NUR 2092/NUR2092 Exam 3 V3 | Health
Assessment Q&A with Rationale |
Rasmussen University
1. When assessing a patient’s visual acuity using a Snellen chart, the nurse records the result
as 20/50. What does this finding indicate?
A. The patient has normal vision and does not require further testing.
B. The patient can see at 50 feet what a normal eye sees at 20 feet.
C. The patient has 20% vision in the left eye and 50% in the right eye.
D. The patient can see at 20 feet what a normal eye sees at 50 feet.
Answer: D
Rationale: In the Snellen chart reading, the top number represents the distance from the
chart, which is standard at 20 feet. The bottom number indicates the distance at which a
person with normal vision could read the same line. A finding of 20/50 suggests that the
patient’s vision is worse than normal, as they must be closer to see what others see from
further away.
2. During a neurological exam, the nurse asks the patient to identify a common object, such
as a key, placed in their hand while their eyes are closed. This tests for:
A. Stereognosis
B. Proprioception
,C. Graphesthesia
D. Kinesthesia
Answer: A
Rationale: Stereognosis is the ability to recognize objects by feeling their form, size, and
weight while the eyes are closed. This test assesses the sensory cortex and the posterior
column of the spinal cord. Inability to identify the object is known as astereognosis, which
may indicate a parietal lobe lesion.
3. The nurse is assessing the deep tendon reflexes of a patient and notes a very brisk
response with clonus. How should the nurse grade this reflex?
A. 1+
B. 2+
C. 3+
D. 4+
Answer: D
Rationale: Reflexes are graded on a scale from 0 to 4+, where 2+ is considered a normal,
expected finding. A grade of 4+ is characterized by very brisk, hyperactive responses with
clonus, which is often indicative of upper motor neuron disease. Grade 1+ indicates a
diminished or sluggish response, while 3+ is brisker than average but not necessarily
pathological.
, 4. Which cranial nerve is being assessed when the nurse asks the patient to stick out their
tongue and move it from side to side?
A. Cranial Nerve IX
B. Cranial Nerve X
C. Cranial Nerve XII
D. Cranial Nerve XI
Answer: C
Rationale: Cranial nerve XII is the hypoglossal nerve, which controls the motor functions
of the tongue. The nurse observes for symmetry, tremors, and the patient’s ability to move
the tongue in various directions. Deviations to one side or muscle wasting may indicate
nerve damage on the affected side.
5. A patient presents with a ‘pins and needles’ sensation in the thumb, index, and middle
fingers. The nurse performs Phalen’s test. A positive result would most likely indicate:
A. Ulnar nerve compression
B. Rheumatoid arthritis
C. Carpal tunnel syndrome
D. Radial nerve palsy
Answer: C
Assessment Q&A with Rationale |
Rasmussen University
1. When assessing a patient’s visual acuity using a Snellen chart, the nurse records the result
as 20/50. What does this finding indicate?
A. The patient has normal vision and does not require further testing.
B. The patient can see at 50 feet what a normal eye sees at 20 feet.
C. The patient has 20% vision in the left eye and 50% in the right eye.
D. The patient can see at 20 feet what a normal eye sees at 50 feet.
Answer: D
Rationale: In the Snellen chart reading, the top number represents the distance from the
chart, which is standard at 20 feet. The bottom number indicates the distance at which a
person with normal vision could read the same line. A finding of 20/50 suggests that the
patient’s vision is worse than normal, as they must be closer to see what others see from
further away.
2. During a neurological exam, the nurse asks the patient to identify a common object, such
as a key, placed in their hand while their eyes are closed. This tests for:
A. Stereognosis
B. Proprioception
,C. Graphesthesia
D. Kinesthesia
Answer: A
Rationale: Stereognosis is the ability to recognize objects by feeling their form, size, and
weight while the eyes are closed. This test assesses the sensory cortex and the posterior
column of the spinal cord. Inability to identify the object is known as astereognosis, which
may indicate a parietal lobe lesion.
3. The nurse is assessing the deep tendon reflexes of a patient and notes a very brisk
response with clonus. How should the nurse grade this reflex?
A. 1+
B. 2+
C. 3+
D. 4+
Answer: D
Rationale: Reflexes are graded on a scale from 0 to 4+, where 2+ is considered a normal,
expected finding. A grade of 4+ is characterized by very brisk, hyperactive responses with
clonus, which is often indicative of upper motor neuron disease. Grade 1+ indicates a
diminished or sluggish response, while 3+ is brisker than average but not necessarily
pathological.
, 4. Which cranial nerve is being assessed when the nurse asks the patient to stick out their
tongue and move it from side to side?
A. Cranial Nerve IX
B. Cranial Nerve X
C. Cranial Nerve XII
D. Cranial Nerve XI
Answer: C
Rationale: Cranial nerve XII is the hypoglossal nerve, which controls the motor functions
of the tongue. The nurse observes for symmetry, tremors, and the patient’s ability to move
the tongue in various directions. Deviations to one side or muscle wasting may indicate
nerve damage on the affected side.
5. A patient presents with a ‘pins and needles’ sensation in the thumb, index, and middle
fingers. The nurse performs Phalen’s test. A positive result would most likely indicate:
A. Ulnar nerve compression
B. Rheumatoid arthritis
C. Carpal tunnel syndrome
D. Radial nerve palsy
Answer: C
