NR304/NR 304 Exam 4 V3 | Health
Assessment II Q&A with Rationale |
Chamberlain University
1. During a neurological assessment, the nurse asks the patient to smile, frown, and puff out
their cheeks. Which cranial nerve is being evaluated?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve IX (Glossopharyngeal)
C. Cranial Nerve VII (Facial)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: C
Rationale: Cranial Nerve VII, the facial nerve, is responsible for controlling the muscles of
facial expression. Testing this nerve involves observing for symmetry when the patient
performs actions like smiling or puffing cheeks. Weakness or asymmetry could indicate a
peripheral nerve lesion like Bell’s palsy.
2. When assessing the musculoskeletal system, the nurse performs the Phalen test. A positive
result would most likely indicate which condition?
A. Osteoarthritis
B. Rheumatoid Arthritis
C. Carpal Tunnel Syndrome
,D. Rotator Cuff Tear
Correct Answer: C
Rationale: The Phalen test involves holding the wrists in acute flexion for 60 seconds to
compress the median nerve. A positive result is characterized by numbness or burning in
the distribution of the median nerve. This clinical finding is a hallmark indicator of Carpal
Tunnel Syndrome.
3. A nurse is teaching a male patient about testicular self-examination (TSE). Which
statement by the patient indicates a need for further instruction?
A. If I feel a firm, painless lump, I should not worry as it is likely a cyst.
B. The best time to do this is during or after a warm shower.
C. I should perform this exam once a month.
D. I need to report any feeling of heaviness in the scrotum to my doctor.
Correct Answer: A
Rationale: A firm, painless lump in the testicle is a classic warning sign of testicular cancer
and requires immediate medical evaluation. The exam should be performed monthly when
the scrotum is relaxed by warmth to facilitate palpation. Correct technique involves using
the thumb and first two fingers to roll the testicle gently.
4. Which anatomical location is the most common site for breast tumors to occur?
A. Upper outer quadrant
, B. Lower outer quadrant
C. Upper inner quadrant
D. Lower inner quadrant
Correct Answer: A
Rationale: The upper outer quadrant, which includes the Tail of Spence, is the most
frequent site for breast malignancies. This area contains a high concentration of glandular
tissue and lymph nodes. Nurses must ensure this specific region is thoroughly palpated
during every clinical breast exam.
5. When evaluating the Glasgow Coma Scale (GCS), the nurse observes a patient who opens
their eyes to speech, is confused in conversation, and withdraws from painful stimuli. What is
the GCS score?
A. 11
B. 9
C. 13
D. 15
Correct Answer: A
Rationale: The score is calculated by adding Eye Opening (3), Verbal Response (4), and
Motor Response (4), totaling 11. Eye opening to speech earns 3 points, confused speech
Assessment II Q&A with Rationale |
Chamberlain University
1. During a neurological assessment, the nurse asks the patient to smile, frown, and puff out
their cheeks. Which cranial nerve is being evaluated?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve IX (Glossopharyngeal)
C. Cranial Nerve VII (Facial)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: C
Rationale: Cranial Nerve VII, the facial nerve, is responsible for controlling the muscles of
facial expression. Testing this nerve involves observing for symmetry when the patient
performs actions like smiling or puffing cheeks. Weakness or asymmetry could indicate a
peripheral nerve lesion like Bell’s palsy.
2. When assessing the musculoskeletal system, the nurse performs the Phalen test. A positive
result would most likely indicate which condition?
A. Osteoarthritis
B. Rheumatoid Arthritis
C. Carpal Tunnel Syndrome
,D. Rotator Cuff Tear
Correct Answer: C
Rationale: The Phalen test involves holding the wrists in acute flexion for 60 seconds to
compress the median nerve. A positive result is characterized by numbness or burning in
the distribution of the median nerve. This clinical finding is a hallmark indicator of Carpal
Tunnel Syndrome.
3. A nurse is teaching a male patient about testicular self-examination (TSE). Which
statement by the patient indicates a need for further instruction?
A. If I feel a firm, painless lump, I should not worry as it is likely a cyst.
B. The best time to do this is during or after a warm shower.
C. I should perform this exam once a month.
D. I need to report any feeling of heaviness in the scrotum to my doctor.
Correct Answer: A
Rationale: A firm, painless lump in the testicle is a classic warning sign of testicular cancer
and requires immediate medical evaluation. The exam should be performed monthly when
the scrotum is relaxed by warmth to facilitate palpation. Correct technique involves using
the thumb and first two fingers to roll the testicle gently.
4. Which anatomical location is the most common site for breast tumors to occur?
A. Upper outer quadrant
, B. Lower outer quadrant
C. Upper inner quadrant
D. Lower inner quadrant
Correct Answer: A
Rationale: The upper outer quadrant, which includes the Tail of Spence, is the most
frequent site for breast malignancies. This area contains a high concentration of glandular
tissue and lymph nodes. Nurses must ensure this specific region is thoroughly palpated
during every clinical breast exam.
5. When evaluating the Glasgow Coma Scale (GCS), the nurse observes a patient who opens
their eyes to speech, is confused in conversation, and withdraws from painful stimuli. What is
the GCS score?
A. 11
B. 9
C. 13
D. 15
Correct Answer: A
Rationale: The score is calculated by adding Eye Opening (3), Verbal Response (4), and
Motor Response (4), totaling 11. Eye opening to speech earns 3 points, confused speech
