1
NSG3160 HEALTH ASSESSMENT EXAM 3 2026/2027 |
Comprehensive Physical Assessment Validation | Pass
Guaranteed - A+ Graded
Section 1: Neurological System Assessment (Questions 1-12)
Q1. A 72-year-old male patient is admitted following a stroke. During cranial nerve
assessment, the nurse asks the patient to smile, show teeth, close both eyes tightly,
and puff out both cheeks. Which cranial nerve is being assessed?
A. Cranial Nerve V (Trigeminal) B. Cranial Nerve VII (Facial) C. Cranial Nerve IX
(Glossopharyngeal) D. Cranial Nerve XII (Hypoglossal)
B. Cranial Nerve VII (Facial) [CORRECT]
Rationale: Cranial Nerve VII (Facial) is assessed by evaluating facial muscle symmetry
and strength through smiling, showing teeth, eye closure, and cheek puffing. CN V
assesses jaw clenching and facial sensation. CN IX assesses gag reflex and palate
elevation. CN XII assesses tongue movement and strength.
Correct Answer: B
Q2. During a neurological assessment, the nurse uses a reflex hammer to tap the
patellar tendon. The lower leg extends briskly with a single, definite response. Using
the standard 0-4+ reflex grading scale, how should the nurse document this finding?
A. 0 (Absent) B. 1+ (Hypoactive) C. 2+ (Normal) D. 3+ (Hyperactive without clonus)
C. 2+ (Normal) [CORRECT]
Rationale: A single, brisk, definite response to patellar tendon tapping is documented
as 2+, which is considered normal. 0 indicates no response (always abnormal). 1+ is a
,2
slight, diminished response. 3+ is very brisk and may or may not be normal
depending on the patient's baseline. 4+ is hyperactive with clonus (always abnormal).
Correct Answer: C
Q3. A nursing student is assessing a patient with suspected upper motor neuron
disease. When stroking the lateral sole of the foot from heel to ball with a blunt
instrument, the great toe extends upward and the smaller toes fan outward. The
student documents this as a normal finding. What is the correct interpretation?
A. The student correctly identified a normal plantar reflex in an adult B. The student
misinterpreted a positive Babinski sign, which is abnormal in adults C. The student
should have used a sharp instrument to elicit the reflex D. The response indicates
lower motor neuron disease
B. The student misinterpreted a positive Babinski sign, which is abnormal in adults
[CORRECT]
Rationale: In adults, a normal plantar reflex produces toe flexion. Toe extension with
fanning (positive Babinski) indicates an upper motor neuron lesion and is always
abnormal in adults. It is only normal in children younger than two years. The student
incorrectly documented this as normal.
Correct Answer: B
Q4. A patient presents with unilateral facial droop, inability to wrinkle the forehead
on the affected side, and difficulty closing the eye. During cranial nerve testing, which
finding differentiates a lower motor neuron lesion of CN VII from an upper motor
neuron lesion?
A. Upper motor neuron lesions spare the forehead because of bilateral cortical
innervation B. Lower motor neuron lesions affect only the lower facial muscles C.
Upper motor neuron lesions cause complete facial paralysis including the forehead
D. Lower motor neuron lesions spare the forehead due to crossed innervation
,3
A. Upper motor neuron lesions spare the forehead because of bilateral cortical
innervation [CORRECT]
Rationale: The upper facial muscles (forehead/eye closure) receive bilateral cortical
innervation, so upper motor neuron lesions spare the forehead. Lower motor neuron
lesions affect the entire ipsilateral face, including forehead wrinkling and eye closure.
This is the key differentiating feature.
Correct Answer: A
Q5. During a focused neurological assessment, the nurse asks the patient to stand
with feet together, arms at sides, and eyes closed. The patient begins to sway and
loses balance. This positive Romberg test indicates dysfunction of which structure?
A. Cerebellum B. Vestibulocochlear nerve (CN VIII) or dorsal column pathways C.
Motor cortex D. Basal ganglia
B. Vestibulocochlear nerve (CN VIII) or dorsal column pathways [CORRECT]
Rationale: The Romberg test assesses proprioception and vestibular function. A
positive test (swaying with eyes closed) indicates impaired proprioception (dorsal
column pathway) or vestibular dysfunction (CN VIII). The cerebellum is assessed by
coordination tests such as finger-to-nose. The motor cortex is assessed by motor
strength testing.
