NUR 101/NUR101 Final Exam V1 | Health
Assessment Q&A with Rationale | Fortis
College
1. When performing a physical assessment, in which order should the nurse perform the four
basic techniques (except for abdominal assessment)?
A. Auscultation, Percussion, Palpation, Inspection
B. Inspection, Palpation, Percussion, Auscultation
C. Palpation, Inspection, Auscultation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: B
Expert Explanation: The standard sequence for physical assessment is inspection,
palpation, percussion, and then auscultation. This systematic approach ensures that the
nurse observes the patient before physically touching them, which helps in maintaining
rapport and gathering initial visual data. Following this order helps prevent any physical
manipulation from altering the findings of subsequent steps.
2. When assessing the abdomen, why does the nurse perform auscultation before palpation
and percussion?
A. To prevent distortion of bowel sounds that might occur after manipulation
B. To allow the patient to relax before deep pressure is applied
,C. To determine the size of the liver before listening to sounds
D. To ensure the patient is comfortable with the touch of the stethoscope
Correct Answer: A
Expert Explanation: Auscultation is performed before palpation and percussion during an
abdominal exam to avoid stimulating peristalsis. Palpating or percussing the abdomen can
create false bowel sounds or change the frequency of existing sounds. Following this
specific order provides the most accurate clinical picture of the patient’s gastrointestinal
activity.
3. Which part of the hand is most sensitive to temperature during a physical assessment?
A. Ulnar surface
B. Palmar surface
C. Dorsal surface
D. Finger pads
Correct Answer: C
Expert Explanation: The dorsal surface (back) of the hand is the most sensitive area for
assessing a patient’s skin temperature. This is because the skin on the back of the hand is
thinner than the skin on the palms. Using this area allows the nurse to detect subtle
variations in heat across different body parts.
, 4. A nurse is collecting subjective data during a health history interview. Which of the
following is an example of subjective data?
A. The patient’s blood pressure is 140/90 mmHg
B. The patient’s skin is warm and dry to the touch
C. The patient reports feeling nauseated and dizzy
D. The patient has a visible rash on their left forearm
Correct Answer: C
Expert Explanation: Subjective data consists of information that the patient expresses and
cannot be directly measured or seen by the examiner. Nausea and dizziness are sensations
felt only by the patient, making them classic examples of subjective findings. Objective data,
on the other hand, includes measurable signs like blood pressure or physical observations
like a rash.
5. When assessing a patient’s level of consciousness using the Glasgow Coma Scale (GCS),
which three areas are evaluated?
A. Orientation, memory, and cognitive function
B. Pupillary reaction, blood pressure, and heart rate
C. Reflexes, gait, and coordination
D. Eye opening, motor response, and verbal response
Correct Answer: D
Assessment Q&A with Rationale | Fortis
College
1. When performing a physical assessment, in which order should the nurse perform the four
basic techniques (except for abdominal assessment)?
A. Auscultation, Percussion, Palpation, Inspection
B. Inspection, Palpation, Percussion, Auscultation
C. Palpation, Inspection, Auscultation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: B
Expert Explanation: The standard sequence for physical assessment is inspection,
palpation, percussion, and then auscultation. This systematic approach ensures that the
nurse observes the patient before physically touching them, which helps in maintaining
rapport and gathering initial visual data. Following this order helps prevent any physical
manipulation from altering the findings of subsequent steps.
2. When assessing the abdomen, why does the nurse perform auscultation before palpation
and percussion?
A. To prevent distortion of bowel sounds that might occur after manipulation
B. To allow the patient to relax before deep pressure is applied
,C. To determine the size of the liver before listening to sounds
D. To ensure the patient is comfortable with the touch of the stethoscope
Correct Answer: A
Expert Explanation: Auscultation is performed before palpation and percussion during an
abdominal exam to avoid stimulating peristalsis. Palpating or percussing the abdomen can
create false bowel sounds or change the frequency of existing sounds. Following this
specific order provides the most accurate clinical picture of the patient’s gastrointestinal
activity.
3. Which part of the hand is most sensitive to temperature during a physical assessment?
A. Ulnar surface
B. Palmar surface
C. Dorsal surface
D. Finger pads
Correct Answer: C
Expert Explanation: The dorsal surface (back) of the hand is the most sensitive area for
assessing a patient’s skin temperature. This is because the skin on the back of the hand is
thinner than the skin on the palms. Using this area allows the nurse to detect subtle
variations in heat across different body parts.
, 4. A nurse is collecting subjective data during a health history interview. Which of the
following is an example of subjective data?
A. The patient’s blood pressure is 140/90 mmHg
B. The patient’s skin is warm and dry to the touch
C. The patient reports feeling nauseated and dizzy
D. The patient has a visible rash on their left forearm
Correct Answer: C
Expert Explanation: Subjective data consists of information that the patient expresses and
cannot be directly measured or seen by the examiner. Nausea and dizziness are sensations
felt only by the patient, making them classic examples of subjective findings. Objective data,
on the other hand, includes measurable signs like blood pressure or physical observations
like a rash.
5. When assessing a patient’s level of consciousness using the Glasgow Coma Scale (GCS),
which three areas are evaluated?
A. Orientation, memory, and cognitive function
B. Pupillary reaction, blood pressure, and heart rate
C. Reflexes, gait, and coordination
D. Eye opening, motor response, and verbal response
Correct Answer: D
