Page 1 of 56
NSG 3160 Health Assessment Exam 4 2026–2027
| Complete Questions, Verified Answers &
Detailed Rationales | High-Yield Study Guide, A+
Rated Exam Prep
Section 1: Neurological System
1. A nurse is assessing a patient’s level of consciousness using the Glasgow
Coma Scale (GCS). The patient opens eyes to pain, makes incomprehensible
sounds, and withdraws from pain. What is the patient’s GCS score?
A) 7
• B) 8
• C) 9
• D) 10
Rationale: The GCS assesses eye opening (1-4), verbal response (1-5), and
motor response (1-6). Opening eyes to pain = 2, incomprehensible sounds =
2, withdrawal to pain = 4. The total is 8, indicating a severe brain injury and
coma.
2. During a neurological examination, the nurse asks the patient to stand with
feet together and eyes closed, observing for swaying. What is the nurse
assessing?
• A) Romberg test
• B) Romberg test
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• C) Weber test
• D) Rinne test
Rationale: The Romberg test assesses proprioception and cerebellar
function (balance). A positive sign is significant swaying or loss of balance
with eyes closed, indicating a sensory ataxia.
3. A patient reports a sudden, severe “thunderclap” headache. This is a classic
symptom of which condition?
• A) Tension headache
• B) Migraine with aura
• C) Cluster headache
• D) Subarachnoid hemorrhage
Rationale: A “thunderclap” headache is the hallmark of a subarachnoid
hemorrhage, often described as the “worst headache of my life.” It requires
immediate neurological evaluation.
4. To test cranial nerve XII (hypoglossal), the nurse should ask the patient to:
• A) Smile and show teeth
• B) Shrug shoulders against resistance
• C) Say “ah” and observe uvula movement
• D) Protrude the tongue and move it side to side
Rationale: Cranial nerve XII (hypoglossal) is a motor nerve that controls
tongue movement. Asking the patient to protrude the tongue and move it
side to side assesses its function. Asymmetry or deviation indicates a lesion.
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5. When assessing deep tendon reflexes (DTRs), the nurse documents a reflex as
“brisk” or “hyperactive.” Which grading score corresponds to this finding?
• A) 1+
• B) 2+
• C) 3+
• D) 0
Rationale: DTRs are graded on a 0-4 scale: 0 = absent, 1+ = hypoactive, 2+ =
normal, 3+ = brisk/hyperactive, 4+ = clonus. A 3+ finding can indicate upper
motor neuron disease or hyperthyroidism.
6. The nurse is assessing a patient’s sensory function. Which finding indicates a
potential cortical lesion?
• A) Inability to identify a key placed in the hand (stereognosis)
• B) Inability to feel a light touch on the forearm
• C) Absence of the patellar reflex
• D) Pain sensation to a pinprick on the foot
Rationale: Stereognosis, the ability to identify an object by touch, is a
cortical sensory function. An inability to perform this indicates a lesion in
the sensory cortex, parietal lobe, or associated pathways.
7. What is the correct order for assessing a patient’s mental status during a
routine health assessment?
• A) Level of consciousness, thought process, appearance, behavior
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• B) Behavior, appearance, thought process, level of consciousness
• C) Appearance, behavior, cognition, thought process
• D) Thought process, level of consciousness, appearance, behavior
Rationale: The standard mental status examination proceeds from the
general to the specific: (1) Appearance, (2) Behavior, (3) Cognition
(orientation, memory, attention), and (4) Thought process and perceptions.
8. A patient with a stroke has difficulty understanding language and cannot
follow a simple command, though they can speak fluently but with nonsensical
words. This is most consistent with:
• A) Expressive aphasia (Broca’s)
• B) Receptive aphasia (Wernicke’s)
• C) Global aphasia
• D) Dysarthria
Rationale: Wernicke’s aphasia is characterized by fluent, often nonsensical
speech with poor comprehension. The patient cannot understand spoken
or written language but can produce words, albeit incorrectly.
9. The nurse is assessing cerebellar function. Which test is used to evaluate
coordination and fine motor skills?