Correct Answer: B
Q6. A 45-year-old patient with diabetes reports numbness and tingling in both feet.
During the neurological exam, the nurse tests light touch sensation using a cotton
wisp, pain/temperature using a sharp/dull instrument, and vibration using a tuning
fork. The nurse is assessing which sensory pathway?
A. Dorsal column-medial lemniscus pathway B. Spinothalamic tract C. Both dorsal
column and spinothalamic pathways D. Corticospinal tract
C. Both dorsal column and spinothalamic pathways [CORRECT]
, 4
Rationale: Light touch, pain, temperature, and vibration assess both major sensory
pathways. The dorsal column-medial lemniscus pathway carries vibration,
proprioception, and fine touch. The spinothalamic tract carries pain, temperature,
and crude touch. The corticospinal tract is a motor pathway, not sensory.
Correct Answer: C
Q7. A nurse is assessing deep tendon reflexes in a patient with suspected
hypothyroidism. The Achilles reflex is barely perceptible even after reinforcement
(Jendrassik maneuver). Using the standard grading scale, how should this finding be
documented?
A. 0 (Absent) B. 1+ (Diminished or barely perceptible) C. 2+ (Normal) D. 3+ (Brisker
than normal)
B. 1+ (Diminished or barely perceptible) [CORRECT]
Rationale: A barely perceptible response, even with reinforcement, is documented as
1+ (hypoactive/diminished). Hypothyroidism can cause delayed relaxation phase of
deep tendon reflexes and diminished responses. 0 indicates absolutely no response.
2+ is a normal, brisk response. 3+ is hyperactive.
Correct Answer: B
Q8. During a mental status examination, a patient is alert, oriented to person and
place but states the year is 2024 when it is 2026. The patient can recall three objects
immediately but only one after five minutes. The nurse calculates a Mini-Mental State
Examination (MMSE) score of 22. How should this be interpreted?
A. No cognitive impairment B. Mild cognitive impairment C. Severe cognitive
impairment D. Normal for age-related changes
B. Mild cognitive impairment [CORRECT]
Rationale: The MMSE is scored out of 30 points. A score of 24-30 indicates no
cognitive impairment, 18-23 indicates mild cognitive impairment, and less than 18
NSG3160 HEALTH ASSESSMENT EXAM 3 2026/2027 |
Comprehensive Physical Assessment Validation | Pass
Guaranteed - A+ Graded
Section 1: Neurological System Assessment (Questions 1-12)
Q1. A 72-year-old male patient is admitted following a stroke. During cranial nerve
assessment, the nurse asks the patient to smile, show teeth, close both eyes tightly,
and puff out both cheeks. Which cranial nerve is being assessed?
A. Cranial Nerve V (Trigeminal) B. Cranial Nerve VII (Facial) C. Cranial Nerve IX
(Glossopharyngeal) D. Cranial Nerve XII (Hypoglossal)
B. Cranial Nerve VII (Facial) [CORRECT]
Rationale: Cranial Nerve VII (Facial) is assessed by evaluating facial muscle symmetry
and strength through smiling, showing teeth, eye closure, and cheek puffing. CN V
assesses jaw clenching and facial sensation. CN IX assesses gag reflex and palate
elevation. CN XII assesses tongue movement and strength.
Correct Answer: B
Q2. During a neurological assessment, the nurse uses a reflex hammer to tap the
patellar tendon. The lower leg extends briskly with a single, definite response. Using
the standard 0-4+ reflex grading scale, how should the nurse document this finding?
A. 0 (Absent) B. 1+ (Hypoactive) C. 2+ (Normal) D. 3+ (Hyperactive without clonus)
C. 2+ (Normal) [CORRECT]
Rationale: A single, brisk, definite response to patellar tendon tapping is documented
as 2+, which is considered normal. 0 indicates no response (always abnormal). 1+ is a
,2
slight, diminished response. 3+ is very brisk and may or may not be normal
depending on the patient's baseline. 4+ is hyperactive with clonus (always abnormal).
Correct Answer: C
Q3. A nursing student is assessing a patient with suspected upper motor neuron
disease. When stroking the lateral sole of the foot from heel to ball with a blunt
instrument, the great toe extends upward and the smaller toes fan outward. The
student documents this as a normal finding. What is the correct interpretation?
