NUR101/ NUR 101(Latest 2024/ 2025
Update) Health Assessment | Practice
Questions and Verified Answers| 100%
Correct| Grade A – Fortis
Q: The nurse is palpating the temporomandibular joint (TMJ) which is located just below the
temporal artery and anterior to the tragus. Which of the following would be a normal finding?
A) Nontender to palpation
B) Crepitus
C) The jaw locking
D) Painful palpation
Answer:
The correct answer is A: Nontender to palpation.
When palpating the TMJ normal findings are smooth movement with no popping, crepitus, or
tenderness.
Q: Which of the following subjective data would you want to collect for your patient when
performing a Head, Face and Neck Exam? (Select all that apply)
A. they have unusually frequent or severe headaches
B. If they have any dizziness
C. If they have any neck pain
D. If they have any chest pain
E. If they have any history of neck injury or surgery
Answer:
Correct answers are A, B, C, E.
Subjective data that you want to collect includes:
Headache
History of head injury, cosmetic or cranial surgery
Dizziness
Neck pain
Noticed lumps or swelling
History of neck injury or surgery
,Q: A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid
gland for the presence of a bruit. A bruit is a sound that is heard best with the
of the stethoscope.
A) Low gurgling; bell
B) Loud, whooshing, blowing; diaphragm
C) Soft, whooshing, pulsatile; bell
D)High-pitched tinkling; diaphragm
Answer:
Correct answer is C:
a bruit is a soft, whooshing, pulsatile sound that is best assessed with the bell of the stethescope.
Q: The nurse is assessing the patient's trachea. Which of the following would be a normal
finding?
A. The trachea rising to midline when the patient swallows
B. The trachea deviating to the left when the person swallows
C. The trachea deviating to the right when the person swallows
D. The trachea not moving when the person swallows
Answer:
Correct answer is A.
The trachea should rise to the midline when the patient swallows. If it deviates to one side or the
other that can indicate stroke or tumor.
Q: The nurse is performing the Diagnostic Positions test (Six Cardinal Fields of Gaze) to check
the extraocular eye muscles. The nurse knows that a healthy finding would be:
A. Each eye moves in opposite directions from each other
B. There is parallel tracking of the object with both eyes.
C. A rapid eye blink is expected.
D. The light reflex of the eyes is located in the same position in each eye.
,Answer:
Correct Answer: B
A normal response for the diagnostic positions test is parallel tracking of the object with both
eyes. Eye movement that is not parallel indicates weakness of an extraocular muscle or
dysfunction of the cranial nerve innervating it.
Q: When assessing the pupillary light reflex, the nurse should use which technique?
A) Shine a penlight from directly in front of the patient and inspect for pupillary constriction.
B) Ask the patient to follow the penlight in eight directions and observe for bilateral pupil
constriction.
C) Shine a light across the pupil from the side and observe for direct and consensual pupillary
constriction.
D) Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to
about 7 cm from the nose.
Answer:
Correct Answer: C
To test the pupillary light reflex, the nurse should advance a light in from the side and note the
direct and consensual pupillary constriction.
Q: When performing the corneal light reflex assessment, the nurse notes that the light is
reflected at 2 o'clock in each eye. The nurse should:
A) consider this a normal finding.
B) refer the individual for further evaluation.
C) document this as an asymmetric light reflex.
D) perform the confrontation test to validate the findings.
Answer:
Correct Answer: A
Reflection of the light on the corneas should be in exactly the same spot on each eye, or
symmetric. If asymmetry is noted, then the nurse should administer the cover test.
Q: The nurse is assessing the pupils of a patient with a pen light. Which finding would be
considered normal?
A) Both eyes cross when exposed to the light.
B) The patient's pupils are fixed and dilated in response to light.
, C) Both pupils dilate in response to light.
D) Both pupils constrict in response to light.
Answer:
Correct Answer: D
The pupils should constrict in response to light.
Q: In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the
patient's pupils. On the basis of this finding, the nurse would:
A) suspect that there is an opacity in the lens or cornea.
B) check the light source of the ophthalmoscope to verify that it is functioning.
C) consider this a normal reflection of the ophthalmoscope light off the inner retina.
D) continue with the ophthalmoscopic examination and refer the patient for further evaluation.
Answer:
Correct Answer: C
The red glow filling the person's pupil is the red reflex, and it is a normal finding caused by the
reflection of the ophthalmoscope light off the inner retina. The other responses are not correct.
Q: The nurse is charting on a patient's eye assessment and notes PERRLA. What does this stand
for?
A. Pupils Equal, Rigid, React to Light, and Accessible
B. Pupils Even, Right, React to Light, and Accomodation
C. Pupils Equal, Round, React to Light and Accomodation
D. Pupils Even, Rigid, Restrict from Light, and Accomodation
Answer:
The correct answer is C
Pupils Equal, Round, React to Light, and Accommodation
Q: During ocular examinations, the nurse keeps in mind that movement of the extraocular
muscles is:
A) decreased in the elderly.
