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NUR 213 HEALTH ASSESSMENT FINAL INTEGRATION EXAM
4 2026 | Physical Examination Actual Exam | Latest Update
2026/2027 | Verified Answers | Pass Guaranteed - A+
Graded
Section 1: Complete Head-to-Toe Assessment Integration (Q1-15)
Q1. A nurse is preparing to perform a complete head-to-toe physical examination on
a newly admitted patient. According to best practice, which sequence represents the
most efficient and systematic approach?
A. Begin with the thorax and lungs, then proceed to the abdomen, and finish with the
general survey and vital signs.
B. Perform the general survey and vital signs first, then proceed from the head
downward to the genitourinary/rectal examination [CORRECT]
C. Start with the neurologic examination, then assess the musculoskeletal system,
and finish with the skin.
D. Assess the abdomen first to rule out acute pathology, then proceed to the head
and neck.
Correct Answer: B
Rationale: The systematic head-to-toe examination begins with the general survey
and vital signs to establish baseline, then proceeds cephalocaudally (head → neck →
thorax/lungs → cardiovascular → abdomen → musculoskeletal → neurologic → skin
→ genitourinary/rectal) to ensure completeness and efficiency. Starting with the
abdomen (D) or thorax (A) risks missing baseline data.
Q2. During the general survey of a 62-year-old patient, the nurse notes the patient is
alert, sitting upright comfortably, has appropriate grooming, and makes eye contact.
The skin color is consistent with ethnicity, and breathing appears unlabored at rest.
How should the nurse document these findings?
A. "Patient appears ill and in moderate distress."
B. "Patient is a well-developed, well-nourished adult in no acute distress, alert and
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oriented, with normal affect and spontaneous respirations." [CORRECT]
C. "General survey unremarkable; no further details needed."
D. "Patient looks fine and seems healthy."
Correct Answer: B
Rationale: Documentation must be specific, professional, and objective. "Well-
developed, well-nourished adult in no acute distress" (NAD) is the standard
comprehensive phrase. Option A contradicts the findings. Option C is insufficiently
detailed. Option D uses vague, non-clinical language.
Q3. A nurse is integrating vital signs into the head-to-toe assessment. The patient
has a blood pressure of 142/88 mmHg, heart rate of 96 bpm, respiratory rate of 18,
temperature 37.1°C oral, and SpO2 95% on room air. Which finding requires follow-
up during the remainder of the examination?
A. Respiratory rate of 18, which is within normal limits.
B. Temperature of 37.1°C, which is a low-grade fever.
C. Blood pressure of 142/88 mmHg, indicating Stage 1 hypertension, and SpO2 95%,
which is borderline low [CORRECT]
D. Heart rate of 96 bpm, which indicates severe tachycardia.
Correct Answer: C
Rationale: Stage 1 hypertension (≥130/80 or ≥140/90 depending on classification
system) requires verification and cardiovascular risk assessment. SpO2 95% is
acceptable but warrants attention if the patient has respiratory symptoms. HR 96 is
normal. Temp 37.1°C is normal.
Q4. When assessing the head and neck, the nurse palpates the thyroid gland while
the patient swallows. Which technique is correct?
A. Palpate from behind the patient with fingers placed on either side of the trachea,
feeling for the thyroid isthmus and lobes as the patient swallows [CORRECT]
B. Press firmly with one finger directly over the larynx to immobilize the gland during
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swallowing.
C. Palpate only the anterior neck while the patient holds their breath.
D. Use the ulnar surface of the hand to percuss the thyroid for size.
Correct Answer: A
Rationale: The posterior approach allows the nurse to use both hands to palpate the
thyroid lobes and isthmus while the patient swallows, as the thyroid moves with the
trachea. Direct pressure on the larynx (B) is uncomfortable and incorrect. Breath-
holding (C) prevents thyroid movement. Percussion (D) is not used for thyroid
assessment.
Q5. During thorax and lung assessment, the nurse auscultates posteriorly at the level
of T10. Which lobe is being assessed?
A. Upper lobe of the left lung
B. Middle lobe of the right lung
C. Lower lobes of both lungs [CORRECT]
D. Lingula of the left lung
Correct Answer: C
Rationale: Posterior auscultation at the scapular line (T7-T10) assesses the lower
lobes. The upper lobes are heard apically and anteriorly above the scapulae. The
right middle lobe and lingula are assessed anteriorly and laterally, not posteriorly at
T10.
