NUR 245 | NUR245 Exam 1: Health Assessment And
Promotion - MCPHS Updated and Latest Questions
and Correct Answers with Rationale
1. A nurse is conducting a health history for a new patient. Which of the following statements
by the nurse best demonstrates the use of an open-ended question?
A. Tell me more about the reasons you came to the clinic today.
B. Are you feeling any pain in your chest right now?
C. Do you have a family history of heart disease?
D. Have you been taking your medication as prescribed?
Correct Answer: A
Rationale: Open-ended questions encourage patients to provide descriptive information
and share their perspective in their own words. Options A, C, and D are closed-ended
questions that typically elicit a simple yes or no response. By asking the patient to tell more
about their visit, the nurse fosters a patient-centered environment. This technique is
essential for gathering a comprehensive health history and establishing rapport. Effective
communication helps the nurse identify the patient’s primary concerns more accurately.
2. When performing a physical assessment, in which order should the nurse perform the four
basic techniques for most body systems?
A. Palpation, Percussion, Auscultation, Inspection
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: B
Rationale: The standard sequence for physical assessment is inspection followed by
palpation, percussion, and finally auscultation. Inspection provides initial visual data that
informs the subsequent steps of the examination. Palpation and percussion are performed
next to assess underlying structures through touch and sound. Auscultation is usually
performed last to listen to internal body sounds produced by organs. Note that the
abdomen is the only exception where auscultation precedes palpation and percussion to
avoid altering bowel sounds.
3. Which part of the hand is most sensitive to vibrations and should be used during palpation
for tactile fremitus?
A. Ulnar surface or base of the fingers
B. Fingertips
,C. Dorsal surface (back) of the hand
D. The thumb and index finger
Correct Answer: A
Rationale: The ulnar surface of the hand and the base of the fingers are the most sensitive
areas for detecting vibrations. This technique is specifically utilized when assessing for
tactile fremitus in the respiratory system. Fingertips are better suited for fine tactile
discrimination such as pulses or skin texture. The dorsal surface of the hand is used to
assess skin temperature because the skin is thinner there. Understanding the specific
utility of different parts of the hand ensures a precise and accurate physical assessment.
4. A nurse is assessing a patient’s abdomen and hears a high-pitched, musical sound during
percussion over the stomach. How should the nurse document this finding?
A. Resonance
B. Dullness
C. Flatness
D. Tympany
Correct Answer: D
Rationale: Tympany is the characteristic high-pitched, drum-like sound heard over air-
filled structures like the stomach or intestines. Resonance is typically heard over normal
lung tissue and has a lower pitch. Dullness is expected over solid organs such as the liver or
a fluid-filled area. Flatness is heard over extremely dense tissue like bone or heavy muscle.
Correct identification of percussion sounds allows the nurse to determine the density and
position of underlying organs.
5. Which of the following describes the correct use of the stethoscope’s bell during
auscultation?
A. Hold it lightly against the skin to hear low-pitched sounds like bruits.
B. Press it firmly against the skin to hear high-pitched heart sounds.
C. Use it to listen for normal breath sounds in the lungs.
D. It is used primarily for blood pressure measurement in adults.
Correct Answer: A
Rationale: The bell of the stethoscope is designed to pick up low-pitched sounds when
held lightly against the patient’s skin. Pressing too hard with the bell can cause the skin to
act as a diaphragm, filtering out those low frequencies. The diaphragm side is used for
high-pitched sounds such as breath sounds and normal heart sounds. Bruits, gallops, and
certain murmurs are best heard using the bell. Mastery of stethoscope technique is vital for
detecting subtle cardiac and vascular abnormalities.
, 6. Which of the following is considered objective data collected during a patient assessment?
A. Patient reports feeling ‘dizzy’ when standing up.
B. Patient’s blood pressure is measured at 142/90 mmHg.
C. Patient describes their pain as ‘stabbing’ in the back.
D. Patient states they have been feeling very anxious lately.
Correct Answer: B
Rationale: Objective data are signs that can be observed, measured, or felt by the
healthcare provider. Blood pressure readings are measurable and verifiable facts, making
them objective data. Subjective data, such as pain descriptions or feelings of dizziness,
consist of information provided by the patient. The nurse must distinguish between these
types of data to form an accurate clinical picture. Proper documentation requires both
subjective reports and objective findings to support nursing diagnoses.
7. A nurse is preparing to assess a patient who does not speak English fluently. What is the
most appropriate action for the nurse to take?
A. Ask a family member to interpret the medical questions.
B. Use hand gestures and simple words to communicate.
C. Skip the history portion and focus only on the physical exam.
D. Request a medical interpreter to assist with the history and assessment.
Correct Answer: D
Rationale: Using a trained medical interpreter ensures that medical information is
translated accurately and maintains patient confidentiality. Family members may not
understand medical terminology or might filter information, leading to errors in the health
history. Hand gestures are insufficient for complex clinical communication and can lead to
dangerous misunderstandings. Skipping the history is a violation of the nursing process
and compromises patient safety. Professional interpreters are the gold standard for
bridging communication gaps in healthcare settings.
