152 • 1 MAXE
NURS College of Nursing — Exam 1 Review
A S S E S S M E N T I S T H E F O U N D AT I O N O F C A R E
251
NURS 251 — Health Assessment Exam 1
C R A N I A L N E R V E S , PA I N A SS E SS M E N T, N E U R O LO G I C A L & I N T E G U M E N TA R Y SYST E M S
INSTITUTION College of Nursing EXAM CODE NURS-251-EX1-2026
PROGRAM NURS 251 — Health Assessment ACADEMIC YEAR
EXAM TITLE Health Assessment Exam 1 TOTAL QUESTIONS 25 Questions — Comprehensive Review
COURSE TITLE NURS 251 — Health Assessment FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question.
▸ Questions cover the 12 cranial nerves, assessment techniques (IPPA), pain scales (PQRST, COLDSPA, FLACC, PAINAD),
neurological assessment (GCS, NIHSS, stroke types), skin assessment (Braden Scale, pressure ulcers, ABCDE melanoma), and
vital signs.
▸ Distinguish carefully between similar assessment tools and their appropriate clinical applications.
▸ Correct answers and detailed rationales appear below each question for comprehensive review.
▸ All content is derived from NURS 251 Health Assessment Exam 1 curriculum.
SECTION I — CRANIAL NERVES, PAIN SCALES & NEUROLOGICAL Questions 1 –
ASSESSMENT 25
1. The 12 cranial nerves in order (I–XII) can be remembered by which mnemonic?
A. "Some Say Money Matters But My Brother Says Big Brains Matter More"
B. "Oh, oh, oh, to touch and feel virgin girls' vaginas, ahh, heaven" (Olfactory, Optic, Oculomotor, Trochlear, Trigeminal,
Abducens, Facial, Vestibulocochlear, Glossopharyngeal, Vagus, Accessory, Hypoglossal)
C. "On Old Olympus' Towering Tops, A Finn And German Viewed Some Hops"
D. Both B and C are correct mnemonics for cranial nerves I–XII
CORRECT ANSWER D — Both B and C are well-known mnemonics for remembering the 12 cranial nerves in order (I:
Olfactory, II: Optic, III: Oculomotor, IV: Trochlear, V: Trigeminal, VI: Abducens, VII: Facial, VIII:
Vestibulocochlear, IX: Glossopharyngeal, X: Vagus, XI: Accessory, XII: Hypoglossal).
RATIONALE The 12 cranial nerves and their functions: I (Olfactory) — smell; II (Optic) — vision; III (Oculomotor) — eye
movement, pupil constriction; IV (Trochlear) — eye movement toward nose/away; V (Trigeminal) — facial
sensation, chewing; VI (Abducens) — lateral eye movement; VII (Facial) — facial expressions; VIII
(Vestibulocochlear) — hearing, balance; IX (Glossopharyngeal) — swallowing, taste; X (Vagus) — autonomic
functions; XI (Accessory) — neck/shoulder movement; XII (Hypoglossal) — tongue movement.
, 2. The four assessment techniques used in physical examination are:
A. Observation, Questioning, Documentation, Follow-up
B. Inspection, Palpation, Percussion, Auscultation (IPPA)
C. Assessment, Planning, Implementation, Evaluation
D. Visualization, Measurement, Recording, Reporting
CORRECT ANSWER B — Inspection (look), Palpation (feel), Percussion (listen for resonance/tympani/flat), and
Auscultation (listen for clear, wheezes, crackles). This is the standard IPPA sequence.
RATIONALE IPPA is the systematic approach to physical examination: Inspection — visual examination using sight (always
first); Palpation — using touch to assess texture, temperature, moisture, organ size, tenderness; Percussion —
tapping body parts to produce sound waves (resonance over air-filled lungs, tympany over hollow organs,
dullness over solid organs, flatness over bone); Auscultation — listening with stethoscope (clear breath
sounds, wheezes, crackles, bowel sounds, heart sounds).
3. The PQRST pain assessment scale evaluates pain by asking about:
A. Pain level, Quality of life, Radiation, Symptoms, and Treatment history
B. Provocation/Palliation, Quality, Region/Radiation, Severity/Signs/Symptoms, and Time (onset, duration, intensity)
C. Physical exam, Quick assessment, Review of systems, Social history, and Testing
D. Position, Quantity, Response, Stability, and Type
CORRECT ANSWER B — P: Provocation/Palliation (what makes it better/worse); Q: Quality (stabbing, burning, etc.); R:
Region/Radiation; S: Severity, Signs, Symptoms; T: Time (onset, duration, intensity).
RATIONALE PQRST is a systematic, subjective pain assessment tool. It is interchangeable with the COLDSPA scale. PQRST
gathers comprehensive pain information: what provokes or palliates it, the quality/character of the pain,
where it is located and if it radiates, how severe it is (scale 1–10) and associated signs/symptoms, and the
temporal pattern (when it started, how long it lasts, intensity over time). This guides diagnosis and treatment
evaluation.
4. The COLDSPA pain assessment scale evaluates pain by asking about:
A. Cold therapy, Observation, Location, Duration, Severity, Pattern, and Associated factors
B. Character, Onset, Location, Duration, Severity, Pattern, and Associated factors
C. Circulation, Oxygenation, Level of consciousness, Dressing, Skin, Pain, and Activity
D. Comfort, Observation, Listening, Documentation, Safety, Prevention, and Assessment
CORRECT ANSWER B — C: Character (describe it); O: Onset (when did it begin); L: Location (where is it); D: Duration (how
long does it last); S: Severity (rate 1–10); P: Pattern (what makes it better/worse); A: Associated factors
(other symptoms).
RATIONALE COLDSPA is interchangeable with PQRST — both are systematic subjective pain assessment tools. COLDSPA
adds the "A" for Associated Factors (what other symptoms occur with the pain — nausea, diaphoresis, etc.).
Both tools provide a comprehensive pain history that helps differentiate the etiology and guide treatment.
Pain is the 5th vital sign and must be assessed and documented regularly.