NUR 101/NUR101 Exam 1 V1 | Health
Assessment Q&A with Rationale | Fortis
College
1. During the initial interview, a patient tells the nurse, ‘I have been having a lot of pain in my
lower back.’ Which of the following is the best response by the nurse?
A. How long has this been going on?
B. Is the pain sharp or dull?
C. Tell me more about your back pain.
D. Have you taken any medication for it?
Correct Answer: C
Expert Explanation: Using an open-ended question or statement encourages the patient to
provide more detail in their own words. This approach prevents the nurse from leading the
patient’s response and allows for a broader range of information gathering. It establishes a
therapeutic rapport and ensures that the patient’s concerns are fully explored before
narrowing down to specifics.
2. Which technique of physical assessment should the nurse perform first when assessing the
thorax and lungs?
A. Inspection
B. Auscultation
,C. Palpation
D. Percussion
Correct Answer: A
Expert Explanation: Inspection is always the first step in a physical examination because
it provides a visual overview of the patient’s condition. The nurse observes for symmetry,
color, and obvious abnormalities before touching the patient. This baseline observation
guides the subsequent steps of the assessment process to ensure accuracy and safety.
3. When assessing the abdomen, what is the correct sequence of assessment techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: A
Expert Explanation: The sequence for an abdominal assessment is modified to include
auscultation before palpation and percussion. Palpating or percussing the abdomen can
stimulate bowel activity and change the bowel sounds heard during auscultation. By
auscultating early, the nurse obtains the most accurate representation of the patient’s
gastrointestinal function.
, 4. A nurse is checking a patient’s radial pulse and finds it to be irregular. What should the
nurse’s next action be?
A. Measure the apical pulse for 60 seconds.
B. Check the pulse in the other arm for comparison.
C. Count the radial pulse for a full minute.
D. Wait 15 minutes and recheck the radial pulse.
Correct Answer: A
Expert Explanation: The apical pulse is the most accurate pulse measurement because it
reflects the actual heart contractions. If a peripheral pulse is irregular, the nurse must
auscultate the heart at the apex for a full minute to determine the true heart rate and
rhythm. This ensures that any deficits or significant arrhythmias are identified and
documented correctly.
5. What type of data is the following statement: ‘My head has been throbbing since I woke up
this morning’?
A. Objective data
B. Secondary data
C. Subjective data
D. Analytical data
Correct Answer: C
Assessment Q&A with Rationale | Fortis
College
1. During the initial interview, a patient tells the nurse, ‘I have been having a lot of pain in my
lower back.’ Which of the following is the best response by the nurse?
A. How long has this been going on?
B. Is the pain sharp or dull?
C. Tell me more about your back pain.
D. Have you taken any medication for it?
Correct Answer: C
Expert Explanation: Using an open-ended question or statement encourages the patient to
provide more detail in their own words. This approach prevents the nurse from leading the
patient’s response and allows for a broader range of information gathering. It establishes a
therapeutic rapport and ensures that the patient’s concerns are fully explored before
narrowing down to specifics.
2. Which technique of physical assessment should the nurse perform first when assessing the
thorax and lungs?
A. Inspection
B. Auscultation
,C. Palpation
D. Percussion
Correct Answer: A
Expert Explanation: Inspection is always the first step in a physical examination because
it provides a visual overview of the patient’s condition. The nurse observes for symmetry,
color, and obvious abnormalities before touching the patient. This baseline observation
guides the subsequent steps of the assessment process to ensure accuracy and safety.
3. When assessing the abdomen, what is the correct sequence of assessment techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: A
Expert Explanation: The sequence for an abdominal assessment is modified to include
auscultation before palpation and percussion. Palpating or percussing the abdomen can
stimulate bowel activity and change the bowel sounds heard during auscultation. By
auscultating early, the nurse obtains the most accurate representation of the patient’s
gastrointestinal function.
, 4. A nurse is checking a patient’s radial pulse and finds it to be irregular. What should the
nurse’s next action be?
A. Measure the apical pulse for 60 seconds.
B. Check the pulse in the other arm for comparison.
C. Count the radial pulse for a full minute.
D. Wait 15 minutes and recheck the radial pulse.
Correct Answer: A
Expert Explanation: The apical pulse is the most accurate pulse measurement because it
reflects the actual heart contractions. If a peripheral pulse is irregular, the nurse must
auscultate the heart at the apex for a full minute to determine the true heart rate and
rhythm. This ensures that any deficits or significant arrhythmias are identified and
documented correctly.
5. What type of data is the following statement: ‘My head has been throbbing since I woke up
this morning’?
A. Objective data
B. Secondary data
C. Subjective data
D. Analytical data
Correct Answer: C