A. The student correctly identified a normal plantar reflex in an adult B. The student
misinterpreted a positive Babinski sign, which is abnormal in adults C. The student
should have used a sharp instrument to elicit the reflex D. The response indicates
lower motor neuron disease
B. The student misinterpreted a positive Babinski sign, which is abnormal in adults
[CORRECT]
Rationale: In adults, a normal plantar reflex produces toe flexion. Toe extension with
fanning (positive Babinski) indicates an upper motor neuron lesion and is always
abnormal in adults. It is only normal in children younger than two years. The student
incorrectly documented this as normal.
Correct Answer: B
Q4. A patient presents with unilateral facial droop, inability to wrinkle the forehead
on the affected side, and difficulty closing the eye. During cranial nerve testing, which
finding differentiates a lower motor neuron lesion of CN VII from an upper motor
neuron lesion?
A. Upper motor neuron lesions spare the forehead because of bilateral cortical
innervation B. Lower motor neuron lesions affect only the lower facial muscles C.
Upper motor neuron lesions cause complete facial paralysis including the forehead
D. Lower motor neuron lesions spare the forehead due to crossed innervation
,3
A. Upper motor neuron lesions spare the forehead because of bilateral cortical
innervation [CORRECT]
Rationale: The upper facial muscles (forehead/eye closure) receive bilateral cortical
innervation, so upper motor neuron lesions spare the forehead. Lower motor neuron
lesions affect the entire ipsilateral face, including forehead wrinkling and eye closure.
This is the key differentiating feature.
Correct Answer: A
Q5. During a focused neurological assessment, the nurse asks the patient to stand
with feet together, arms at sides, and eyes closed. The patient begins to sway and
loses balance. This positive Romberg test indicates dysfunction of which structure?
A. Cerebellum B. Vestibulocochlear nerve (CN VIII) or dorsal column pathways C.
Motor cortex D. Basal ganglia
B. Vestibulocochlear nerve (CN VIII) or dorsal column pathways [CORRECT]
Rationale: The Romberg test assesses proprioception and vestibular function. A
positive test (swaying with eyes closed) indicates impaired proprioception (dorsal
column pathway) or vestibular dysfunction (CN VIII). The cerebellum is assessed by
coordination tests such as finger-to-nose. The motor cortex is assessed by motor
strength testing.
Correct Answer: B
Q6. A 45-year-old patient with diabetes reports numbness and tingling in both feet.
During the neurological exam, the nurse tests light touch sensation using a cotton
wisp, pain/temperature using a sharp/dull instrument, and vibration using a tuning
fork. The nurse is assessing which sensory pathway?
A. Dorsal column-medial lemniscus pathway B. Spinothalamic tract C. Both dorsal
column and spinothalamic pathways D. Corticospinal tract
C. Both dorsal column and spinothalamic pathways [CORRECT]
, 4
Rationale: Light touch, pain, temperature, and vibration assess both major sensory
pathways. The dorsal column-medial lemniscus pathway carries vibration,
proprioception, and fine touch. The spinothalamic tract carries pain, temperature,
and crude touch. The corticospinal tract is a motor pathway, not sensory.
Correct Answer: C
Q7. A nurse is assessing deep tendon reflexes in a patient with suspected
hypothyroidism. The Achilles reflex is barely perceptible even after reinforcement
(Jendrassik maneuver). Using the standard grading scale, how should this finding be
documented?
A. 0 (Absent) B. 1+ (Diminished or barely perceptible) C. 2+ (Normal) D. 3+ (Brisker
than normal)
B. 1+ (Diminished or barely perceptible) [CORRECT]
Rationale: A barely perceptible response, even with reinforcement, is documented as
1+ (hypoactive/diminished). Hypothyroidism can cause delayed relaxation phase of
deep tendon reflexes and diminished responses. 0 indicates absolutely no response.
2+ is a normal, brisk response. 3+ is hyperactive.
Correct Answer: B
Q8. During a mental status examination, a patient is alert, oriented to person and
place but states the year is 2024 when it is 2026. The patient can recall three objects
immediately but only one after five minutes. The nurse calculates a Mini-Mental State
Examination (MMSE) score of 22. How should this be interpreted?
A. No cognitive impairment B. Mild cognitive impairment C. Severe cognitive
impairment D. Normal for age-related changes
B. Mild cognitive impairment [CORRECT]
Rationale: The MMSE is scored out of 30 points. A score of 24-30 indicates no
cognitive impairment, 18-23 indicates mild cognitive impairment, and less than 18
