NUR 2092/NUR2092 Exam 4 V1 | Health
Assessment Q&A with Rationale |
Rasmussen University
1. During a neurological exam, the nurse asks the patient to identify a number ‘written’ on
the palm of their hand with a blunt instrument. This test is known as:
A. Stereognosis
B. Graphesthesia
C. Extinction
D. Two-point discrimination
Answer: B
Rationale: Graphesthesia is the ability to read a number by having it traced on the skin. It
is a sensitive measure of sensory loss if the person cannot recognize the number. This test
specifically evaluates the sensory cortex and is often used when motor impairments
prevent other tests.
2. When assessing the musculoskeletal system of an elderly patient, the nurse notes a
rounded thoracic convexity. This finding is documented as:
A. Kyphosis
B. Scoliosis
C. Lordosis
,D. List
Answer: A
Rationale: Kyphosis is an exaggerated posterior curvature of the thoracic spine that is
common in older adults. It is often associated with osteoporosis and vertebral collapse. The
nurse should assess for associated pain or respiratory restriction caused by the postural
change.
3. The nurse is performing a testicular self-examination (TSE) education session. Which
statement by the patient indicates a need for further teaching?
A. If I feel a lump that is painful, it is likely nothing to worry about.
B. The best time to do this is after a warm shower.
C. I should perform this exam once a month.
D. I should report any firm, painless lumps to my doctor.
Answer: A
Rationale: Testicular cancer often presents as a painless, firm lump, so any new mass must
be evaluated regardless of pain. Pain is actually less common in early testicular cancer than
in inflammatory conditions like epididymitis. Consistent monthly exams allow the patient
to become familiar with their normal anatomy and detect changes early.
4. A patient exhibits a positive Romberg sign. The nurse interprets this finding as a deficiency
in:
A. Lower motor neuron integrity
, B. Occipital lobe integration
C. Cerebellar function or proprioception
D. Temporal lobe processing
Answer: C
Rationale: A positive Romberg sign occurs when a patient loses balance when closing their
eyes while standing. This indicates a problem with proprioception or vestibular function
rather than strictly cerebellar ataxia. The cerebellum helps maintain balance, but the
Romberg specifically tests the sensory input required for it.
5. While assessing the cranial nerves, the nurse asks the patient to shrug their shoulders
against resistance. Which cranial nerve is being tested?
A. CN XI (Spinal Accessory)
B. CN X (Vagus)
C. CN IX (Glossopharyngeal)
D. CN XII (Hypoglossal)
Answer: A
Rationale: Cranial Nerve XI, the Spinal Accessory nerve, innervates the trapezius and
sternomastoid muscles. Testing involves shrugging the shoulders and turning the head
against resistance. Weakness or asymmetry may indicate nerve damage or muscle
pathology.
Assessment Q&A with Rationale |
Rasmussen University
1. During a neurological exam, the nurse asks the patient to identify a number ‘written’ on
the palm of their hand with a blunt instrument. This test is known as:
A. Stereognosis
B. Graphesthesia
C. Extinction
D. Two-point discrimination
Answer: B
Rationale: Graphesthesia is the ability to read a number by having it traced on the skin. It
is a sensitive measure of sensory loss if the person cannot recognize the number. This test
specifically evaluates the sensory cortex and is often used when motor impairments
prevent other tests.
2. When assessing the musculoskeletal system of an elderly patient, the nurse notes a
rounded thoracic convexity. This finding is documented as:
A. Kyphosis
B. Scoliosis
C. Lordosis
,D. List
Answer: A
Rationale: Kyphosis is an exaggerated posterior curvature of the thoracic spine that is
common in older adults. It is often associated with osteoporosis and vertebral collapse. The
nurse should assess for associated pain or respiratory restriction caused by the postural
change.
3. The nurse is performing a testicular self-examination (TSE) education session. Which
statement by the patient indicates a need for further teaching?
A. If I feel a lump that is painful, it is likely nothing to worry about.
B. The best time to do this is after a warm shower.
C. I should perform this exam once a month.
D. I should report any firm, painless lumps to my doctor.
Answer: A
Rationale: Testicular cancer often presents as a painless, firm lump, so any new mass must
be evaluated regardless of pain. Pain is actually less common in early testicular cancer than
in inflammatory conditions like epididymitis. Consistent monthly exams allow the patient
to become familiar with their normal anatomy and detect changes early.
4. A patient exhibits a positive Romberg sign. The nurse interprets this finding as a deficiency
in:
A. Lower motor neuron integrity
, B. Occipital lobe integration
C. Cerebellar function or proprioception
D. Temporal lobe processing
Answer: C
Rationale: A positive Romberg sign occurs when a patient loses balance when closing their
eyes while standing. This indicates a problem with proprioception or vestibular function
rather than strictly cerebellar ataxia. The cerebellum helps maintain balance, but the
Romberg specifically tests the sensory input required for it.
5. While assessing the cranial nerves, the nurse asks the patient to shrug their shoulders
against resistance. Which cranial nerve is being tested?
A. CN XI (Spinal Accessory)
B. CN X (Vagus)
C. CN IX (Glossopharyngeal)
D. CN XII (Hypoglossal)
Answer: A
Rationale: Cranial Nerve XI, the Spinal Accessory nerve, innervates the trapezius and
sternomastoid muscles. Testing involves shrugging the shoulders and turning the head
against resistance. Weakness or asymmetry may indicate nerve damage or muscle
pathology.
