NUR 2092/NUR2092 Exam 4 V2 | Health
Assessment Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a patient’s cranial nerves. To test Cranial Nerve VII (Facial), which
action should the nurse ask the patient to perform?
A. Stick out the tongue and move it side to side.
B. Shrug the shoulders against resistance.
C. Clench the teeth while palpating masseter muscles.
D. Smile, frown, and puff out the cheeks.
Answer: D
Rationale: Cranial Nerve VII, the facial nerve, is responsible for the muscles of facial
expression. By asking the patient to smile, frown, and puff out their cheeks, the nurse can
evaluate the symmetry and strength of these muscles. If the patient is unable to perform
these tasks symmetrically, it may indicate a cranial nerve palsy or central nervous system
lesion.
2. During a neurological assessment, the nurse uses the Glasgow Coma Scale (GCS). Which
three areas are evaluated in this scale?
A. Pupillary response, motor response, and speech clarity.
B. Deep tendon reflexes, gait, and sensory perception.
,C. Level of consciousness, orientation, and memory.
D. Eye opening, verbal response, and motor response.
Answer: D
Rationale: The Glasgow Coma Scale is a standardized tool used to assess the level of
consciousness in patients with acute brain injury. It evaluates three specific categories: eye
opening, verbal response, and motor response. Each category is scored individually, and
the total score helps clinicians determine the severity of neurological impairment.
3. The nurse is performing the Romberg test. What is the correct procedure for this
assessment?
A. The patient stands with feet together and eyes closed for 20 seconds.
B. The patient walks in a straight line, heel-to-toe.
C. The patient hops on one foot and then the other.
D. The patient touches their nose with their eyes closed.
Answer: A
Rationale: The Romberg test is used to evaluate cerebellar function and proprioception
regarding balance. The patient is asked to stand with feet together and arms at the side,
first with eyes open and then with eyes closed. A positive Romberg sign occurs if the
patient loses balance when the eyes are closed, indicating a problem with vestibular or
sensory input.
, 4. A patient presents with joint pain that is worse in the morning but improves with activity.
The nurse notes Heberden and Bouchard nodes on the fingers. Which condition is most
likely?
A. Rheumatoid Arthritis
B. Gouty Arthritis
C. Osteoarthritis
D. Systemic Lupus Erythematosus
Answer: C
Rationale: Osteoarthritis is a degenerative joint disease characterized by the wearing
down of articular cartilage. Heberden nodes (distal joints) and Bouchard nodes (proximal
joints) are classic physical findings of this condition. Unlike rheumatoid arthritis, the pain
in osteoarthritis often improves after the joints are moved and warmed up.
5. When assessing deep tendon reflexes, the nurse finds that the patient’s patellar reflex is
very brisk and hyperactive with clonus. How should this be documented?
A. 4+
B. 2+
C. 3+
D. 1+
Answer: A
Assessment Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a patient’s cranial nerves. To test Cranial Nerve VII (Facial), which
action should the nurse ask the patient to perform?
A. Stick out the tongue and move it side to side.
B. Shrug the shoulders against resistance.
C. Clench the teeth while palpating masseter muscles.
D. Smile, frown, and puff out the cheeks.
Answer: D
Rationale: Cranial Nerve VII, the facial nerve, is responsible for the muscles of facial
expression. By asking the patient to smile, frown, and puff out their cheeks, the nurse can
evaluate the symmetry and strength of these muscles. If the patient is unable to perform
these tasks symmetrically, it may indicate a cranial nerve palsy or central nervous system
lesion.
2. During a neurological assessment, the nurse uses the Glasgow Coma Scale (GCS). Which
three areas are evaluated in this scale?
A. Pupillary response, motor response, and speech clarity.
B. Deep tendon reflexes, gait, and sensory perception.
,C. Level of consciousness, orientation, and memory.
D. Eye opening, verbal response, and motor response.
Answer: D
Rationale: The Glasgow Coma Scale is a standardized tool used to assess the level of
consciousness in patients with acute brain injury. It evaluates three specific categories: eye
opening, verbal response, and motor response. Each category is scored individually, and
the total score helps clinicians determine the severity of neurological impairment.
3. The nurse is performing the Romberg test. What is the correct procedure for this
assessment?
A. The patient stands with feet together and eyes closed for 20 seconds.
B. The patient walks in a straight line, heel-to-toe.
C. The patient hops on one foot and then the other.
D. The patient touches their nose with their eyes closed.
Answer: A
Rationale: The Romberg test is used to evaluate cerebellar function and proprioception
regarding balance. The patient is asked to stand with feet together and arms at the side,
first with eyes open and then with eyes closed. A positive Romberg sign occurs if the
patient loses balance when the eyes are closed, indicating a problem with vestibular or
sensory input.
, 4. A patient presents with joint pain that is worse in the morning but improves with activity.
The nurse notes Heberden and Bouchard nodes on the fingers. Which condition is most
likely?
A. Rheumatoid Arthritis
B. Gouty Arthritis
C. Osteoarthritis
D. Systemic Lupus Erythematosus
Answer: C
Rationale: Osteoarthritis is a degenerative joint disease characterized by the wearing
down of articular cartilage. Heberden nodes (distal joints) and Bouchard nodes (proximal
joints) are classic physical findings of this condition. Unlike rheumatoid arthritis, the pain
in osteoarthritis often improves after the joints are moved and warmed up.
5. When assessing deep tendon reflexes, the nurse finds that the patient’s patellar reflex is
very brisk and hyperactive with clonus. How should this be documented?
A. 4+
B. 2+
C. 3+
D. 1+
Answer: A
