NR 305 Health Assessment - Exam 5 Comprehensive Study Guide 2026
|Chamberlain College
1. When assessing a patient’s deep tendon reflexes, the nurse assigns a score of
2+. How should the nurse interpret this finding?
A. Diminished, low normal
B. Hyperactive with clonus
C. Brisker than average
D. Average, normal
Answer: D
Rationale: On a scale of 0 to 4+, a 2+ reflex is considered average or normal. 1+ is
diminished, 3+ is brisker than average, and 4+ is hyperactive.
2. The nurse asks a patient to stick out their tongue and move it from side to
side. Which cranial nerve is being assessed?
A. CN IX (Glossopharyngeal)
B. CN X (Vagus)
C. CN XII (Hypoglossal)
D. CN XI (Spinal Accessory)
Answer: C
Rationale: Cranial Nerve XII, the hypoglossal nerve, controls the muscles of the tongue.
Symmetry and movement are assessed by having the patient protrude the tongue.
,3. Which assessment finding is consistent with an adult patient having a positive
Babinski reflex?
A. Dorsiflexion of the great toe and fanning of all toes
B. Flexion of the great toe and fanning of all toes
C. Plantar flexion of all toes
D. Withdrawal of the foot from the stimulus
Answer: A
Rationale: A positive Babinski sign (abnormal in adults) involves dorsiflexion of the big toe
and fanning of the other toes, indicating upper motor neuron disease.
4. To assess for carpal tunnel syndrome, the nurse asks the patient to hold both
hands back to back while flexing the wrists 90 degrees for 60 seconds. What is
this test called?
A. Phalen’s test
B. Tinel’s sign
C. McMurray’s test
D. Bulge sign
Answer: A
Rationale: Phalen’s test compresses the median nerve. Numbness or burning during this
maneuver indicates carpal tunnel syndrome.
5. A patient presents with an exaggerated thoracic curvature of the spine, often
seen in elderly women with osteoporosis. The nurse documents this as:
A. Kyphosis
B. Scoliosis
C. Lordosis
D. Ankylosis
Answer: A
, Rationale: Kyphosis is an exaggerated outward curvature of the thoracic spine
(hunchback). Lordosis is an inward lumbar curve, and scoliosis is a lateral curve.
6. During a musculoskeletal assessment, the nurse asks the patient to move
their arm away from the midline of the body. This movement is called:
A. Abduction
B. Adduction
C. Flexion
D. Extension
Answer: A
Rationale: Abduction is moving a limb away from the midline. Adduction is moving it
toward the midline.
7. Which Glasgow Coma Scale (GCS) score would indicate that a patient is in a
deep coma?
A. 15
B. 10
C. 7
D. 3
Answer: D
Rationale: The GCS ranges from 3 to 15. A score of 3 is the lowest possible score, indicating
no response in eye opening, verbal response, or motor response.
8. The nurse is testing the function of Cranial Nerve V (Trigeminal). Which action
should the nurse ask the patient to perform?
A. Smile and frown
B. Clench the teeth
C. Shrug the shoulders
D. Follow a moving finger with eyes
Answer: B
|Chamberlain College
1. When assessing a patient’s deep tendon reflexes, the nurse assigns a score of
2+. How should the nurse interpret this finding?
A. Diminished, low normal
B. Hyperactive with clonus
C. Brisker than average
D. Average, normal
Answer: D
Rationale: On a scale of 0 to 4+, a 2+ reflex is considered average or normal. 1+ is
diminished, 3+ is brisker than average, and 4+ is hyperactive.
2. The nurse asks a patient to stick out their tongue and move it from side to
side. Which cranial nerve is being assessed?
A. CN IX (Glossopharyngeal)
B. CN X (Vagus)
C. CN XII (Hypoglossal)
D. CN XI (Spinal Accessory)
Answer: C
Rationale: Cranial Nerve XII, the hypoglossal nerve, controls the muscles of the tongue.
Symmetry and movement are assessed by having the patient protrude the tongue.
,3. Which assessment finding is consistent with an adult patient having a positive
Babinski reflex?
A. Dorsiflexion of the great toe and fanning of all toes
B. Flexion of the great toe and fanning of all toes
C. Plantar flexion of all toes
D. Withdrawal of the foot from the stimulus
Answer: A
Rationale: A positive Babinski sign (abnormal in adults) involves dorsiflexion of the big toe
and fanning of the other toes, indicating upper motor neuron disease.
4. To assess for carpal tunnel syndrome, the nurse asks the patient to hold both
hands back to back while flexing the wrists 90 degrees for 60 seconds. What is
this test called?
A. Phalen’s test
B. Tinel’s sign
C. McMurray’s test
D. Bulge sign
Answer: A
Rationale: Phalen’s test compresses the median nerve. Numbness or burning during this
maneuver indicates carpal tunnel syndrome.
5. A patient presents with an exaggerated thoracic curvature of the spine, often
seen in elderly women with osteoporosis. The nurse documents this as:
A. Kyphosis
B. Scoliosis
C. Lordosis
D. Ankylosis
Answer: A
, Rationale: Kyphosis is an exaggerated outward curvature of the thoracic spine
(hunchback). Lordosis is an inward lumbar curve, and scoliosis is a lateral curve.
6. During a musculoskeletal assessment, the nurse asks the patient to move
their arm away from the midline of the body. This movement is called:
A. Abduction
B. Adduction
C. Flexion
D. Extension
Answer: A
Rationale: Abduction is moving a limb away from the midline. Adduction is moving it
toward the midline.
7. Which Glasgow Coma Scale (GCS) score would indicate that a patient is in a
deep coma?
A. 15
B. 10
C. 7
D. 3
Answer: D
Rationale: The GCS ranges from 3 to 15. A score of 3 is the lowest possible score, indicating
no response in eye opening, verbal response, or motor response.
8. The nurse is testing the function of Cranial Nerve V (Trigeminal). Which action
should the nurse ask the patient to perform?
A. Smile and frown
B. Clench the teeth
C. Shrug the shoulders
D. Follow a moving finger with eyes
Answer: B