Q6. A nurse is performing the cardiovascular portion of the head-to-toe examination.
Which sequence follows best practice for the cardiac physical exam?
A. Auscultation first, then inspection, palpation, and percussion
B. Inspection, palpation, percussion, then auscultation [CORRECT]
C. Percussion first, then auscultation, inspection, and palpation
D. Palpation only; inspection and auscultation are unnecessary if pulses are palpable.
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Correct Answer: B
Rationale: The standard cardiac exam sequence is IPPA: Inspection (precordium,
apical impulse), Palpation (apical impulse, thrills, heaves), Percussion (cardiac
borders), then Auscultation (heart sounds). Auscultation before palpation (A) may
miss tactile findings. Palpation alone (D) is incomplete.
Q7. During abdominal assessment, the nurse should auscultate before palpation and
percussion. What is the rationale for this sequence?
A. Palpation and percussion can alter bowel sounds and vascular sounds, leading to
inaccurate auscultatory findings [CORRECT]
B. Auscultation is less uncomfortable for the patient and should be done first to build
rapport.
C. The stethoscope must be placed on cold skin to detect friction rubs, which
requires early contact.
D. Palpation before auscultation is only contraindicated if the patient has a known
abdominal aortic aneurysm.
Correct Answer: A
Rationale: Palpation and percussion stimulate peristalsis and can mask or alter
bowel sounds and bruits. Auscultation must precede these maneuvers to obtain
accurate baseline findings. Rapport (B) is secondary. Cold skin (C) is irrelevant. AAA
(D) is not the primary rationale.
Q8. When integrating the musculoskeletal examination into the head-to-toe
assessment, the nurse should assess which structures in a systematic manner?
A. Inspect and palpate joints for swelling, then assess range of motion, muscle
strength, and functional mobility [CORRECT]
B. Assess range of motion first, then ask the patient to walk, and skip inspection if the
patient has no complaints.
C. Palpate only the joints that are painful and document the rest as "non-tender."
D. Test muscle strength only on the dominant side to save time.
NUR 213 HEALTH ASSESSMENT FINAL INTEGRATION EXAM
4 2026 | Physical Examination Actual Exam | Latest Update
2026/2027 | Verified Answers | Pass Guaranteed - A+
Graded
Section 1: Complete Head-to-Toe Assessment Integration (Q1-15)
Q1. A nurse is preparing to perform a complete head-to-toe physical examination on
a newly admitted patient. According to best practice, which sequence represents the
most efficient and systematic approach?
A. Begin with the thorax and lungs, then proceed to the abdomen, and finish with the
general survey and vital signs.
B. Perform the general survey and vital signs first, then proceed from the head
downward to the genitourinary/rectal examination [CORRECT]
C. Start with the neurologic examination, then assess the musculoskeletal system,
and finish with the skin.
D. Assess the abdomen first to rule out acute pathology, then proceed to the head
and neck.
Correct Answer: B
Rationale: The systematic head-to-toe examination begins with the general survey
and vital signs to establish baseline, then proceeds cephalocaudally (head → neck →
thorax/lungs → cardiovascular → abdomen → musculoskeletal → neurologic → skin
→ genitourinary/rectal) to ensure completeness and efficiency. Starting with the
abdomen (D) or thorax (A) risks missing baseline data.
Q2. During the general survey of a 62-year-old patient, the nurse notes the patient is
alert, sitting upright comfortably, has appropriate grooming, and makes eye contact.
The skin color is consistent with ethnicity, and breathing appears unlabored at rest.
How should the nurse document these findings?
A. "Patient appears ill and in moderate distress."
B. "Patient is a well-developed, well-nourished adult in no acute distress, alert and
,2
oriented, with normal affect and spontaneous respirations." [CORRECT]
C. "General survey unremarkable; no further details needed."
D. "Patient looks fine and seems healthy."
Correct Answer: B
Rationale: Documentation must be specific, professional, and objective. "Well-
developed, well-nourished adult in no acute distress" (NAD) is the standard
comprehensive phrase. Option A contradicts the findings. Option C is insufficiently
detailed. Option D uses vague, non-clinical language.
