NUR 101/NUR101 Exam 3 V3 | Health
Assessment Q&A with Rationale | Fortis
College
1. When performing an abdominal assessment on a client, which sequence should the nurse
follow to ensure accurate findings?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Percussion, Palpation, Auscultation, Inspection
Correct Answer: C
Expert Explanation: In abdominal assessment, the nurse must auscultate before
percussing or palpating the abdomen. This is because physical manipulation of the
abdomen can stimulate peristalsis and result in false-positive bowel sounds. Following this
specific sequence ensures that the objective data collected regarding bowel activity is
representative of the client’s actual physiological state.
2. A nurse is assessing a client for possible cholecystitis. Which specialized physical
examination technique should the nurse use?
A. Murphy’s Sign
B. Blumberg’s Sign
,C. McBurney’s Point tenderness
D. Iliopsoas Muscle Test
Correct Answer: A
Expert Explanation: Murphy’s sign is specifically used to assess for inflammation of the
gallbladder, or cholecystitis. The nurse asks the client to take a deep breath while applying
pressure under the right costal margin; if the client experiences sharp pain and stops
inhaling, the test is positive. This technique focuses on the liver and gallbladder area rather
than the appendix, which is evaluated using the other listed signs.
3. During a musculoskeletal exam, the nurse asks the client to move their arm away from the
midline of the body. How should the nurse document this movement?
A. Adduction
B. Flexion
C. Extension
D. Abduction
Correct Answer: D
Expert Explanation: Abduction is defined as moving a limb away from the midline of the
body. Conversely, adduction involves moving the limb toward the midline, which is an
important distinction during Range of Motion (ROM) testing. Clear documentation of these
movements is essential for tracking a client’s joint mobility and functional status over time.
, 4. The nurse is evaluating a client’s deep tendon reflexes (DTRs) and notes a normal, expected
response. Which numerical grade should be assigned?
A. 1+
B. 3+
C. 2+
D. 4+
Correct Answer: C
Expert Explanation: Reflexes are graded on a scale from 0 to 4, with 2+ representing a
normal, active response. A grade of 1+ indicates a diminished or sluggish response, while
3+ is brisker than average and 4+ is hyperactive with clonus. Accurate grading allows the
healthcare team to monitor for signs of neurological improvement or deterioration.
5. Which cranial nerve is being tested when the nurse asks the client to smile, frown, and puff
out their cheeks?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve VII (Facial)
C. Cranial Nerve X (Vagus)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: B
Assessment Q&A with Rationale | Fortis
College
1. When performing an abdominal assessment on a client, which sequence should the nurse
follow to ensure accurate findings?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Percussion, Palpation, Auscultation, Inspection
Correct Answer: C
Expert Explanation: In abdominal assessment, the nurse must auscultate before
percussing or palpating the abdomen. This is because physical manipulation of the
abdomen can stimulate peristalsis and result in false-positive bowel sounds. Following this
specific sequence ensures that the objective data collected regarding bowel activity is
representative of the client’s actual physiological state.
2. A nurse is assessing a client for possible cholecystitis. Which specialized physical
examination technique should the nurse use?
A. Murphy’s Sign
B. Blumberg’s Sign
,C. McBurney’s Point tenderness
D. Iliopsoas Muscle Test
Correct Answer: A
Expert Explanation: Murphy’s sign is specifically used to assess for inflammation of the
gallbladder, or cholecystitis. The nurse asks the client to take a deep breath while applying
pressure under the right costal margin; if the client experiences sharp pain and stops
inhaling, the test is positive. This technique focuses on the liver and gallbladder area rather
than the appendix, which is evaluated using the other listed signs.
3. During a musculoskeletal exam, the nurse asks the client to move their arm away from the
midline of the body. How should the nurse document this movement?
A. Adduction
B. Flexion
C. Extension
D. Abduction
Correct Answer: D
Expert Explanation: Abduction is defined as moving a limb away from the midline of the
body. Conversely, adduction involves moving the limb toward the midline, which is an
important distinction during Range of Motion (ROM) testing. Clear documentation of these
movements is essential for tracking a client’s joint mobility and functional status over time.
, 4. The nurse is evaluating a client’s deep tendon reflexes (DTRs) and notes a normal, expected
response. Which numerical grade should be assigned?
A. 1+
B. 3+
C. 2+
D. 4+
Correct Answer: C
Expert Explanation: Reflexes are graded on a scale from 0 to 4, with 2+ representing a
normal, active response. A grade of 1+ indicates a diminished or sluggish response, while
3+ is brisker than average and 4+ is hyperactive with clonus. Accurate grading allows the
healthcare team to monitor for signs of neurological improvement or deterioration.
5. Which cranial nerve is being tested when the nurse asks the client to smile, frown, and puff
out their cheeks?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve VII (Facial)
C. Cranial Nerve X (Vagus)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: B
