NUR 3270/NUR3270 Exam 4 V2 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing Cranial Nerve II, what specific physical assessment technique should the
nurse utilize?
A. Checking the gag reflex with a tongue blade
B. Palpating the temporal and masseter muscles
C. Assessing facial symmetry during a smile
D. Testing visual acuity using a Snellen chart
Answer: D
Rationale: Cranial Nerve II is the Optic nerve, which is responsible for vision and visual
fields. Using a Snellen chart allows the nurse to quantify the patient’s distance visual acuity
accurately. Other options such as the gag reflex or facial symmetry involve different cranial
nerves like IX, X, or VII.
2. A patient presents with a ‘staggering’ gait and difficulty maintaining balance. Which part of
the brain is most likely affected?
A. Cerebellum
B. Cerebrum
C. Hypothalamus
,D. Medulla Oblongata
Answer: A
Rationale: The cerebellum is the primary center for coordination of voluntary movements,
equilibrium, and muscle tone. Damage to this area results in ataxia, which is characterized
by uncoordinated or unsteady gait. Assessing the Romberg test is a common way to
evaluate cerebellar function in clinical practice.
3. Which Glasgow Coma Scale (GCS) score would indicate that a patient is in a deep coma?
A. 15
B. 11
C. 3
D. 7
Answer: C
Rationale: The Glasgow Coma Scale ranges from a minimum of 3 to a maximum of 15. A
score of 3 is the lowest possible score and represents no eye opening, no verbal response,
and no motor response. Generally, a score of 8 or less is used to define a comatose state in
clinical guidelines.
4. During a musculoskeletal exam, 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
Answer: B
Rationale: Abduction is the movement of a limb away from the midline of the body.
Conversely, adduction is moving the limb toward the midline. Understanding these terms is
essential for documenting range of motion accurately during a physical assessment.
5. A nurse is performing the Romberg test. Which of the following instructions should the
nurse give to the patient?
A. Hop on one foot for five seconds without losing balance
B. Walk heel-to-toe in a straight line for ten steps
C. Touch your nose with your index finger while eyes are closed
D. Stand with feet together and eyes open, then close eyes for 20 seconds
Answer: D
Rationale: The Romberg test assesses balance by asking the patient to stand with feet
together and arms at their sides. The nurse observes the patient with eyes open and then
with eyes closed for about 20 seconds. A positive result occurs if the patient loses balance
or sways significantly when the eyes are closed.
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing Cranial Nerve II, what specific physical assessment technique should the
nurse utilize?
A. Checking the gag reflex with a tongue blade
B. Palpating the temporal and masseter muscles
C. Assessing facial symmetry during a smile
D. Testing visual acuity using a Snellen chart
Answer: D
Rationale: Cranial Nerve II is the Optic nerve, which is responsible for vision and visual
fields. Using a Snellen chart allows the nurse to quantify the patient’s distance visual acuity
accurately. Other options such as the gag reflex or facial symmetry involve different cranial
nerves like IX, X, or VII.
2. A patient presents with a ‘staggering’ gait and difficulty maintaining balance. Which part of
the brain is most likely affected?
A. Cerebellum
B. Cerebrum
C. Hypothalamus
,D. Medulla Oblongata
Answer: A
Rationale: The cerebellum is the primary center for coordination of voluntary movements,
equilibrium, and muscle tone. Damage to this area results in ataxia, which is characterized
by uncoordinated or unsteady gait. Assessing the Romberg test is a common way to
evaluate cerebellar function in clinical practice.
3. Which Glasgow Coma Scale (GCS) score would indicate that a patient is in a deep coma?
A. 15
B. 11
C. 3
D. 7
Answer: C
Rationale: The Glasgow Coma Scale ranges from a minimum of 3 to a maximum of 15. A
score of 3 is the lowest possible score and represents no eye opening, no verbal response,
and no motor response. Generally, a score of 8 or less is used to define a comatose state in
clinical guidelines.
4. During a musculoskeletal exam, 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
Answer: B
Rationale: Abduction is the movement of a limb away from the midline of the body.
Conversely, adduction is moving the limb toward the midline. Understanding these terms is
essential for documenting range of motion accurately during a physical assessment.
5. A nurse is performing the Romberg test. Which of the following instructions should the
nurse give to the patient?
A. Hop on one foot for five seconds without losing balance
B. Walk heel-to-toe in a straight line for ten steps
C. Touch your nose with your index finger while eyes are closed
D. Stand with feet together and eyes open, then close eyes for 20 seconds
Answer: D
Rationale: The Romberg test assesses balance by asking the patient to stand with feet
together and arms at their sides. The nurse observes the patient with eyes open and then
with eyes closed for about 20 seconds. A positive result occurs if the patient loses balance
or sways significantly when the eyes are closed.