8. During a skin assessment, the nurse notes a lesion that is flat, non-palpable, and less than 1
cm in diameter. This should be documented as a:
A. Papule
B. Vesicle
C. Plaque
D. Macule
Correct Answer: D
Promotion - MCPHS Updated and Latest Questions
and Correct Answers with Rationale
1. A nurse is conducting a health history for a new patient. Which of the following statements
by the nurse best demonstrates the use of an open-ended question?
A. Tell me more about the reasons you came to the clinic today.
B. Are you feeling any pain in your chest right now?
C. Do you have a family history of heart disease?
D. Have you been taking your medication as prescribed?
Correct Answer: A
Rationale: Open-ended questions encourage patients to provide descriptive information
and share their perspective in their own words. Options A, C, and D are closed-ended
questions that typically elicit a simple yes or no response. By asking the patient to tell more
about their visit, the nurse fosters a patient-centered environment. This technique is
essential for gathering a comprehensive health history and establishing rapport. Effective
communication helps the nurse identify the patient’s primary concerns more accurately.
2. When performing a physical assessment, in which order should the nurse perform the four
basic techniques for most body systems?
A. Palpation, Percussion, Auscultation, Inspection
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: B
Rationale: The standard sequence for physical assessment is inspection followed by
palpation, percussion, and finally auscultation. Inspection provides initial visual data that
informs the subsequent steps of the examination. Palpation and percussion are performed
next to assess underlying structures through touch and sound. Auscultation is usually
performed last to listen to internal body sounds produced by organs. Note that the
abdomen is the only exception where auscultation precedes palpation and percussion to
avoid altering bowel sounds.
3. Which part of the hand is most sensitive to vibrations and should be used during palpation
for tactile fremitus?
A. Ulnar surface or base of the fingers
B. Fingertips
,C. Dorsal surface (back) of the hand
D. The thumb and index finger
Correct Answer: A
Rationale: The ulnar surface of the hand and the base of the fingers are the most sensitive
areas for detecting vibrations. This technique is specifically utilized when assessing for
tactile fremitus in the respiratory system. Fingertips are better suited for fine tactile
discrimination such as pulses or skin texture. The dorsal surface of the hand is used to
assess skin temperature because the skin is thinner there. Understanding the specific
utility of different parts of the hand ensures a precise and accurate physical assessment.
4. A nurse is assessing a patient’s abdomen and hears a high-pitched, musical sound during
percussion over the stomach. How should the nurse document this finding?
A. Resonance
B. Dullness
C. Flatness
D. Tympany
Correct Answer: D
Rationale: Tympany is the characteristic high-pitched, drum-like sound heard over air-
filled structures like the stomach or intestines. Resonance is typically heard over normal
lung tissue and has a lower pitch. Dullness is expected over solid organs such as the liver or
a fluid-filled area. Flatness is heard over extremely dense tissue like bone or heavy muscle.
Correct identification of percussion sounds allows the nurse to determine the density and
position of underlying organs.
5. Which of the following describes the correct use of the stethoscope’s bell during
auscultation?
A. Hold it lightly against the skin to hear low-pitched sounds like bruits.
B. Press it firmly against the skin to hear high-pitched heart sounds.
C. Use it to listen for normal breath sounds in the lungs.
D. It is used primarily for blood pressure measurement in adults.
Correct Answer: A
Rationale: The bell of the stethoscope is designed to pick up low-pitched sounds when
held lightly against the patient’s skin. Pressing too hard with the bell can cause the skin to
act as a diaphragm, filtering out those low frequencies. The diaphragm side is used for
high-pitched sounds such as breath sounds and normal heart sounds. Bruits, gallops, and
certain murmurs are best heard using the bell. Mastery of stethoscope technique is vital for
detecting subtle cardiac and vascular abnormalities.
, 6. Which of the following is considered objective data collected during a patient assessment?
A. Patient reports feeling ‘dizzy’ when standing up.
B. Patient’s blood pressure is measured at 142/90 mmHg.
C. Patient describes their pain as ‘stabbing’ in the back.
D. Patient states they have been feeling very anxious lately.
Correct Answer: B
Rationale: Objective data are signs that can be observed, measured, or felt by the
healthcare provider. Blood pressure readings are measurable and verifiable facts, making
them objective data. Subjective data, such as pain descriptions or feelings of dizziness,
consist of information provided by the patient. The nurse must distinguish between these
types of data to form an accurate clinical picture. Proper documentation requires both
subjective reports and objective findings to support nursing diagnoses.
7. A nurse is preparing to assess a patient who does not speak English fluently. What is the
most appropriate action for the nurse to take?
A. Ask a family member to interpret the medical questions.
B. Use hand gestures and simple words to communicate.
C. Skip the history portion and focus only on the physical exam.
D. Request a medical interpreter to assist with the history and assessment.
Correct Answer: D
Rationale: Using a trained medical interpreter ensures that medical information is
translated accurately and maintains patient confidentiality. Family members may not
understand medical terminology or might filter information, leading to errors in the health
history. Hand gestures are insufficient for complex clinical communication and can lead to
dangerous misunderstandings. Skipping the history is a violation of the nursing process
and compromises patient safety. Professional interpreters are the gold standard for
bridging communication gaps in healthcare settings.
8. During a skin assessment, the nurse notes a lesion that is flat, non-palpable, and less than 1
cm in diameter. This should be documented as a:
A. Papule
B. Vesicle
C. Plaque
D. Macule
Correct Answer: D