B) impaired in a patient with cataracts.
Update) Health Assessment | Practice
Questions and Verified Answers| 100%
Correct| Grade A – Fortis
Q: The nurse is palpating the temporomandibular joint (TMJ) which is located just below the
temporal artery and anterior to the tragus. Which of the following would be a normal finding?
A) Nontender to palpation
B) Crepitus
C) The jaw locking
D) Painful palpation
Answer:
The correct answer is A: Nontender to palpation.
When palpating the TMJ normal findings are smooth movement with no popping, crepitus, or
tenderness.
Q: Which of the following subjective data would you want to collect for your patient when
performing a Head, Face and Neck Exam? (Select all that apply)
A. they have unusually frequent or severe headaches
B. If they have any dizziness
C. If they have any neck pain
D. If they have any chest pain
E. If they have any history of neck injury or surgery
Answer:
Correct answers are A, B, C, E.
Subjective data that you want to collect includes:
Headache
History of head injury, cosmetic or cranial surgery
Dizziness
Neck pain
Noticed lumps or swelling
History of neck injury or surgery
,Q: A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid
gland for the presence of a bruit. A bruit is a sound that is heard best with the
of the stethoscope.
A) Low gurgling; bell
B) Loud, whooshing, blowing; diaphragm
C) Soft, whooshing, pulsatile; bell
D)High-pitched tinkling; diaphragm
Answer:
Correct answer is C:
a bruit is a soft, whooshing, pulsatile sound that is best assessed with the bell of the stethescope.
Q: The nurse is assessing the patient's trachea. Which of the following would be a normal
finding?
A. The trachea rising to midline when the patient swallows
B. The trachea deviating to the left when the person swallows
C. The trachea deviating to the right when the person swallows
D. The trachea not moving when the person swallows
Answer:
Correct answer is A.
The trachea should rise to the midline when the patient swallows. If it deviates to one side or the
other that can indicate stroke or tumor.
Q: The nurse is performing the Diagnostic Positions test (Six Cardinal Fields of Gaze) to check
the extraocular eye muscles. The nurse knows that a healthy finding would be:
A. Each eye moves in opposite directions from each other
B. There is parallel tracking of the object with both eyes.
C. A rapid eye blink is expected.
D. The light reflex of the eyes is located in the same position in each eye.
,Answer:
Correct Answer: B
A normal response for the diagnostic positions test is parallel tracking of the object with both
eyes. Eye movement that is not parallel indicates weakness of an extraocular muscle or
dysfunction of the cranial nerve innervating it.
Q: When assessing the pupillary light reflex, the nurse should use which technique?
A) Shine a penlight from directly in front of the patient and inspect for pupillary constriction.
B) Ask the patient to follow the penlight in eight directions and observe for bilateral pupil
constriction.
C) Shine a light across the pupil from the side and observe for direct and consensual pupillary
constriction.
D) Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to
about 7 cm from the nose.
Answer:
Correct Answer: C
To test the pupillary light reflex, the nurse should advance a light in from the side and note the
direct and consensual pupillary constriction.
Q: When performing the corneal light reflex assessment, the nurse notes that the light is
reflected at 2 o'clock in each eye. The nurse should:
A) consider this a normal finding.
B) refer the individual for further evaluation.
C) document this as an asymmetric light reflex.
D) perform the confrontation test to validate the findings.
Answer:
Correct Answer: A
Reflection of the light on the corneas should be in exactly the same spot on each eye, or
symmetric. If asymmetry is noted, then the nurse should administer the cover test.
Q: The nurse is assessing the pupils of a patient with a pen light. Which finding would be
considered normal?
A) Both eyes cross when exposed to the light.
B) The patient's pupils are fixed and dilated in response to light.
, C) Both pupils dilate in response to light.
D) Both pupils constrict in response to light.
Answer:
Correct Answer: D
The pupils should constrict in response to light.
Q: In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the
patient's pupils. On the basis of this finding, the nurse would:
A) suspect that there is an opacity in the lens or cornea.
B) check the light source of the ophthalmoscope to verify that it is functioning.
C) consider this a normal reflection of the ophthalmoscope light off the inner retina.
D) continue with the ophthalmoscopic examination and refer the patient for further evaluation.
Answer:
Correct Answer: C
The red glow filling the person's pupil is the red reflex, and it is a normal finding caused by the
reflection of the ophthalmoscope light off the inner retina. The other responses are not correct.
Q: The nurse is charting on a patient's eye assessment and notes PERRLA. What does this stand
for?
A. Pupils Equal, Rigid, React to Light, and Accessible
B. Pupils Even, Right, React to Light, and Accomodation
C. Pupils Equal, Round, React to Light and Accomodation
D. Pupils Even, Rigid, Restrict from Light, and Accomodation
Answer:
The correct answer is C
Pupils Equal, Round, React to Light, and Accommodation
Q: During ocular examinations, the nurse keeps in mind that movement of the extraocular
muscles is:
A) decreased in the elderly.
B) impaired in a patient with cataracts.
