NSG3160 Health Assessment Exam 3 Version 2
Questions with Correct Answers and Expert
Explanation for Each Question
1. A nurse is assessing a patient’s gait and notices the patient is dragging one leg in a
semicircle. How should the nurse document this finding?
A. Ataxic gait
B. Spastic hemiparesis gait
C. Scissors gait
D. Steppage gait
Correct Answer: B
Expert Explanation: The description of dragging a leg in a semicircle is
characteristic of spastic hemiparesis, often seen after a stroke. An ataxic gait is
usually uncoordinated and wide-based rather than circular in movement. The nurse
must identify these patterns to determine potential neurological or musculoskeletal
deficits. Documenting the specific gait pattern helps in planning appropriate safety
interventions for the patient. Accurate observation of the swing phase is vital for
professional clinical reasoning in health assessments.
2. While testing muscle strength, the patient is able to move their arm against gravity
but cannot resist any applied pressure. What grade should the nurse assign?
A. Grade 3
,B. Grade 2
C. Grade 4
D. Grade 5
Correct Answer: A
Expert Explanation: Grade 3 strength is defined as the ability to complete full
range of motion against gravity alone. Grade 2 involves full range of motion with
gravity eliminated by positioning the limb. Grade 4 and 5 represent varying degrees
of resistance that the patient is unable to meet in this scenario. This standardized
grading system allows for objective communication between healthcare providers
regarding patient progress. The nurse uses this data to evaluate the effectiveness of
physical therapy or recovery interventions.
3. The nurse is performing a musculoskeletal assessment on an older adult patient.
Which finding is considered a normal age-related change?
A. Decreased height due to vertebral shortening
B. Increased bone density
C. Increased muscle mass
D. Enhanced joint flexibility
Correct Answer: A
,Expert Explanation: Aging typically results in a decrease in height due to the
thinning of intervertebral discs and vertebral compression. Bone density and
muscle mass generally decrease rather than increase as an individual gets older.
Flexibilities of joints also tend to decrease with age due to changes in connective
tissue. The nurse must differentiate between normal physiological aging and
pathological disease states like osteoporosis. Understanding these changes helps the
nurse set realistic goals for the patient’s mobility and safety.
4. Which assessment technique is most appropriate for a nurse to use when checking
for a small amount of fluid in the knee joint?
A. McMurray test
B. Bulge sign
C. Phalen’s test
D. Ballottement of the patella
Correct Answer: B
Expert Explanation: The bulge sign is used to detect small amounts of fluid in the
suprapatellar bursa. Ballottement is typically used for larger amounts of fluid
accumulation in the joint. The McMurray test assesses for meniscus tears rather
than simple fluid accumulation. Phalen’s test is used specifically for carpal tunnel
, syndrome assessment in the wrist. Utilizing the correct technique ensures accurate
clinical reasoning and prioritization of further diagnostic testing.
5. A patient presents with hard, painless nodules over the distal interphalangeal
joints. The nurse identifies these as:
A. Bouchard’s nodes
B. Rheumatoid nodules
C. Heberden’s nodes
D. Tophi
Correct Answer: C
Expert Explanation: Heberden’s nodes are characteristic bony overgrowths at the
distal interphalangeal joints associated with osteoarthritis. Bouchard’s nodes occur
at the proximal interphalangeal joints in the same condition. Rheumatoid nodules
are typically soft and associated with systemic inflammatory disease rather than
localized wear. Tophi are deposits of uric acid crystals found in patients suffering
from chronic gout. Recognition of these specific physical markers allows the nurse
to accurately document and monitor joint disease.
Questions with Correct Answers and Expert
Explanation for Each Question
1. A nurse is assessing a patient’s gait and notices the patient is dragging one leg in a
semicircle. How should the nurse document this finding?
A. Ataxic gait
B. Spastic hemiparesis gait
C. Scissors gait
D. Steppage gait
Correct Answer: B
Expert Explanation: The description of dragging a leg in a semicircle is
characteristic of spastic hemiparesis, often seen after a stroke. An ataxic gait is
usually uncoordinated and wide-based rather than circular in movement. The nurse
must identify these patterns to determine potential neurological or musculoskeletal
deficits. Documenting the specific gait pattern helps in planning appropriate safety
interventions for the patient. Accurate observation of the swing phase is vital for
professional clinical reasoning in health assessments.
2. While testing muscle strength, the patient is able to move their arm against gravity
but cannot resist any applied pressure. What grade should the nurse assign?
A. Grade 3
,B. Grade 2
C. Grade 4
D. Grade 5
Correct Answer: A
Expert Explanation: Grade 3 strength is defined as the ability to complete full
range of motion against gravity alone. Grade 2 involves full range of motion with
gravity eliminated by positioning the limb. Grade 4 and 5 represent varying degrees
of resistance that the patient is unable to meet in this scenario. This standardized
grading system allows for objective communication between healthcare providers
regarding patient progress. The nurse uses this data to evaluate the effectiveness of
physical therapy or recovery interventions.
3. The nurse is performing a musculoskeletal assessment on an older adult patient.
Which finding is considered a normal age-related change?
A. Decreased height due to vertebral shortening
B. Increased bone density
C. Increased muscle mass
D. Enhanced joint flexibility
Correct Answer: A
,Expert Explanation: Aging typically results in a decrease in height due to the
thinning of intervertebral discs and vertebral compression. Bone density and
muscle mass generally decrease rather than increase as an individual gets older.
Flexibilities of joints also tend to decrease with age due to changes in connective
tissue. The nurse must differentiate between normal physiological aging and
pathological disease states like osteoporosis. Understanding these changes helps the
nurse set realistic goals for the patient’s mobility and safety.
4. Which assessment technique is most appropriate for a nurse to use when checking
for a small amount of fluid in the knee joint?
A. McMurray test
B. Bulge sign
C. Phalen’s test
D. Ballottement of the patella
Correct Answer: B
Expert Explanation: The bulge sign is used to detect small amounts of fluid in the
suprapatellar bursa. Ballottement is typically used for larger amounts of fluid
accumulation in the joint. The McMurray test assesses for meniscus tears rather
than simple fluid accumulation. Phalen’s test is used specifically for carpal tunnel
, syndrome assessment in the wrist. Utilizing the correct technique ensures accurate
clinical reasoning and prioritization of further diagnostic testing.
5. A patient presents with hard, painless nodules over the distal interphalangeal
joints. The nurse identifies these as:
A. Bouchard’s nodes
B. Rheumatoid nodules
C. Heberden’s nodes
D. Tophi
Correct Answer: C
Expert Explanation: Heberden’s nodes are characteristic bony overgrowths at the
distal interphalangeal joints associated with osteoarthritis. Bouchard’s nodes occur
at the proximal interphalangeal joints in the same condition. Rheumatoid nodules
are typically soft and associated with systemic inflammatory disease rather than
localized wear. Tophi are deposits of uric acid crystals found in patients suffering
from chronic gout. Recognition of these specific physical markers allows the nurse
to accurately document and monitor joint disease.
