NUR 3270/NUR3270 Exam 4 V1 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing the neurological status of an adult patient, the nurse notes a positive
Romberg test. What is the most accurate interpretation of this finding?
A. The patient has a significant loss of motor strength in the lower extremities.
B. The patient exhibits normal balance and vestibular function.
C. The patient has a deficit in cerebellar function or proprioception.
D. The patient is experiencing a lesion in the frontal lobe of the brain.
Correct Answer: C
Expert Explanation: A positive Romberg sign occurs when a patient loses balance while
standing with eyes closed and feet together. This indicates a problem with proprioception,
vestibular function, or cerebellar coordination. The nurse should ensure patient safety by
standing nearby during this assessment to prevent falls.
2. A nurse is performing a musculoskeletal assessment on an older adult. Which finding is
considered a common age-related change in the spinal column?
A. Kyphosis or an exaggerated thoracic curve
B. Increased lumbar lordosis
C. Lateral deviation known as scoliosis
,D. Increased height due to intervertebral expansion
Correct Answer: A
Expert Explanation: Kyphosis is an outward curvature of the thoracic spine that is
commonly seen in the elderly population due to osteoporosis or disc thinning. This change
often leads to a decrease in height and a change in the center of gravity. It is distinct from
lordosis, which is an inward curve of the lumbar region often seen in pregnancy.
3. During a breast examination, the nurse palpates a firm, non-tender, fixed mass in the
upper outer quadrant. Which action is the priority?
A. Document the finding as a normal fibrocystic change.
B. Notify the healthcare provider for further diagnostic testing.
C. Advise the patient to re-check the area after her next period.
D. Perform a vigorous massage of the area to see if it dissipates.
Correct Answer: B
Expert Explanation: A firm, fixed, and non-tender mass is highly suspicious for
malignancy and requires immediate follow-up. The upper outer quadrant is the most
common site for breast cancer because it contains the Tail of Spence. The nurse should
facilitate imaging such as a mammogram or ultrasound as ordered by the provider.
4. Which cranial nerve is the nurse assessing when asking the patient to shrug their shoulders
against resistance?
A. Cranial Nerve IX (Glossopharyngeal)
, B. Cranial Nerve XI (Spinal Accessory)
C. Cranial Nerve X (Vagus)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: B
Expert Explanation: Cranial Nerve XI, the Spinal Accessory nerve, controls the trapezius
and sternocleidomastoid muscles. To assess its function, the nurse asks the patient to shrug
their shoulders and turn their head against resistance. Weakness or asymmetry in these
movements could indicate nerve damage or muscle pathology.
5. The nurse is assessing a patient for carpal tunnel syndrome. Which maneuver involves the
patient holding their hands back-to-back at a 90-degree angle for 60 seconds?
A. Tinel’s sign
B. Lasegue’s test
C. Bulge sign
D. Phalen’s test
Correct Answer: D
Expert Explanation: Phalen’s test is a specific assessment tool used to identify
compression of the median nerve in the carpal tunnel. If the patient experiences numbness
or burning within 60 seconds, the test is considered positive. This maneuver helps
differentiate carpal tunnel syndrome from other wrist or hand injuries.
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing the neurological status of an adult patient, the nurse notes a positive
Romberg test. What is the most accurate interpretation of this finding?
A. The patient has a significant loss of motor strength in the lower extremities.
B. The patient exhibits normal balance and vestibular function.
C. The patient has a deficit in cerebellar function or proprioception.
D. The patient is experiencing a lesion in the frontal lobe of the brain.
Correct Answer: C
Expert Explanation: A positive Romberg sign occurs when a patient loses balance while
standing with eyes closed and feet together. This indicates a problem with proprioception,
vestibular function, or cerebellar coordination. The nurse should ensure patient safety by
standing nearby during this assessment to prevent falls.
2. A nurse is performing a musculoskeletal assessment on an older adult. Which finding is
considered a common age-related change in the spinal column?
A. Kyphosis or an exaggerated thoracic curve
B. Increased lumbar lordosis
C. Lateral deviation known as scoliosis
,D. Increased height due to intervertebral expansion
Correct Answer: A
Expert Explanation: Kyphosis is an outward curvature of the thoracic spine that is
commonly seen in the elderly population due to osteoporosis or disc thinning. This change
often leads to a decrease in height and a change in the center of gravity. It is distinct from
lordosis, which is an inward curve of the lumbar region often seen in pregnancy.
3. During a breast examination, the nurse palpates a firm, non-tender, fixed mass in the
upper outer quadrant. Which action is the priority?
A. Document the finding as a normal fibrocystic change.
B. Notify the healthcare provider for further diagnostic testing.
C. Advise the patient to re-check the area after her next period.
D. Perform a vigorous massage of the area to see if it dissipates.
Correct Answer: B
Expert Explanation: A firm, fixed, and non-tender mass is highly suspicious for
malignancy and requires immediate follow-up. The upper outer quadrant is the most
common site for breast cancer because it contains the Tail of Spence. The nurse should
facilitate imaging such as a mammogram or ultrasound as ordered by the provider.
4. Which cranial nerve is the nurse assessing when asking the patient to shrug their shoulders
against resistance?
A. Cranial Nerve IX (Glossopharyngeal)
, B. Cranial Nerve XI (Spinal Accessory)
C. Cranial Nerve X (Vagus)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: B
Expert Explanation: Cranial Nerve XI, the Spinal Accessory nerve, controls the trapezius
and sternocleidomastoid muscles. To assess its function, the nurse asks the patient to shrug
their shoulders and turn their head against resistance. Weakness or asymmetry in these
movements could indicate nerve damage or muscle pathology.
5. The nurse is assessing a patient for carpal tunnel syndrome. Which maneuver involves the
patient holding their hands back-to-back at a 90-degree angle for 60 seconds?
A. Tinel’s sign
B. Lasegue’s test
C. Bulge sign
D. Phalen’s test
Correct Answer: D
Expert Explanation: Phalen’s test is a specific assessment tool used to identify
compression of the median nerve in the carpal tunnel. If the patient experiences numbness
or burning within 60 seconds, the test is considered positive. This maneuver helps
differentiate carpal tunnel syndrome from other wrist or hand injuries.