Q3. A nurse is integrating vital signs into the head-to-toe assessment. The patient
has a blood pressure of 142/88 mmHg, heart rate of 96 bpm, respiratory rate of 18,
temperature 37.1°C oral, and SpO2 95% on room air. Which finding requires follow-
up during the remainder of the examination?
A. Respiratory rate of 18, which is within normal limits.
B. Temperature of 37.1°C, which is a low-grade fever.
C. Blood pressure of 142/88 mmHg, indicating Stage 1 hypertension, and SpO2 95%,
which is borderline low [CORRECT]
D. Heart rate of 96 bpm, which indicates severe tachycardia.
Correct Answer: C
Rationale: Stage 1 hypertension (≥130/80 or ≥140/90 depending on classification
system) requires verification and cardiovascular risk assessment. SpO2 95% is
acceptable but warrants attention if the patient has respiratory symptoms. HR 96 is
normal. Temp 37.1°C is normal.
Q4. When assessing the head and neck, the nurse palpates the thyroid gland while
the patient swallows. Which technique is correct?
A. Palpate from behind the patient with fingers placed on either side of the trachea,
feeling for the thyroid isthmus and lobes as the patient swallows [CORRECT]
B. Press firmly with one finger directly over the larynx to immobilize the gland during
,3
swallowing.
C. Palpate only the anterior neck while the patient holds their breath.
D. Use the ulnar surface of the hand to percuss the thyroid for size.
Correct Answer: A
Rationale: The posterior approach allows the nurse to use both hands to palpate the
thyroid lobes and isthmus while the patient swallows, as the thyroid moves with the
trachea. Direct pressure on the larynx (B) is uncomfortable and incorrect. Breath-
holding (C) prevents thyroid movement. Percussion (D) is not used for thyroid
assessment.
Q5. During thorax and lung assessment, the nurse auscultates posteriorly at the level
of T10. Which lobe is being assessed?
A. Upper lobe of the left lung
B. Middle lobe of the right lung
C. Lower lobes of both lungs [CORRECT]
D. Lingula of the left lung
Correct Answer: C
Rationale: Posterior auscultation at the scapular line (T7-T10) assesses the lower
lobes. The upper lobes are heard apically and anteriorly above the scapulae. The
right middle lobe and lingula are assessed anteriorly and laterally, not posteriorly at
T10.
Q6. A nurse is performing the cardiovascular portion of the head-to-toe examination.
Which sequence follows best practice for the cardiac physical exam?
A. Auscultation first, then inspection, palpation, and percussion
B. Inspection, palpation, percussion, then auscultation [CORRECT]
C. Percussion first, then auscultation, inspection, and palpation
D. Palpation only; inspection and auscultation are unnecessary if pulses are palpable.
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Correct Answer: B
Rationale: The standard cardiac exam sequence is IPPA: Inspection (precordium,
apical impulse), Palpation (apical impulse, thrills, heaves), Percussion (cardiac
borders), then Auscultation (heart sounds). Auscultation before palpation (A) may
miss tactile findings. Palpation alone (D) is incomplete.
Q7. During abdominal assessment, the nurse should auscultate before palpation and
percussion. What is the rationale for this sequence?
A. Palpation and percussion can alter bowel sounds and vascular sounds, leading to
inaccurate auscultatory findings [CORRECT]
B. Auscultation is less uncomfortable for the patient and should be done first to build
rapport.
C. The stethoscope must be placed on cold skin to detect friction rubs, which
requires early contact.
D. Palpation before auscultation is only contraindicated if the patient has a known
abdominal aortic aneurysm.
Correct Answer: A
Rationale: Palpation and percussion stimulate peristalsis and can mask or alter
bowel sounds and bruits. Auscultation must precede these maneuvers to obtain
accurate baseline findings. Rapport (B) is secondary. Cold skin (C) is irrelevant. AAA
(D) is not the primary rationale.
Q8. When integrating the musculoskeletal examination into the head-to-toe
assessment, the nurse should assess which structures in a systematic manner?
A. Inspect and palpate joints for swelling, then assess range of motion, muscle
strength, and functional mobility [CORRECT]
B. Assess range of motion first, then ask the patient to walk, and skip inspection if the
patient has no complaints.
C. Palpate only the joints that are painful and document the rest as "non-tender."
D. Test muscle strength only on the dominant side to save time.
