NUR 2092/NUR2092 Exam 3 V2 | Health
Assessment Q&A with Rationale |
Rasmussen University
1. When assessing the musculoskeletal system, a nurse asks the patient to move their arm
away from the midline of the body. What is the correct term for this movement?
A. Adduction
B. Extension
C. Circumduction
D. Abduction
Correct Answer: D
Expert Explanation: Abduction is the movement of a limb away from the midline of the
body. In contrast, adduction moves the limb toward the midline. This distinction is vital for
accurately documenting range of motion during a physical assessment.
2. The nurse is performing a neurological assessment and wants to test Cranial Nerve II.
Which tool should the nurse use?
A. Reflex hammer
B. Snellen eye chart
C. Tuning fork
,D. Cotton wisp
Correct Answer: B
Expert Explanation: Cranial Nerve II is the optic nerve, which is responsible for vision and
visual acuity. The Snellen chart is the standard tool used to measure how well a patient can
see at a distance. Testing this nerve helps identify potential deficits in the sensory visual
pathway.
3. During a breast examination, where is the most common site for breast tumors to occur?
A. Upper inner quadrant
B. Upper outer quadrant
C. Lower outer quadrant
D. Lower inner quadrant
Correct Answer: B
Expert Explanation: The upper outer quadrant contains the Tail of Spence, which projects
into the axilla. This specific area is the most frequent location for both benign and
malignant breast tumors. It is essential for nurses to palpate this region thoroughly during
every clinical breast exam.
4. A nurse is testing a patient’s deep tendon reflexes and notes that the response is very brisk
with clonus. How should this be documented?
A. 1+
, B. 4+
C. 3+
D. 2+
Correct Answer: B
Expert Explanation: A reflex grade of 4+ indicates a very brisk response that is
hyperactive and often associated with clonus. A normal reflex is typically graded as 2+,
while 1+ is diminished and 3+ is brisker than average. This finding may suggest upper
motor neuron disease or other neurological conditions.
5. Which assessment technique is used to check for the presence of a large amount of fluid in
the knee joint?
A. Ballottement of the patella
B. Bulge sign
C. McMurray test
D. Phalen test
Correct Answer: A
Expert Explanation: Ballottement of the patella is used when larger amounts of fluid are
suspected in the suprapatellar pouch. The nurse pushes the patella down against the femur,
and if fluid is present, the patella will bounce back. This is different from the bulge sign,
which is used for smaller amounts of fluid.
Assessment Q&A with Rationale |
Rasmussen University
1. When assessing the musculoskeletal system, a nurse asks the patient to move their arm
away from the midline of the body. What is the correct term for this movement?
A. Adduction
B. Extension
C. Circumduction
D. Abduction
Correct Answer: D
Expert Explanation: Abduction is the movement of a limb away from the midline of the
body. In contrast, adduction moves the limb toward the midline. This distinction is vital for
accurately documenting range of motion during a physical assessment.
2. The nurse is performing a neurological assessment and wants to test Cranial Nerve II.
Which tool should the nurse use?
A. Reflex hammer
B. Snellen eye chart
C. Tuning fork
,D. Cotton wisp
Correct Answer: B
Expert Explanation: Cranial Nerve II is the optic nerve, which is responsible for vision and
visual acuity. The Snellen chart is the standard tool used to measure how well a patient can
see at a distance. Testing this nerve helps identify potential deficits in the sensory visual
pathway.
3. During a breast examination, where is the most common site for breast tumors to occur?
A. Upper inner quadrant
B. Upper outer quadrant
C. Lower outer quadrant
D. Lower inner quadrant
Correct Answer: B
Expert Explanation: The upper outer quadrant contains the Tail of Spence, which projects
into the axilla. This specific area is the most frequent location for both benign and
malignant breast tumors. It is essential for nurses to palpate this region thoroughly during
every clinical breast exam.
4. A nurse is testing a patient’s deep tendon reflexes and notes that the response is very brisk
with clonus. How should this be documented?
A. 1+
, B. 4+
C. 3+
D. 2+
Correct Answer: B
Expert Explanation: A reflex grade of 4+ indicates a very brisk response that is
hyperactive and often associated with clonus. A normal reflex is typically graded as 2+,
while 1+ is diminished and 3+ is brisker than average. This finding may suggest upper
motor neuron disease or other neurological conditions.
5. Which assessment technique is used to check for the presence of a large amount of fluid in
the knee joint?
A. Ballottement of the patella
B. Bulge sign
C. McMurray test
D. Phalen test
Correct Answer: A
Expert Explanation: Ballottement of the patella is used when larger amounts of fluid are
suspected in the suprapatellar pouch. The nurse pushes the patella down against the femur,
and if fluid is present, the patella will bounce back. This is different from the bulge sign,
which is used for smaller amounts of fluid.
