NSG3160 | NSG3160 Health Assessment Exam 4
Version 3 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. When performing a musculoskeletal assessment, the nurse asks the patient to move
their arm away from the midline. What term describes this movement?
A. Abduction
B. Adduction
C. Flexion
D. Extension
Correct Answer: A
Expert Explanation: Abduction is defined as the movement of a limb away from the
body’s midline. This assessment helps the nurse determine the range of motion in
the shoulder or hip joints. The nurse should compare both sides for symmetry and
fluid motion. Normal findings include smooth movement without pain or resistance.
Limitations in abduction can indicate muscle tears or joint inflammation.
2. Which cranial nerve is being tested when the nurse asks the patient to clench their
teeth and palpates the temporal and masseter muscles?
A. CN V (Trigeminal)
B. CN III (Oculomotor)
,C. CN VII (Facial)
D. CN IX (Glossopharyngeal)
Correct Answer: A
Expert Explanation: The trigeminal nerve contains both sensory and motor fibers
that control the muscles of mastication. By asking the patient to clench their teeth,
the nurse evaluates the motor strength of the masseter muscles. A normal response
shows bilateral strength and equal tension in the muscles. This nerve also transmits
facial sensation which is tested separately with light touch. Identifying weakness
here may point to a brainstem lesion or nerve damage.
3. During a breast examination, the nurse notes a dimpling of the skin that resembles
an orange peel. What is the clinical term for this finding?
A. Mastitis
B. Fibroadenoma
C. Gynecomastia
D. Peau d’orange
Correct Answer: D
Expert Explanation: Peau d’orange is a French term meaning skin of an orange.
This condition is often caused by lymphatic obstruction which leads to localized
,edema. It is frequently associated with inflammatory breast cancer or advanced
malignancies. The nurse must document the exact location and extent of the skin
change. Immediate referral for diagnostic imaging is necessary when this sign is
observed.
4. The nurse is performing a neurological assessment and asks the patient to stand
with feet together and eyes closed. The patient begins to sway significantly. What is
this result called?
A. Positive Babinski sign
B. Negative Romberg sign
C. Positive Ortolani sign
D. Positive Romberg sign
Correct Answer: D
Expert Explanation: A positive Romberg sign occurs when a patient loses balance
after closing their eyes while standing. This test evaluates the patient’s
proprioception and vestibular function. Under normal conditions, a person uses
visual, vestibular, and proprioceptive cues to maintain balance. Losing balance with
eyes closed suggests a sensory ataxia or vestibular deficiency. The nurse should
stand close to the patient during this test to prevent falls.
, 5. When assessing deep tendon reflexes, the nurse strikes the patellar tendon and
observes the leg kick forward. What grade should the nurse assign to this normal
reflex?
A. 1+
B. 2+
C. 3+
D. 4+
Correct Answer: B
Expert Explanation: A reflex grade of 2+ is considered the standard normal
response for deep tendon reflexes. Reflexes are graded on a scale from 0 to 4+ based
on the intensity of the contraction. A 1+ indicates a diminished or sluggish response.
A 3+ is brisker than average, while 4+ indicates hyperactive reflexes with clonus.
Consistent 2+ findings across all sites indicate a healthy and intact reflex arc.
6. A nurse is assessing a patient’s spinal curvature and notices an exaggerated inward
curve of the lumbar spine. Which condition is the nurse observing?
A. Scoliosis
B. Kyphosis
C. Ankylosis
Version 3 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. When performing a musculoskeletal assessment, the nurse asks the patient to move
their arm away from the midline. What term describes this movement?
A. Abduction
B. Adduction
C. Flexion
D. Extension
Correct Answer: A
Expert Explanation: Abduction is defined as the movement of a limb away from the
body’s midline. This assessment helps the nurse determine the range of motion in
the shoulder or hip joints. The nurse should compare both sides for symmetry and
fluid motion. Normal findings include smooth movement without pain or resistance.
Limitations in abduction can indicate muscle tears or joint inflammation.
2. Which cranial nerve is being tested when the nurse asks the patient to clench their
teeth and palpates the temporal and masseter muscles?
A. CN V (Trigeminal)
B. CN III (Oculomotor)
,C. CN VII (Facial)
D. CN IX (Glossopharyngeal)
Correct Answer: A
Expert Explanation: The trigeminal nerve contains both sensory and motor fibers
that control the muscles of mastication. By asking the patient to clench their teeth,
the nurse evaluates the motor strength of the masseter muscles. A normal response
shows bilateral strength and equal tension in the muscles. This nerve also transmits
facial sensation which is tested separately with light touch. Identifying weakness
here may point to a brainstem lesion or nerve damage.
3. During a breast examination, the nurse notes a dimpling of the skin that resembles
an orange peel. What is the clinical term for this finding?
A. Mastitis
B. Fibroadenoma
C. Gynecomastia
D. Peau d’orange
Correct Answer: D
Expert Explanation: Peau d’orange is a French term meaning skin of an orange.
This condition is often caused by lymphatic obstruction which leads to localized
,edema. It is frequently associated with inflammatory breast cancer or advanced
malignancies. The nurse must document the exact location and extent of the skin
change. Immediate referral for diagnostic imaging is necessary when this sign is
observed.
4. The nurse is performing a neurological assessment and asks the patient to stand
with feet together and eyes closed. The patient begins to sway significantly. What is
this result called?
A. Positive Babinski sign
B. Negative Romberg sign
C. Positive Ortolani sign
D. Positive Romberg sign
Correct Answer: D
Expert Explanation: A positive Romberg sign occurs when a patient loses balance
after closing their eyes while standing. This test evaluates the patient’s
proprioception and vestibular function. Under normal conditions, a person uses
visual, vestibular, and proprioceptive cues to maintain balance. Losing balance with
eyes closed suggests a sensory ataxia or vestibular deficiency. The nurse should
stand close to the patient during this test to prevent falls.
, 5. When assessing deep tendon reflexes, the nurse strikes the patellar tendon and
observes the leg kick forward. What grade should the nurse assign to this normal
reflex?
A. 1+
B. 2+
C. 3+
D. 4+
Correct Answer: B
Expert Explanation: A reflex grade of 2+ is considered the standard normal
response for deep tendon reflexes. Reflexes are graded on a scale from 0 to 4+ based
on the intensity of the contraction. A 1+ indicates a diminished or sluggish response.
A 3+ is brisker than average, while 4+ indicates hyperactive reflexes with clonus.
Consistent 2+ findings across all sites indicate a healthy and intact reflex arc.
6. A nurse is assessing a patient’s spinal curvature and notices an exaggerated inward
curve of the lumbar spine. Which condition is the nurse observing?
A. Scoliosis
B. Kyphosis
C. Ankylosis
