NSG121/NSG 121 Exam 4 V3 | Health
Assessment Q&A with Rationale | Herzing
University
1. When assessing a patient’s deep tendon reflexes, the nurse notes a very brisk response
with intermittent clonus. How should the nurse document this finding?
A. 1+
B. 2+
C. 3+
D. 4+
Correct Answer: D
Rationale: A 4+ reflex is characterized by being very brisk, hyperactive with clonus, and
indicative of disease. A normal reflex is graded as 2+, while 1+ is diminished and 3+ is
brisker than average but not necessarily indicative of pathology. Identifying clonus is a
critical step in neurological assessment for upper motor neuron lesions.
2. During a musculoskeletal assessment, the nurse asks the patient to move their arm away
from the midline of the body. This movement is called:
A. Adduction
B. Abduction
C. Flexion
,D. Extension
Correct Answer: B
Rationale: Abduction is the movement of a limb away from the midline of the body. In
contrast, adduction moves the limb toward the midline, while flexion decreases the angle of
the joint. Precise terminology is essential for accurate documentation of range of motion in
nursing practice.
3. Which cranial nerve is the nurse assessing when asking the patient to shrug their shoulders
against resistance?
A. CN IX (Glossopharyngeal)
B. CN X (Vagus)
C. CN XII (Hypoglossal)
D. CN XI (Spinal Accessory)
Correct Answer: D
Rationale: Cranial Nerve XI, the spinal accessory nerve, innervates the sternomastoid and
trapezius muscles. The nurse assesses this by checking the strength of the shoulder shrug
and neck rotation against resistance. Impairment might indicate damage to the nerve or
related spinal structures.
4. The nurse is performing a breast exam on a female patient. In which quadrant are most
breast tumors found?
A. Upper Inner Quadrant
, B. Upper Outer Quadrant
C. Lower Inner Quadrant
D. Lower Outer Quadrant
Correct Answer: B
Rationale: The upper outer quadrant, which includes the Tail of Spence, is the most
common site for breast tumors. This area contains a high concentration of glandular tissue
where malignancies frequently develop. Nurses must ensure thorough palpation of this
specific region during clinical breast examinations.
5. A positive Romberg test is indicated when the patient:
A. Is unable to touch their nose with their finger eyes closed.
B. Displays a fan-like motion of the toes.
C. Loses balance when standing with eyes closed.
D. Experiences pain when lifting the leg straight.
Correct Answer: C
Rationale: The Romberg test assesses cerebellar function and proprioception by having
the patient stand with feet together and eyes closed. A positive result occurs if the patient
sways or loses balance, suggesting vestibular or sensory ataxia. This test is a fundamental
part of the neurological screening for coordination and balance.
Assessment Q&A with Rationale | Herzing
University
1. When assessing a patient’s deep tendon reflexes, the nurse notes a very brisk response
with intermittent clonus. How should the nurse document this finding?
A. 1+
B. 2+
C. 3+
D. 4+
Correct Answer: D
Rationale: A 4+ reflex is characterized by being very brisk, hyperactive with clonus, and
indicative of disease. A normal reflex is graded as 2+, while 1+ is diminished and 3+ is
brisker than average but not necessarily indicative of pathology. Identifying clonus is a
critical step in neurological assessment for upper motor neuron lesions.
2. During a musculoskeletal assessment, the nurse asks the patient to move their arm away
from the midline of the body. This movement is called:
A. Adduction
B. Abduction
C. Flexion
,D. Extension
Correct Answer: B
Rationale: Abduction is the movement of a limb away from the midline of the body. In
contrast, adduction moves the limb toward the midline, while flexion decreases the angle of
the joint. Precise terminology is essential for accurate documentation of range of motion in
nursing practice.
3. Which cranial nerve is the nurse assessing when asking the patient to shrug their shoulders
against resistance?
A. CN IX (Glossopharyngeal)
B. CN X (Vagus)
C. CN XII (Hypoglossal)
D. CN XI (Spinal Accessory)
Correct Answer: D
Rationale: Cranial Nerve XI, the spinal accessory nerve, innervates the sternomastoid and
trapezius muscles. The nurse assesses this by checking the strength of the shoulder shrug
and neck rotation against resistance. Impairment might indicate damage to the nerve or
related spinal structures.
4. The nurse is performing a breast exam on a female patient. In which quadrant are most
breast tumors found?
A. Upper Inner Quadrant
, B. Upper Outer Quadrant
C. Lower Inner Quadrant
D. Lower Outer Quadrant
Correct Answer: B
Rationale: The upper outer quadrant, which includes the Tail of Spence, is the most
common site for breast tumors. This area contains a high concentration of glandular tissue
where malignancies frequently develop. Nurses must ensure thorough palpation of this
specific region during clinical breast examinations.
5. A positive Romberg test is indicated when the patient:
A. Is unable to touch their nose with their finger eyes closed.
B. Displays a fan-like motion of the toes.
C. Loses balance when standing with eyes closed.
D. Experiences pain when lifting the leg straight.
Correct Answer: C
Rationale: The Romberg test assesses cerebellar function and proprioception by having
the patient stand with feet together and eyes closed. A positive result occurs if the patient
sways or loses balance, suggesting vestibular or sensory ataxia. This test is a fundamental
part of the neurological screening for coordination and balance.