• A) Babinski test
• B) Finger-to-nose test
• C) Ophthalmoscopic exam
NSG 3160 Health Assessment Exam 4 2026–2027
| Complete Questions, Verified Answers &
Detailed Rationales | High-Yield Study Guide, A+
Rated Exam Prep
Section 1: Neurological System
1. A nurse is assessing a patient’s level of consciousness using the Glasgow
Coma Scale (GCS). The patient opens eyes to pain, makes incomprehensible
sounds, and withdraws from pain. What is the patient’s GCS score?
A) 7
• B) 8
• C) 9
• D) 10
Rationale: The GCS assesses eye opening (1-4), verbal response (1-5), and
motor response (1-6). Opening eyes to pain = 2, incomprehensible sounds =
2, withdrawal to pain = 4. The total is 8, indicating a severe brain injury and
coma.
2. During a neurological examination, the nurse asks the patient to stand with
feet together and eyes closed, observing for swaying. What is the nurse
assessing?
• A) Romberg test
• B) Romberg test
,Page 2 of 56
• C) Weber test
• D) Rinne test
Rationale: The Romberg test assesses proprioception and cerebellar
function (balance). A positive sign is significant swaying or loss of balance
with eyes closed, indicating a sensory ataxia.
3. A patient reports a sudden, severe “thunderclap” headache. This is a classic
symptom of which condition?
• A) Tension headache
• B) Migraine with aura
• C) Cluster headache
• D) Subarachnoid hemorrhage
Rationale: A “thunderclap” headache is the hallmark of a subarachnoid
hemorrhage, often described as the “worst headache of my life.” It requires
immediate neurological evaluation.
4. To test cranial nerve XII (hypoglossal), the nurse should ask the patient to:
• A) Smile and show teeth
• B) Shrug shoulders against resistance
• C) Say “ah” and observe uvula movement
• D) Protrude the tongue and move it side to side
Rationale: Cranial nerve XII (hypoglossal) is a motor nerve that controls
tongue movement. Asking the patient to protrude the tongue and move it
side to side assesses its function. Asymmetry or deviation indicates a lesion.
,Page 3 of 56
5. When assessing deep tendon reflexes (DTRs), the nurse documents a reflex as
“brisk” or “hyperactive.” Which grading score corresponds to this finding?
• A) 1+
• B) 2+
• C) 3+
• D) 0
Rationale: DTRs are graded on a 0-4 scale: 0 = absent, 1+ = hypoactive, 2+ =
normal, 3+ = brisk/hyperactive, 4+ = clonus. A 3+ finding can indicate upper
motor neuron disease or hyperthyroidism.
6. The nurse is assessing a patient’s sensory function. Which finding indicates a
potential cortical lesion?
• A) Inability to identify a key placed in the hand (stereognosis)
• B) Inability to feel a light touch on the forearm
• C) Absence of the patellar reflex
• D) Pain sensation to a pinprick on the foot
Rationale: Stereognosis, the ability to identify an object by touch, is a
cortical sensory function. An inability to perform this indicates a lesion in
the sensory cortex, parietal lobe, or associated pathways.
7. What is the correct order for assessing a patient’s mental status during a
routine health assessment?
• A) Level of consciousness, thought process, appearance, behavior
, Page 4 of 56
• B) Behavior, appearance, thought process, level of consciousness
• C) Appearance, behavior, cognition, thought process
• D) Thought process, level of consciousness, appearance, behavior
Rationale: The standard mental status examination proceeds from the
general to the specific: (1) Appearance, (2) Behavior, (3) Cognition
(orientation, memory, attention), and (4) Thought process and perceptions.
8. A patient with a stroke has difficulty understanding language and cannot
follow a simple command, though they can speak fluently but with nonsensical
words. This is most consistent with:
• A) Expressive aphasia (Broca’s)
• B) Receptive aphasia (Wernicke’s)
• C) Global aphasia
• D) Dysarthria
Rationale: Wernicke’s aphasia is characterized by fluent, often nonsensical
speech with poor comprehension. The patient cannot understand spoken
or written language but can produce words, albeit incorrectly.
9. The nurse is assessing cerebellar function. Which test is used to evaluate
coordination and fine motor skills?
• A) Babinski test
• B) Finger-to-nose test
• C) Ophthalmoscopic exam
