NR414 Exam 3: Health Assessment Across the Lifespan V2
Updated and Latest Questions and Correct Answers- Regis
University
1. When assessing a 75-year-old patient, the nurse notes an increased forward curvature of
the thoracic spine. What is this condition called?
A. Kyphosis
B. Scoliosis
C. Lordosis
D. Ankylosis
Correct Answer: A
Explanation: Kyphosis is a common postural change associated with the aging process. It involves an
exaggerated outward curvature of the thoracic spine. This condition often results from osteoporosis or
disc degeneration in older adults. Nurses must assess for kyphosis to determine its impact on respiratory
expansion. Lordosis is typically an inward curvature of the lumbar spine seen in pregnancy. Scoliosis is a
lateral curvature most often identified during adolescence. Ankylosis refers to the stiffening or fixation of
a joint due to disease. Identifying spinal deformities is crucial for developing a mobility care plan. The
nurse should document the degree of curvature and any associated pain. This assessment helps in
preventing further complications related to balance and posture.
2. A nurse is testing the function of Cranial Nerve II. Which tool should the nurse use?
A. Tuning fork
B. Penlight
C. Snellen chart
D. Ophthalmoscope
Correct Answer: C
Explanation: Cranial Nerve II is the optic nerve responsible for visual acuity and visual fields. The
Snellen chart is the standard tool used to measure central visual acuity. Patients stand 20 feet away and
read the smallest line possible. A penlight is used to test the pupillary light reflex involving Cranial Nerve
III. A tuning fork is utilized for hearing tests related to Cranial Nerve VIII. An ophthalmoscope allows for
internal eye examination but is not the primary tool for acuity. Accurate assessment of visual acuity is
essential for patient safety. Changes in vision can indicate neurological issues or primary eye disease. The
nurse must ensure the patient wears corrective lenses if prescribed during testing. Documenting the
results as a fraction provides a standardized measure of sight.
,3. Which reflex is considered a normal finding in a 2-month-old infant but abnormal in an
adult?
A. Babinski reflex
B. Patellar reflex
C. Biceps reflex
D. Achilles reflex
Correct Answer: A
Explanation: The Babinski reflex is a primitive reflex found in infants due to immature myelination.
When the sole of the foot is stroked, the toes fan out in a positive response. This finding is normal until
approximately 24 months of age. In an adult, the normal response is the plantar reflex where toes curl
downward. A positive Babinski in an adult indicates upper motor neuron disease. Patellar, biceps, and
Achilles reflexes are deep tendon reflexes present throughout life. These deep tendon reflexes are graded
on a scale from 0 to 4 plus. The disappearance of primitive reflexes marks significant neurological
development in pediatrics. Assessment of these reflexes is vital during neonatal and infant screenings.
Understanding age-appropriate responses prevents misinterpretation of neurological health.
4. The nurse asks the patient to identify a common object, like a key, placed in their hand
while their eyes are closed. What is this test called?
A. Graphesthesia
B. Extinction
C. Stereognosis
D. Two-point discrimination
Correct Answer: C
Explanation: Stereognosis tests the ability of the sensory cortex to perceive forms and nature of objects.
The patient must have intact fine touch and cognitive processing for this test. Graphesthesia involves
identifying numbers or letters traced on the palm of the hand. Extinction tests the ability to feel two
simultaneous touches on opposite sides of the body. Two-point discrimination determines the minimum
distance at which two stimuli are felt as separate. These tests evaluate the functions of the parietal lobe of
the brain. Failure to identify the object may indicate a lesion in the sensory cortex. The nurse should use
familiar objects to ensure the test is valid. It is important that the patient’s eyes remain closed throughout
the procedure. Documenting these findings helps track neurological recovery or decline.
, 5. During a musculoskeletal exam, the nurse performs the Phalen test. This test is used to
screen for which condition?
A. Herniated disc
B. Rotator cuff tear
C. Carpal tunnel syndrome
D. Hip dysplasia
Correct Answer: C
Explanation: The Phalen test involves holding the wrists in acute flexion for 60 seconds. Numbness or
burning during this maneuver suggests compression of the median nerve. This is a primary diagnostic
screening tool for carpal tunnel syndrome. Herniated discs are typically assessed via the straight leg raise
test. Rotator cuff integrity is often checked using the drop arm test or empty can test. Hip dysplasia in
infants is screened using the Ortolani and Barlow maneuvers. Occupational history often correlates with
positive Phalen test results in adults. Carpal tunnel results from repetitive motion and inflammation
within the wrist. The nurse should also check for Tinel’s sign by percussing the median nerve. Early
detection allows for conservative management like splinting or ergonomic changes.
6. A 4-year-old child is asked to stand on one foot and hop. Which area of the brain is being
assessed?
A. Cerebellum
B. Brainstem
C. Cerebrum
D. Hypothalamus
Correct Answer: A
Explanation: The cerebellum is responsible for coordination, balance, and voluntary muscle movements.
Hopping on one foot requires significant motor integration and equilibrium. Assessing a child’s gross
motor skills helps determine developmental progress. The cerebrum handles higher-level functions like
thought, emotion, and memory. The brainstem controls involuntary vital functions such as breathing and
heart rate. The hypothalamus regulates homeostasis, including temperature and hunger. If a child cannot
perform age-appropriate balance tasks, further neurological testing is needed. Ataxia is a term used to
describe uncoordinated or unsteady movements. Pediatric assessments rely heavily on observing the
child during play or specific tasks. The nurse must consider the child’s age and developmental stage when
interpreting results.
