) and reflects acute, short-term nutritional
changes.
7. A nurse is assessing a client with suspected deep vein thrombosis (DVT) in the left calf. Which
clinical manifestation supports this assessment?
A. Cool, pale skin with absent distal pulses in the affected foot.
B. Unilateral calf swelling, localized tenderness, warmth, and erythema.
C. Bilateral symmetrical edema occurring strictly at the end of the day.
D. Sharp, shooting nerve pain radiating down the lateral aspect of the leg.
CORRECT ANSWER : B
Rationale: Deep vein thrombosis typically presents with unilateral localized findings caused by
venous outflow obstruction, including calf swelling, localized tenderness, warmth, and redness.
Arterial insufficiency presents with cool, pale skin and absent pulses, while bilateral edema
suggests systemic etiology.
8. A nurse is conducting a skin assessment on an immobile client and notes a non-blanching area of
erythema over the sacrum. The epidermis remains intact. How should the nurse stage this
pressure injury?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Stage 3 pressure injury
D. Unstageable pressure injury
CORRECT ANSWER : A
Rationale: A Stage 1 pressure injury is characterized by intact skin with non-blanching erythema
over a localized area, typically over a bony prominence. Stage 2 involves partial-thickness skin
loss with exposed dermis, while Stage 3 involves full-thickness tissue loss.
