NUR 3270/NUR3270 Exam 4 V3 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing a patient’s cranial nerves, the nurse asks the patient to smile, frown, and
puff out their cheeks. Which cranial nerve is being tested?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve VII (Facial)
C. Cranial Nerve II (Optic)
D. Cranial Nerve X (Vagus)
Correct Answer: B
Expert Explanation: Cranial nerve VII is the facial nerve, which is responsible for the
motor activities of the muscles of facial expression. By asking the patient to smile, frown, or
puff out cheeks, the nurse can assess for symmetry and muscle strength. Asymmetry in
these movements may indicate a neurological deficit such as Bell’s palsy or a stroke.
2. During a musculoskeletal assessment, the nurse notes a grating sound and sensation when
the patient moves their knee. What is the correct term for this finding?
A. Subluxation
B. Effusion
C. Crepitus
,D. Ankylosis
Correct Answer: C
Expert Explanation: Crepitus is a dry, crackling, or grating sound or sensation caused by
the rubbing together of dry surfaces of joints. It often occurs in patients with osteoarthritis
when the articular cartilage has worn away. This finding should be documented and
further investigated to determine the extent of joint damage.
3. The nurse is performing a breast examination and identifies a mass in the upper outer
quadrant. Why is this specific location significant?
A. This is the Tail of Spence, where most breast tumors are found.
B. This area is primarily composed of fatty tissue and rarely contains tumors.
C. It is the location of the milk ducts, which are prone to infection.
D. This area is less accessible for palpation during a self-exam.
Correct Answer: A
Expert Explanation: The upper outer quadrant of the breast, which includes the Tail of
Spence, is the most common site for breast cancer. This area contains a high concentration
of glandular tissue compared to other quadrants. Accurate palpation of this region is a
critical component of a comprehensive breast health assessment.
4. A patient exhibits a positive Romberg test. How should the nurse interpret this finding?
A. The patient has difficulty maintaining balance with eyes closed.
, B. The patient has a loss of motor strength in the lower extremities.
C. The patient has a deficiency in the oculomotor nerve.
D. The patient has normal cerebellar function.
Correct Answer: A
Expert Explanation: A positive Romberg test occurs when a patient loses balance and
steps out when their eyes are closed. This test assesses the integrity of the sensory system,
specifically proprioception and vestibular function. It helps the nurse identify issues
related to the cerebellum or the posterior columns of the spinal cord.
5. Which reflex grade is considered normal and active during a neurological physical
examination?
A. 2+
B. 1+
C. 3+
D. 4+
Correct Answer: A
Expert Explanation: Deep tendon reflexes are graded on a 0 to 4+ scale, where 2+ is the
standard expected response. A grade of 1+ indicates a diminished reflex, while 3+ is brisker
than average. Recognizing 2+ as normal allows the nurse to distinguish between healthy
neurological function and potential abnormalities.
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing a patient’s cranial nerves, the nurse asks the patient to smile, frown, and
puff out their cheeks. Which cranial nerve is being tested?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve VII (Facial)
C. Cranial Nerve II (Optic)
D. Cranial Nerve X (Vagus)
Correct Answer: B
Expert Explanation: Cranial nerve VII is the facial nerve, which is responsible for the
motor activities of the muscles of facial expression. By asking the patient to smile, frown, or
puff out cheeks, the nurse can assess for symmetry and muscle strength. Asymmetry in
these movements may indicate a neurological deficit such as Bell’s palsy or a stroke.
2. During a musculoskeletal assessment, the nurse notes a grating sound and sensation when
the patient moves their knee. What is the correct term for this finding?
A. Subluxation
B. Effusion
C. Crepitus
,D. Ankylosis
Correct Answer: C
Expert Explanation: Crepitus is a dry, crackling, or grating sound or sensation caused by
the rubbing together of dry surfaces of joints. It often occurs in patients with osteoarthritis
when the articular cartilage has worn away. This finding should be documented and
further investigated to determine the extent of joint damage.
3. The nurse is performing a breast examination and identifies a mass in the upper outer
quadrant. Why is this specific location significant?
A. This is the Tail of Spence, where most breast tumors are found.
B. This area is primarily composed of fatty tissue and rarely contains tumors.
C. It is the location of the milk ducts, which are prone to infection.
D. This area is less accessible for palpation during a self-exam.
Correct Answer: A
Expert Explanation: The upper outer quadrant of the breast, which includes the Tail of
Spence, is the most common site for breast cancer. This area contains a high concentration
of glandular tissue compared to other quadrants. Accurate palpation of this region is a
critical component of a comprehensive breast health assessment.
4. A patient exhibits a positive Romberg test. How should the nurse interpret this finding?
A. The patient has difficulty maintaining balance with eyes closed.
, B. The patient has a loss of motor strength in the lower extremities.
C. The patient has a deficiency in the oculomotor nerve.
D. The patient has normal cerebellar function.
Correct Answer: A
Expert Explanation: A positive Romberg test occurs when a patient loses balance and
steps out when their eyes are closed. This test assesses the integrity of the sensory system,
specifically proprioception and vestibular function. It helps the nurse identify issues
related to the cerebellum or the posterior columns of the spinal cord.
5. Which reflex grade is considered normal and active during a neurological physical
examination?
A. 2+
B. 1+
C. 3+
D. 4+
Correct Answer: A
Expert Explanation: Deep tendon reflexes are graded on a 0 to 4+ scale, where 2+ is the
standard expected response. A grade of 1+ indicates a diminished reflex, while 3+ is brisker
than average. Recognizing 2+ as normal allows the nurse to distinguish between healthy
neurological function and potential abnormalities.
