NUR 6001/NUR6001 Exam 4 V2 | Advanced
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing a patient’s deep tendon reflexes, the nurse notes they are brisk and
hyperactive with intermittent clonus. How should this be documented?
A. 1+
B. 2+
C. 3+
D. 4+
Answer: D
Rationale: A score of 4+ indicates a very brisk, hyperactive reflex with clonus, which is
often indicative of upper motor neuron disease. In contrast, 2+ is considered normal while
1+ is diminished. Documentation must be accurate to ensure appropriate clinical follow-up
for neurological conditions.
2. The nurse is performing a McMurray test on a patient. This maneuver is specifically used to
assess for which of the following?
A. Anterior cruciate ligament tear
B. Joint effusion
C. Torn meniscus
,D. Hip dysplasia
Answer: C
Rationale: The McMurray test involves rotating the leg while the knee is flexed and
extended to check for clicks or pain. A positive result strongly suggests a medial or lateral
meniscus tear in the knee joint. This assessment is vital for patients presenting with knee
locking or localized joint line tenderness.
3. During a neurological exam, the patient is unable to identify a familiar object placed in
their hand with their eyes closed. What is the correct term for this finding?
A. Agnosia
B. Anosmia
C. Ataxia
D. Astereognosis
Answer: D
Rationale: Astereognosis is the inability to identify objects by touch, which typically
indicates a lesion in the sensory cortex or posterior column. The ability to recognize objects
by feel is known as stereognosis. This test evaluates the patient’s higher-level cortical
sensory function during a comprehensive physical exam.
4. Which cranial nerve is responsible for the motor function of shrugging the shoulders
against resistance?
A. CN IX
, B. CN X
C. CN XII
D. CN XI
Answer: D
Rationale: Cranial Nerve XI, the Spinal Accessory nerve, controls the trapezius and
sternocleidomastoid muscles. To test this nerve, the examiner asks the patient to shrug
their shoulders and turn their head against resistance. Weakness or asymmetry in this
movement could indicate nerve damage or muscle pathology.
5. While assessing a newborn, the nurse performs the Ortolani maneuver. What is the
primary purpose of this test?
A. To check for spinal bifida
B. To evaluate the Moro reflex
C. To assess for congenital hip dislocation
D. To test for clubfoot
Answer: C
Rationale: The Ortolani maneuver is performed by abducting the infant’s hips to see if the
femoral head can be relocated into the acetabulum. A ‘clunk’ sound or felt sensation
indicates a positive test for hip instability or dislocation. Early detection is critical for
successful non-surgical intervention in developmental dysplasia of the hip.
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing a patient’s deep tendon reflexes, the nurse notes they are brisk and
hyperactive with intermittent clonus. How should this be documented?
A. 1+
B. 2+
C. 3+
D. 4+
Answer: D
Rationale: A score of 4+ indicates a very brisk, hyperactive reflex with clonus, which is
often indicative of upper motor neuron disease. In contrast, 2+ is considered normal while
1+ is diminished. Documentation must be accurate to ensure appropriate clinical follow-up
for neurological conditions.
2. The nurse is performing a McMurray test on a patient. This maneuver is specifically used to
assess for which of the following?
A. Anterior cruciate ligament tear
B. Joint effusion
C. Torn meniscus
,D. Hip dysplasia
Answer: C
Rationale: The McMurray test involves rotating the leg while the knee is flexed and
extended to check for clicks or pain. A positive result strongly suggests a medial or lateral
meniscus tear in the knee joint. This assessment is vital for patients presenting with knee
locking or localized joint line tenderness.
3. During a neurological exam, the patient is unable to identify a familiar object placed in
their hand with their eyes closed. What is the correct term for this finding?
A. Agnosia
B. Anosmia
C. Ataxia
D. Astereognosis
Answer: D
Rationale: Astereognosis is the inability to identify objects by touch, which typically
indicates a lesion in the sensory cortex or posterior column. The ability to recognize objects
by feel is known as stereognosis. This test evaluates the patient’s higher-level cortical
sensory function during a comprehensive physical exam.
4. Which cranial nerve is responsible for the motor function of shrugging the shoulders
against resistance?
A. CN IX
, B. CN X
C. CN XII
D. CN XI
Answer: D
Rationale: Cranial Nerve XI, the Spinal Accessory nerve, controls the trapezius and
sternocleidomastoid muscles. To test this nerve, the examiner asks the patient to shrug
their shoulders and turn their head against resistance. Weakness or asymmetry in this
movement could indicate nerve damage or muscle pathology.
5. While assessing a newborn, the nurse performs the Ortolani maneuver. What is the
primary purpose of this test?
A. To check for spinal bifida
B. To evaluate the Moro reflex
C. To assess for congenital hip dislocation
D. To test for clubfoot
Answer: C
Rationale: The Ortolani maneuver is performed by abducting the infant’s hips to see if the
femoral head can be relocated into the acetabulum. A ‘clunk’ sound or felt sensation
indicates a positive test for hip instability or dislocation. Early detection is critical for
successful non-surgical intervention in developmental dysplasia of the hip.
