NUR 101/NUR101 Exam 2 V2 | Health
Assessment Q&A with Rationale | Fortis
College
1. When assessing a patient’s skin turgor, which area should the nurse use for the most
accurate results in an elderly patient?
A. Under the clavicle
B. The forearm
C. The back of the hand
D. The abdomen
Correct Answer: A
Expert Explanation: Skin turgor assessment helps determine a patient’s hydration status.
In elderly patients, the back of the hand is unreliable due to the loss of subcutaneous fat
and elasticity associated with aging. The sternum or the area under the clavicle provides a
more accurate reflection of systemic hydration.
2. A nurse is evaluating a lesion and notes it is less than 1 cm, flat, and non-palpable. How
should this be documented?
A. Papule
B. Pustule
C. Plaque
,D. Macule
Correct Answer: D
Expert Explanation: A macule is a flat, circumscribed area of color change that is less than
1 cm in diameter, such as a freckle. A papule is elevated, while a plaque is a larger elevated
surface area. Understanding primary skin lesions is essential for accurate clinical
documentation in nursing.
3. During a head and neck assessment, where should the nurse palpate for the preauricular
lymph nodes?
A. Behind the ear
B. At the base of the skull
C. Under the jawline
D. In front of the ear
Correct Answer: D
Expert Explanation: The preauricular lymph nodes are located immediately in front of the
tragus of the ear. Assessing lymph nodes requires gentle circular motion with the finger
pads. Normal lymph nodes should be small, mobile, soft, and non-tender upon palpation.
4. Which technique is correct when using an otoscope to examine an adult patient’s ear
canal?
A. Pull the pinna down and back
, B. Insert the speculum as far as possible
C. Pull the pinna straight out
D. Pull the pinna up and back
Correct Answer: D
Expert Explanation: To straighten the ear canal in an adult, the nurse must pull the pinna
up and back. For children under the age of three, the pinna is pulled down and back. This
maneuver allows for a clear visualization of the tympanic membrane during the
assessment.
5. A patient presents with a ‘swimmer’s ear’ infection. Which physical finding should the
nurse expect?
A. Tenderness when moving the pinna
B. A pearly gray tympanic membrane
C. Fluid behind the eardrum
D. Hearing loss in the inner ear
Correct Answer: A
Expert Explanation: Swimmer’s ear, or otitis externa, involves inflammation of the outer
ear canal. Pain or tenderness when manipulating the pinna or tragus is a hallmark
diagnostic sign of this condition. A pearly gray eardrum is a normal finding and does not
indicate infection.
Assessment Q&A with Rationale | Fortis
College
1. When assessing a patient’s skin turgor, which area should the nurse use for the most
accurate results in an elderly patient?
A. Under the clavicle
B. The forearm
C. The back of the hand
D. The abdomen
Correct Answer: A
Expert Explanation: Skin turgor assessment helps determine a patient’s hydration status.
In elderly patients, the back of the hand is unreliable due to the loss of subcutaneous fat
and elasticity associated with aging. The sternum or the area under the clavicle provides a
more accurate reflection of systemic hydration.
2. A nurse is evaluating a lesion and notes it is less than 1 cm, flat, and non-palpable. How
should this be documented?
A. Papule
B. Pustule
C. Plaque
,D. Macule
Correct Answer: D
Expert Explanation: A macule is a flat, circumscribed area of color change that is less than
1 cm in diameter, such as a freckle. A papule is elevated, while a plaque is a larger elevated
surface area. Understanding primary skin lesions is essential for accurate clinical
documentation in nursing.
3. During a head and neck assessment, where should the nurse palpate for the preauricular
lymph nodes?
A. Behind the ear
B. At the base of the skull
C. Under the jawline
D. In front of the ear
Correct Answer: D
Expert Explanation: The preauricular lymph nodes are located immediately in front of the
tragus of the ear. Assessing lymph nodes requires gentle circular motion with the finger
pads. Normal lymph nodes should be small, mobile, soft, and non-tender upon palpation.
4. Which technique is correct when using an otoscope to examine an adult patient’s ear
canal?
A. Pull the pinna down and back
, B. Insert the speculum as far as possible
C. Pull the pinna straight out
D. Pull the pinna up and back
Correct Answer: D
Expert Explanation: To straighten the ear canal in an adult, the nurse must pull the pinna
up and back. For children under the age of three, the pinna is pulled down and back. This
maneuver allows for a clear visualization of the tympanic membrane during the
assessment.
5. A patient presents with a ‘swimmer’s ear’ infection. Which physical finding should the
nurse expect?
A. Tenderness when moving the pinna
B. A pearly gray tympanic membrane
C. Fluid behind the eardrum
D. Hearing loss in the inner ear
Correct Answer: A
Expert Explanation: Swimmer’s ear, or otitis externa, involves inflammation of the outer
ear canal. Pain or tenderness when manipulating the pinna or tragus is a hallmark
diagnostic sign of this condition. A pearly gray eardrum is a normal finding and does not
indicate infection.