Updated and Latest Questions and Correct Answers- Regis
University
1. When assessing a 75-year-old patient, the nurse notes an increased forward curvature of
the thoracic spine. What is this condition called?
A. Kyphosis
B. Scoliosis
C. Lordosis
D. Ankylosis
Correct Answer: A
Explanation: Kyphosis is a common postural change associated with the aging process. It involves an
exaggerated outward curvature of the thoracic spine. This condition often results from osteoporosis or
disc degeneration in older adults. Nurses must assess for kyphosis to determine its impact on respiratory
expansion. Lordosis is typically an inward curvature of the lumbar spine seen in pregnancy. Scoliosis is a
lateral curvature most often identified during adolescence. Ankylosis refers to the stiffening or fixation of
a joint due to disease. Identifying spinal deformities is crucial for developing a mobility care plan. The
nurse should document the degree of curvature and any associated pain. This assessment helps in
preventing further complications related to balance and posture.
2. A nurse is testing the function of Cranial Nerve II. Which tool should the nurse use?
A. Tuning fork
B. Penlight
C. Snellen chart
D. Ophthalmoscope
Correct Answer: C
Explanation: Cranial Nerve II is the optic nerve responsible for visual acuity and visual fields. The
Snellen chart is the standard tool used to measure central visual acuity. Patients stand 20 feet away and
read the smallest line possible. A penlight is used to test the pupillary light reflex involving Cranial Nerve
III. A tuning fork is utilized for hearing tests related to Cranial Nerve VIII. An ophthalmoscope allows for
internal eye examination but is not the primary tool for acuity. Accurate assessment of visual acuity is
essential for patient safety. Changes in vision can indicate neurological issues or primary eye disease. The
nurse must ensure the patient wears corrective lenses if prescribed during testing. Documenting the
results as a fraction provides a standardized measure of sight.
,3. Which reflex is considered a normal finding in a 2-month-old infant but abnormal in an
adult?
A. Babinski reflex
B. Patellar reflex
C. Biceps reflex
D. Achilles reflex
Correct Answer: A
Explanation: The Babinski reflex is a primitive reflex found in infants due to immature myelination.
When the sole of the foot is stroked, the toes fan out in a positive response. This finding is normal until
approximately 24 months of age. In an adult, the normal response is the plantar reflex where toes curl
downward. A positive Babinski in an adult indicates upper motor neuron disease. Patellar, biceps, and
Achilles reflexes are deep tendon reflexes present throughout life. These deep tendon reflexes are graded
on a scale from 0 to 4 plus. The disappearance of primitive reflexes marks significant neurological
development in pediatrics. Assessment of these reflexes is vital during neonatal and infant screenings.
Understanding age-appropriate responses prevents misinterpretation of neurological health.
4. The nurse asks the patient to identify a common object, like a key, placed in their hand
while their eyes are closed. What is this test called?
A. Graphesthesia
B. Extinction
C. Stereognosis
D. Two-point discrimination
Correct Answer: C
Explanation: Stereognosis tests the ability of the sensory cortex to perceive forms and nature of objects.
The patient must have intact fine touch and cognitive processing for this test. Graphesthesia involves
identifying numbers or letters traced on the palm of the hand. Extinction tests the ability to feel two
simultaneous touches on opposite sides of the body. Two-point discrimination determines the minimum
distance at which two stimuli are felt as separate. These tests evaluate the functions of the parietal lobe of
the brain. Failure to identify the object may indicate a lesion in the sensory cortex. The nurse should use
familiar objects to ensure the test is valid. It is important that the patient’s eyes remain closed throughout
the procedure. Documenting these findings helps track neurological recovery or decline.
, 5. During a musculoskeletal exam, the nurse performs the Phalen test. This test is used to
screen for which condition?
A. Herniated disc
B. Rotator cuff tear
C. Carpal tunnel syndrome
D. Hip dysplasia
Correct Answer: C
Explanation: The Phalen test involves holding the wrists in acute flexion for 60 seconds. Numbness or
burning during this maneuver suggests compression of the median nerve. This is a primary diagnostic
screening tool for carpal tunnel syndrome. Herniated discs are typically assessed via the straight leg raise
test. Rotator cuff integrity is often checked using the drop arm test or empty can test. Hip dysplasia in
infants is screened using the Ortolani and Barlow maneuvers. Occupational history often correlates with
positive Phalen test results in adults. Carpal tunnel results from repetitive motion and inflammation
within the wrist. The nurse should also check for Tinel’s sign by percussing the median nerve. Early
detection allows for conservative management like splinting or ergonomic changes.
6. A 4-year-old child is asked to stand on one foot and hop. Which area of the brain is being
assessed?
A. Cerebellum
B. Brainstem
C. Cerebrum
D. Hypothalamus
Correct Answer: A
Explanation: The cerebellum is responsible for coordination, balance, and voluntary muscle movements.
Hopping on one foot requires significant motor integration and equilibrium. Assessing a child’s gross
motor skills helps determine developmental progress. The cerebrum handles higher-level functions like
thought, emotion, and memory. The brainstem controls involuntary vital functions such as breathing and
heart rate. The hypothalamus regulates homeostasis, including temperature and hunger. If a child cannot
perform age-appropriate balance tasks, further neurological testing is needed. Ataxia is a term used to
describe uncoordinated or unsteady movements. Pediatric assessments rely heavily on observing the
child during play or specific tasks. The nurse must consider the child’s age and developmental stage when
interpreting results.
