NUR 3270/NUR3270 Exam 3 V1 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. A patient is asked to smile, frown, and puff out their cheeks. Which cranial nerve is the
nurse assessing?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve XII (Hypoglossal)
C. Cranial Nerve IX (Glossopharyngeal)
D. Cranial Nerve VII (Facial)
Correct Answer: D
Expert Explanation: Cranial Nerve VII, the facial nerve, is responsible for motor symmetry
of the face. The nurse observes for any drooping or weakness while the patient performs
these expressions. Damage to this nerve is often associated with Bell’s palsy or stroke.
2. When assessing the Deep Tendon Reflexes (DTR) of a patient, the nurse notes a very brisk
response with clonus. How should this be documented?
A. 1+
B. 4+
C. 3+
,D. 2+
Correct Answer: B
Expert Explanation: A 4+ reflex grade indicates a very brisk, hyperactive response with
intermittent or sustained clonus. This finding is often indicative of upper motor neuron
disease. A normal, expected reflex response is typically documented as 2+.
3. During a musculoskeletal exam, the nurse asks the patient to move their arm away from
the midline of the body. What is this movement called?
A. Adduction
B. Flexion
C. Abduction
D. Extension
Correct Answer: C
Expert Explanation: Abduction is the movement of a limb or other part away from the
midline of the body. Adduction is the opposite movement, bringing the limb closer to the
midline. Understanding these terms is essential for documenting range of motion
accurately.
4. A nurse is performing a breast examination and notes a small, hard, non-tender fixed mass
in the upper outer quadrant. What should be the next step?
A. Inform the patient it is likely a benign cyst
, B. Tell the patient to return in 6 months for a re-evaluation
C. Instruct the patient to increase caffeine intake
D. Document the findings and report them to the healthcare provider
Correct Answer: D
Expert Explanation: The upper outer quadrant (Tail of Spence) is the most common site
for breast tumors. A fixed, non-tender, hard mass is a suspicious finding that requires
further diagnostic testing such as a mammogram or ultrasound. The nurse’s responsibility
is to document the precise location and characteristics and notify the physician
immediately.
5. Which test is used to assess for a meniscus tear in the knee?
A. McMurray’s test
B. Bulge sign
C. Phalen’s test
D. Lachman’s test
Correct Answer: A
Expert Explanation: McMurray’s test is performed by rotating the lower leg while
extending the knee to check for pain or a ‘click,’ which indicates a torn meniscus. The bulge
sign is used to detect small amounts of fluid in the knee joint. Lachman’s test is primarily
used to assess the integrity of the Anterior Cruciate Ligament (ACL).
Health Assessment Q&A with Rationale |
William Paterson University
1. A patient is asked to smile, frown, and puff out their cheeks. Which cranial nerve is the
nurse assessing?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve XII (Hypoglossal)
C. Cranial Nerve IX (Glossopharyngeal)
D. Cranial Nerve VII (Facial)
Correct Answer: D
Expert Explanation: Cranial Nerve VII, the facial nerve, is responsible for motor symmetry
of the face. The nurse observes for any drooping or weakness while the patient performs
these expressions. Damage to this nerve is often associated with Bell’s palsy or stroke.
2. When assessing the Deep Tendon Reflexes (DTR) of a patient, the nurse notes a very brisk
response with clonus. How should this be documented?
A. 1+
B. 4+
C. 3+
,D. 2+
Correct Answer: B
Expert Explanation: A 4+ reflex grade indicates a very brisk, hyperactive response with
intermittent or sustained clonus. This finding is often indicative of upper motor neuron
disease. A normal, expected reflex response is typically documented as 2+.
3. During a musculoskeletal exam, the nurse asks the patient to move their arm away from
the midline of the body. What is this movement called?
A. Adduction
B. Flexion
C. Abduction
D. Extension
Correct Answer: C
Expert Explanation: Abduction is the movement of a limb or other part away from the
midline of the body. Adduction is the opposite movement, bringing the limb closer to the
midline. Understanding these terms is essential for documenting range of motion
accurately.
4. A nurse is performing a breast examination and notes a small, hard, non-tender fixed mass
in the upper outer quadrant. What should be the next step?
A. Inform the patient it is likely a benign cyst
, B. Tell the patient to return in 6 months for a re-evaluation
C. Instruct the patient to increase caffeine intake
D. Document the findings and report them to the healthcare provider
Correct Answer: D
Expert Explanation: The upper outer quadrant (Tail of Spence) is the most common site
for breast tumors. A fixed, non-tender, hard mass is a suspicious finding that requires
further diagnostic testing such as a mammogram or ultrasound. The nurse’s responsibility
is to document the precise location and characteristics and notify the physician
immediately.
5. Which test is used to assess for a meniscus tear in the knee?
A. McMurray’s test
B. Bulge sign
C. Phalen’s test
D. Lachman’s test
Correct Answer: A
Expert Explanation: McMurray’s test is performed by rotating the lower leg while
extending the knee to check for pain or a ‘click,’ which indicates a torn meniscus. The bulge
sign is used to detect small amounts of fluid in the knee joint. Lachman’s test is primarily
used to assess the integrity of the Anterior Cruciate Ligament (ACL).
