NUR 6001/NUR6001 Exam 3 V2 | Advanced
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing a patient for carpal tunnel syndrome, the nurse asks the patient to hold
their wrists in a position of forced flexion for 60 seconds. What is the name of this test?
A. Tinel’s sign
B. McMurray’s test
C. Phalen’s test
D. Lachman’s test
Correct Answer: C
Expert Explanation: Phalen’s test is a diagnostic procedure used to identify compression
of the median nerve. The patient is instructed to press the backs of their hands together
while maintaining maximum wrist flexion. If numbness or tingling occurs within one
minute, the test is positive for carpal tunnel syndrome.
2. A patient is unable to shrug their shoulders against resistance. Which cranial nerve is likely
affected?
A. CN IX (Glossopharyngeal)
B. CN X (Vagus)
C. CN XI (Spinal Accessory)
,D. CN XII (Hypoglossal)
Correct Answer: C
Expert Explanation: Cranial nerve XI, the spinal accessory nerve, innervates the trapezius
and sternocleidomastoid muscles. Assessing shoulder shrug and head rotation against
resistance evaluates this nerve’s motor function. Weakness or asymmetry in these
movements suggests nerve damage or dysfunction.
3. During a breast examination, the nurse notes a dimpling of the skin that resembles the
texture of an orange peel. What is this clinical finding called?
A. Fibroadenoma
B. Paget’s disease
C. Peau d’orange
D. Mastitis
Correct Answer: C
Expert Explanation: Peau d’orange is a sign of cutaneous lymphatic edema often
associated with inflammatory breast cancer. The skin becomes thickened and the hair
follicles appear more prominent, creating a pitted texture. This finding warrants immediate
further investigation due to its association with malignancy.
4. When grading muscle strength, a nurse notes that a patient can complete a full range of
motion against gravity but not against any added resistance. What grade should be assigned?
A. Grade 1
, B. Grade 2
C. Grade 4
D. Grade 3
Correct Answer: D
Expert Explanation: Muscle strength is graded on a scale of 0 to 5. A grade of 3 indicates
that the muscle can move the limb through a full range of motion against gravity. If the
patient could move with resistance, they would be graded a 4 or 5.
5. The Romberg test is used to assess which of the following?
A. Cerebellar function and balance
B. Visual acuity
C. Hearing loss
D. Deep tendon reflexes
Correct Answer: A
Expert Explanation: The Romberg test evaluates the patient’s ability to maintain an
upright position with eyes closed. It primarily assesses proprioception, vestibular function,
and cerebellar coordination. A positive sign occurs if the patient loses balance or sways
significantly.
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing a patient for carpal tunnel syndrome, the nurse asks the patient to hold
their wrists in a position of forced flexion for 60 seconds. What is the name of this test?
A. Tinel’s sign
B. McMurray’s test
C. Phalen’s test
D. Lachman’s test
Correct Answer: C
Expert Explanation: Phalen’s test is a diagnostic procedure used to identify compression
of the median nerve. The patient is instructed to press the backs of their hands together
while maintaining maximum wrist flexion. If numbness or tingling occurs within one
minute, the test is positive for carpal tunnel syndrome.
2. A patient is unable to shrug their shoulders against resistance. Which cranial nerve is likely
affected?
A. CN IX (Glossopharyngeal)
B. CN X (Vagus)
C. CN XI (Spinal Accessory)
,D. CN XII (Hypoglossal)
Correct Answer: C
Expert Explanation: Cranial nerve XI, the spinal accessory nerve, innervates the trapezius
and sternocleidomastoid muscles. Assessing shoulder shrug and head rotation against
resistance evaluates this nerve’s motor function. Weakness or asymmetry in these
movements suggests nerve damage or dysfunction.
3. During a breast examination, the nurse notes a dimpling of the skin that resembles the
texture of an orange peel. What is this clinical finding called?
A. Fibroadenoma
B. Paget’s disease
C. Peau d’orange
D. Mastitis
Correct Answer: C
Expert Explanation: Peau d’orange is a sign of cutaneous lymphatic edema often
associated with inflammatory breast cancer. The skin becomes thickened and the hair
follicles appear more prominent, creating a pitted texture. This finding warrants immediate
further investigation due to its association with malignancy.
4. When grading muscle strength, a nurse notes that a patient can complete a full range of
motion against gravity but not against any added resistance. What grade should be assigned?
A. Grade 1
, B. Grade 2
C. Grade 4
D. Grade 3
Correct Answer: D
Expert Explanation: Muscle strength is graded on a scale of 0 to 5. A grade of 3 indicates
that the muscle can move the limb through a full range of motion against gravity. If the
patient could move with resistance, they would be graded a 4 or 5.
5. The Romberg test is used to assess which of the following?
A. Cerebellar function and balance
B. Visual acuity
C. Hearing loss
D. Deep tendon reflexes
Correct Answer: A
Expert Explanation: The Romberg test evaluates the patient’s ability to maintain an
upright position with eyes closed. It primarily assesses proprioception, vestibular function,
and cerebellar coordination. A positive sign occurs if the patient loses balance or sways
significantly.
