NUR 3270/NUR3270 Exam 4 V2 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing the Cranial Nerve VII (Facial Nerve), which action should the nurse ask the
patient to perform?
A. Shrug the shoulders against resistance
B. Stick out the tongue and move it side to side
C. Smile, frown, and puff out the cheeks
D. Read a Snellen eye chart from 20 feet away
Correct Answer: C
Expert Explanation: Cranial Nerve VII is responsible for the motor function of facial
expressions. Asking the patient to smile, frown, and puff their cheeks allows the nurse to
check for symmetry and muscle strength. Asymmetry could indicate a lesion or condition
such as Bell’s palsy or a stroke.
2. A nurse is performing a musculoskeletal assessment and notes a lateral curvature of the
thoracic spine. This finding is documented as:
A. Scoliosis
B. Lordosis
C. Kyphosis
,D. Ankylosis
Correct Answer: A
Expert Explanation: Scoliosis is defined as a lateral S-shaped curvature of the thoracic and
lumbar spine. It is often assessed during adolescence using the Adams Forward Bend test.
Kyphosis refers to an exaggerated outward curvature of the thoracic spine, while lordosis
is an inward curvature of the lumbar spine.
3. During a breast exam, the nurse knows that most breast tumors are located in which
quadrant?
A. Upper Outer Quadrant
B. Upper Inner Quadrant
C. Lower Outer Quadrant
D. Lower Inner Quadrant
Correct Answer: A
Expert Explanation: The Upper Outer Quadrant, which contains the Tail of Spence, is the
most common site for breast cancer. This area extends into the axilla and contains a high
concentration of glandular tissue. Nurses must ensure this specific region is thoroughly
palpated during every clinical breast examination.
4. Which finding is considered a normal response when testing the plantar reflex (Babinski) in
a healthy adult?
A. Dorsiflexion of the big toe with fanning of other toes
, B. Plantar flexion of the toes
C. No movement of the toes at all
D. Withdrawal of the foot from the stimulus
Correct Answer: B
Expert Explanation: In a healthy adult, the normal response to the plantar reflex is the
curling downward of the toes, which is plantar flexion. A positive Babinski sign, involving
dorsiflexion of the big toe, is normal in infants but abnormal in adults. An abnormal
Babinski in an adult suggests upper motor neuron disease.
5. To assess for carpal tunnel syndrome, the nurse asks the patient to hold their hands back-
to-back while flexing the wrists 90 degrees for 60 seconds. This test is known as:
A. Phalen’s Test
B. Tinel’s Sign
C. McMurray’s Test
D. Bulge Sign
Correct Answer: A
Expert Explanation: Phalen’s test compresses the median nerve to elicit symptoms of
carpal tunnel syndrome. If the patient experiences numbness or burning within 60
seconds, the test is considered positive. Tinel’s sign involves percussion over the median
nerve at the wrist.
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing the Cranial Nerve VII (Facial Nerve), which action should the nurse ask the
patient to perform?
A. Shrug the shoulders against resistance
B. Stick out the tongue and move it side to side
C. Smile, frown, and puff out the cheeks
D. Read a Snellen eye chart from 20 feet away
Correct Answer: C
Expert Explanation: Cranial Nerve VII is responsible for the motor function of facial
expressions. Asking the patient to smile, frown, and puff their cheeks allows the nurse to
check for symmetry and muscle strength. Asymmetry could indicate a lesion or condition
such as Bell’s palsy or a stroke.
2. A nurse is performing a musculoskeletal assessment and notes a lateral curvature of the
thoracic spine. This finding is documented as:
A. Scoliosis
B. Lordosis
C. Kyphosis
,D. Ankylosis
Correct Answer: A
Expert Explanation: Scoliosis is defined as a lateral S-shaped curvature of the thoracic and
lumbar spine. It is often assessed during adolescence using the Adams Forward Bend test.
Kyphosis refers to an exaggerated outward curvature of the thoracic spine, while lordosis
is an inward curvature of the lumbar spine.
3. During a breast exam, the nurse knows that most breast tumors are located in which
quadrant?
A. Upper Outer Quadrant
B. Upper Inner Quadrant
C. Lower Outer Quadrant
D. Lower Inner Quadrant
Correct Answer: A
Expert Explanation: The Upper Outer Quadrant, which contains the Tail of Spence, is the
most common site for breast cancer. This area extends into the axilla and contains a high
concentration of glandular tissue. Nurses must ensure this specific region is thoroughly
palpated during every clinical breast examination.
4. Which finding is considered a normal response when testing the plantar reflex (Babinski) in
a healthy adult?
A. Dorsiflexion of the big toe with fanning of other toes
, B. Plantar flexion of the toes
C. No movement of the toes at all
D. Withdrawal of the foot from the stimulus
Correct Answer: B
Expert Explanation: In a healthy adult, the normal response to the plantar reflex is the
curling downward of the toes, which is plantar flexion. A positive Babinski sign, involving
dorsiflexion of the big toe, is normal in infants but abnormal in adults. An abnormal
Babinski in an adult suggests upper motor neuron disease.
5. To assess for carpal tunnel syndrome, the nurse asks the patient to hold their hands back-
to-back while flexing the wrists 90 degrees for 60 seconds. This test is known as:
A. Phalen’s Test
B. Tinel’s Sign
C. McMurray’s Test
D. Bulge Sign
Correct Answer: A
Expert Explanation: Phalen’s test compresses the median nerve to elicit symptoms of
carpal tunnel syndrome. If the patient experiences numbness or burning within 60
seconds, the test is considered positive. Tinel’s sign involves percussion over the median
nerve at the wrist.
