NR304/NR 304 Exam 4 V1 | Health
Assessment II Q&A with Rationale |
Chamberlain University
1. When conducting a neurological assessment on an adult patient, which finding would the
nurse interpret as a positive Babinski sign?
A. The patient’s big toe dorsiflexes and the other toes fan out.
B. The patient’s toes curl downward toward the floor.
C. The patient reports a sharp, tingling sensation in the heel.
D. The patient’s foot jerks away in a rapid withdrawal reflex.
Correct Answer: A
Rationale: In an adult, a positive Babinski sign is characterized by dorsiflexion of the big
toe and fanning of the other toes. This finding is considered abnormal and typically
indicates an upper motor neuron lesion or corticospinal tract disease. In contrast, the
normal response in an adult is the plantar reflex, where the toes curl downward.
2. A nurse is evaluating the motor function of Cranial Nerve VII. Which action should the
nurse ask the patient to perform?
A. Shrug the shoulders against resistance.
B. Stick out the tongue and move it side to side.
C. Follow a penlight through the six cardinal fields of gaze.
,D. Smile, frown, and puff out the cheeks.
Correct Answer: D
Rationale: Cranial Nerve VII, the facial nerve, is responsible for the muscles of facial
expression. Assessing symmetry while the patient smiles, frowns, or puffs out their cheeks
allows the nurse to evaluate its motor component. Other nerves like CN XI involve shoulder
shrugging and CN XII involves tongue movement.
3. The nurse is assessing a patient for carpal tunnel syndrome using the Phalen test. What
instruction should the nurse give the patient?
A. Percuss the median nerve at the wrist to see if it causes tingling.
B. Press the backs of the hands together while flexing the wrists at 90 degrees for 60
seconds.
C. Grip the nurse’s hands as tightly as possible for 30 seconds.
D. Extend the arms fully and rotate the wrists in a circular motion.
Correct Answer: B
Rationale: The Phalen test requires the patient to hold the backs of their hands together
with wrists flexed at 90 degrees for one minute. A positive result occurs if the patient
experiences numbness, burning, or tingling in the distribution of the median nerve. This
test is a standard assessment for carpal tunnel syndrome in clinical practice.
, 4. Which part of the brain is primarily responsible for the coordination of voluntary
movements, equilibrium, and muscle tone?
A. The Occipital Lobe
B. The Frontal Lobe
C. The Temporal Lobe
D. The Cerebellum
Correct Answer: D
Rationale: The cerebellum is the portion of the brain that integrates sensory input to
coordinate movement and maintain balance. It does not initiate movement but ensures that
it is smooth and rhythmic. Damage to this area often results in ataxia or problems with
equilibrium.
5. While performing a musculoskeletal assessment, the nurse notes a lateral curvature of the
spine. How should this finding be documented?
A. Scoliosis
B. Kyphosis
C. Lordosis
D. Ankylosis
Correct Answer: A
Assessment II Q&A with Rationale |
Chamberlain University
1. When conducting a neurological assessment on an adult patient, which finding would the
nurse interpret as a positive Babinski sign?
A. The patient’s big toe dorsiflexes and the other toes fan out.
B. The patient’s toes curl downward toward the floor.
C. The patient reports a sharp, tingling sensation in the heel.
D. The patient’s foot jerks away in a rapid withdrawal reflex.
Correct Answer: A
Rationale: In an adult, a positive Babinski sign is characterized by dorsiflexion of the big
toe and fanning of the other toes. This finding is considered abnormal and typically
indicates an upper motor neuron lesion or corticospinal tract disease. In contrast, the
normal response in an adult is the plantar reflex, where the toes curl downward.
2. A nurse is evaluating the motor function of Cranial Nerve VII. Which action should the
nurse ask the patient to perform?
A. Shrug the shoulders against resistance.
B. Stick out the tongue and move it side to side.
C. Follow a penlight through the six cardinal fields of gaze.
,D. Smile, frown, and puff out the cheeks.
Correct Answer: D
Rationale: Cranial Nerve VII, the facial nerve, is responsible for the muscles of facial
expression. Assessing symmetry while the patient smiles, frowns, or puffs out their cheeks
allows the nurse to evaluate its motor component. Other nerves like CN XI involve shoulder
shrugging and CN XII involves tongue movement.
3. The nurse is assessing a patient for carpal tunnel syndrome using the Phalen test. What
instruction should the nurse give the patient?
A. Percuss the median nerve at the wrist to see if it causes tingling.
B. Press the backs of the hands together while flexing the wrists at 90 degrees for 60
seconds.
C. Grip the nurse’s hands as tightly as possible for 30 seconds.
D. Extend the arms fully and rotate the wrists in a circular motion.
Correct Answer: B
Rationale: The Phalen test requires the patient to hold the backs of their hands together
with wrists flexed at 90 degrees for one minute. A positive result occurs if the patient
experiences numbness, burning, or tingling in the distribution of the median nerve. This
test is a standard assessment for carpal tunnel syndrome in clinical practice.
, 4. Which part of the brain is primarily responsible for the coordination of voluntary
movements, equilibrium, and muscle tone?
A. The Occipital Lobe
B. The Frontal Lobe
C. The Temporal Lobe
D. The Cerebellum
Correct Answer: D
Rationale: The cerebellum is the portion of the brain that integrates sensory input to
coordinate movement and maintain balance. It does not initiate movement but ensures that
it is smooth and rhythmic. Damage to this area often results in ataxia or problems with
equilibrium.
5. While performing a musculoskeletal assessment, the nurse notes a lateral curvature of the
spine. How should this finding be documented?
A. Scoliosis
B. Kyphosis
C. Lordosis
D. Ankylosis
Correct Answer: A
