NUR 101/NUR101 Final Exam V3 | Health
Assessment Q&A with Rationale | Fortis
College
1. When conducting a patient interview, which technique best facilitates the collection of
subjective data?
A. Using open-ended questions to allow the patient to describe symptoms
B. Asking closed-ended questions to save time
C. Interrupting the patient to clarify specific dates
D. Providing the patient with potential diagnoses to choose from
Correct Answer: A
Expert Explanation: Open-ended questions encourage the patient to provide a narrative
description of their health status and concerns. This technique minimizes bias and allows
the nurse to identify the patient’s priorities. It is essential for gathering rich, qualitative
subjective data during the initial assessment phase.
2. During a physical examination, the nurse notes a patient’s blood pressure is 150/94 mmHg.
Which category of data does this represent?
A. Subjective data
B. Secondary data
C. Inferred data
,D. Objective data
Correct Answer: D
Expert Explanation: Objective data consists of measurable and observable signs obtained
through physical examination and diagnostic testing. Blood pressure is a quantifiable value
that can be verified by another healthcare professional. Subjective data, conversely, would
be the patient stating they feel like their heart is racing.
3. Which physical examination technique should the nurse perform first when assessing the
abdomen?
A. Palpation
B. Inspection
C. Auscultation
D. Percussion
Correct Answer: B
Expert Explanation: The standard sequence for most physical exams is inspection,
palpation, percussion, and auscultation. However, for the abdominal exam, inspection is
followed by auscultation to avoid altering bowel sounds. Palpation and percussion can
stimulate peristalsis, leading to inaccurate findings if performed before auscultation.
4. When assessing a patient’s pupillary response, the nurse notes that both pupils constrict
when light is shone into the right eye. What is the term for the constriction of the left pupil?
A. Direct light reflex
, B. Consensual light reflex
C. Accommodation
D. Convergence
Correct Answer: B
Expert Explanation: The consensual light reflex is the simultaneous constriction of the
pupil in the eye that is not being directly stimulated by light. This occurs because the optic
nerve carries the stimulus to the brain, which then sends motor signals back to both eyes. A
lack of this response can indicate neurological impairment or damage to the optic
pathways.
5. A nurse is assessing a patient for pitting edema and notes a 4mm indentation that subsides
within 10 to 15 seconds. How should the nurse document this finding?
A. 1+ Edema
B. 3+ Edema
C. 2+ Edema
D. 4+ Edema
Correct Answer: C
Expert Explanation: Edema is typically graded on a scale of 1+ to 4+ based on the depth
and duration of the indentation. A 2+ grade corresponds to a moderate indentation of
Assessment Q&A with Rationale | Fortis
College
1. When conducting a patient interview, which technique best facilitates the collection of
subjective data?
A. Using open-ended questions to allow the patient to describe symptoms
B. Asking closed-ended questions to save time
C. Interrupting the patient to clarify specific dates
D. Providing the patient with potential diagnoses to choose from
Correct Answer: A
Expert Explanation: Open-ended questions encourage the patient to provide a narrative
description of their health status and concerns. This technique minimizes bias and allows
the nurse to identify the patient’s priorities. It is essential for gathering rich, qualitative
subjective data during the initial assessment phase.
2. During a physical examination, the nurse notes a patient’s blood pressure is 150/94 mmHg.
Which category of data does this represent?
A. Subjective data
B. Secondary data
C. Inferred data
,D. Objective data
Correct Answer: D
Expert Explanation: Objective data consists of measurable and observable signs obtained
through physical examination and diagnostic testing. Blood pressure is a quantifiable value
that can be verified by another healthcare professional. Subjective data, conversely, would
be the patient stating they feel like their heart is racing.
3. Which physical examination technique should the nurse perform first when assessing the
abdomen?
A. Palpation
B. Inspection
C. Auscultation
D. Percussion
Correct Answer: B
Expert Explanation: The standard sequence for most physical exams is inspection,
palpation, percussion, and auscultation. However, for the abdominal exam, inspection is
followed by auscultation to avoid altering bowel sounds. Palpation and percussion can
stimulate peristalsis, leading to inaccurate findings if performed before auscultation.
4. When assessing a patient’s pupillary response, the nurse notes that both pupils constrict
when light is shone into the right eye. What is the term for the constriction of the left pupil?
A. Direct light reflex
, B. Consensual light reflex
C. Accommodation
D. Convergence
Correct Answer: B
Expert Explanation: The consensual light reflex is the simultaneous constriction of the
pupil in the eye that is not being directly stimulated by light. This occurs because the optic
nerve carries the stimulus to the brain, which then sends motor signals back to both eyes. A
lack of this response can indicate neurological impairment or damage to the optic
pathways.
5. A nurse is assessing a patient for pitting edema and notes a 4mm indentation that subsides
within 10 to 15 seconds. How should the nurse document this finding?
A. 1+ Edema
B. 3+ Edema
C. 2+ Edema
D. 4+ Edema
Correct Answer: C
Expert Explanation: Edema is typically graded on a scale of 1+ to 4+ based on the depth
and duration of the indentation. A 2+ grade corresponds to a moderate indentation of
