NUR 101/NUR101 Exam 3 V2 | Health
Assessment Q&A with Rationale | Fortis
College
1. When assessing skin turgor in an elderly patient, which anatomical site should the nurse
use to obtain the most accurate result?
A. The sternum or subclavicular area
B. The forearm
C. The back of the hand
D. The abdomen
Correct Answer: A
Expert Explanation: Skin turgor is a clinical indicator used to assess a patient’s hydration
status. In elderly populations, the skin on the extremities often loses elasticity due to aging,
making it an unreliable site for testing. Using the sternum or subclavicular area provides a
more accurate reflection of interstitial fluid volume and skin recoil.
2. The nurse asks a patient to stick out their tongue and observes it for symmetry and
tremors. Which cranial nerve is being evaluated?
A. Cranial Nerve XII (Hypoglossal)
B. Cranial Nerve X (Vagus)
C. Cranial Nerve XI (Spinal Accessory)
,D. Cranial Nerve IX (Glossopharyngeal)
Correct Answer: A
Expert Explanation: Cranial Nerve XII, the hypoglossal nerve, is responsible for the motor
function of the tongue. Assessment involves checking for midline protrusion, strength, and
any signs of atrophy or fasciculation. If the tongue deviates to one side, it may indicate a
lesion or damage to this specific nerve.
3. In the ABCDE mnemonic for assessing skin lesions for potential melanoma, what does the
‘E’ represent?
A. Evolving
B. Elevation
C. Erythema
D. Exudate
Correct Answer: A
Expert Explanation: The ABCDE mnemonic is a critical tool for identifying early signs of
malignant melanoma. The ‘E’ stands for Evolving, which refers to any change in the size,
shape, color, or symptoms of a mole over time. Ongoing assessment of skin lesions is vital
for early detection and improving patient outcomes in dermatology.
4. A patient’s Glasgow Coma Scale (GCS) score is recorded as 7. How should the nurse
interpret this finding?
A. The patient is fully alert and oriented
, B. The patient is in a mild state of confusion
C. The patient has perfect motor and verbal responses
D. The patient is in a comatose state
Correct Answer: D
Expert Explanation: The Glasgow Coma Scale measures eye-opening, verbal, and motor
responses with a maximum score of 15. A total score of 8 or less is generally accepted as
the clinical definition of a comatose state or severe brain injury. Nurses must monitor these
scores closely to detect neurological deterioration in acute care settings.
5. Which spinal curvature is characterized by an exaggerated inward curve of the lumbar
spine, often seen during pregnancy?
A. Kyphosis
B. Lordosis
C. Scoliosis
D. Ankylosis
Correct Answer: B
Expert Explanation: Lordosis is an abnormal increase in the forward curvature of the
lumbar spine, which can be caused by shifting weight centers during pregnancy or obesity.
It contrasts with kyphosis, which is an exaggerated thoracic curve often called ‘hunchback.’
Assessment Q&A with Rationale | Fortis
College
1. When assessing skin turgor in an elderly patient, which anatomical site should the nurse
use to obtain the most accurate result?
A. The sternum or subclavicular area
B. The forearm
C. The back of the hand
D. The abdomen
Correct Answer: A
Expert Explanation: Skin turgor is a clinical indicator used to assess a patient’s hydration
status. In elderly populations, the skin on the extremities often loses elasticity due to aging,
making it an unreliable site for testing. Using the sternum or subclavicular area provides a
more accurate reflection of interstitial fluid volume and skin recoil.
2. The nurse asks a patient to stick out their tongue and observes it for symmetry and
tremors. Which cranial nerve is being evaluated?
A. Cranial Nerve XII (Hypoglossal)
B. Cranial Nerve X (Vagus)
C. Cranial Nerve XI (Spinal Accessory)
,D. Cranial Nerve IX (Glossopharyngeal)
Correct Answer: A
Expert Explanation: Cranial Nerve XII, the hypoglossal nerve, is responsible for the motor
function of the tongue. Assessment involves checking for midline protrusion, strength, and
any signs of atrophy or fasciculation. If the tongue deviates to one side, it may indicate a
lesion or damage to this specific nerve.
3. In the ABCDE mnemonic for assessing skin lesions for potential melanoma, what does the
‘E’ represent?
A. Evolving
B. Elevation
C. Erythema
D. Exudate
Correct Answer: A
Expert Explanation: The ABCDE mnemonic is a critical tool for identifying early signs of
malignant melanoma. The ‘E’ stands for Evolving, which refers to any change in the size,
shape, color, or symptoms of a mole over time. Ongoing assessment of skin lesions is vital
for early detection and improving patient outcomes in dermatology.
4. A patient’s Glasgow Coma Scale (GCS) score is recorded as 7. How should the nurse
interpret this finding?
A. The patient is fully alert and oriented
, B. The patient is in a mild state of confusion
C. The patient has perfect motor and verbal responses
D. The patient is in a comatose state
Correct Answer: D
Expert Explanation: The Glasgow Coma Scale measures eye-opening, verbal, and motor
responses with a maximum score of 15. A total score of 8 or less is generally accepted as
the clinical definition of a comatose state or severe brain injury. Nurses must monitor these
scores closely to detect neurological deterioration in acute care settings.
5. Which spinal curvature is characterized by an exaggerated inward curve of the lumbar
spine, often seen during pregnancy?
A. Kyphosis
B. Lordosis
C. Scoliosis
D. Ankylosis
Correct Answer: B
Expert Explanation: Lordosis is an abnormal increase in the forward curvature of the
lumbar spine, which can be caused by shifting weight centers during pregnancy or obesity.
It contrasts with kyphosis, which is an exaggerated thoracic curve often called ‘hunchback.’
