NSG 351 Exam 4 V2 | NSG 351 Health
Assessment | Actual Q&A with Rationale
(NSG351 Exam 4) | James Madison
University
1. A nurse is assessing a patient’s range of motion and notes a limitation in movement. Which
instrument should the nurse use to provide a precise measurement of the joint angle?
A. Tape measure
B. Reflex hammer
C. Goniometer
D. Monofilament
Answer: C
Rationale: A goniometer is a specialized tool used to measure the precise degrees of joint
motion. It is essential when a patient presents with limited range of motion to establish a
baseline. Accurate measurement helps in tracking the progress of rehabilitation or the
progression of a disease.
2. When grading muscle strength, the nurse observes that the patient can move their arm
against gravity but not against any added resistance. How should the nurse document this
finding?
A. 1/5
,B. 3/5
C. 2/5
D. 4/5
Answer: B
Rationale: A grade of 3/5 indicates that the muscle can complete a full range of motion
against gravity but fails when resistance is applied. This scale is standardized from 0 to 5,
where 5 is normal strength. Documentation must be accurate to ensure the clinical team
understands the patient’s functional limitations.
3. A school nurse is screening adolescents for scoliosis. Which instruction should the nurse
provide to the student during the assessment?
A. “Lean back as far as you can.”
B. “Bend forward at the waist toward your toes.”
C. “Walk across the room in a straight line.”
D. “Stand on one leg with your eyes closed.”
Answer: B
Rationale: The Adams Forward Bend test is the standard screening method for detecting
scoliosis in adolescents. By bending forward, any rib hump or spinal curvature becomes
more prominent to the observer. The nurse looks for asymmetry in the ribs, scapula, or
waistline during this maneuver.
, 4. An older adult patient presents with an exaggerated posterior curvature of the thoracic
spine. What term should the nurse use to document this finding?
A. Lordosis
B. Kyphosis
C. Scoliosis
D. Ankylosis
Answer: B
Rationale: Kyphosis is commonly referred to as a ‘hunchback’ and involves an abnormal
outward curvature of the thoracic spine. It is frequently seen in older adults due to
osteoporosis or disc degeneration. Lordosis, conversely, is an inward curvature of the
lumbar spine.
5. During a musculoskeletal exam, a patient reports numbness and tingling in the thumb and
first two fingers. The nurse asks the patient to hold their hands back-to-back for 60 seconds.
What is this test called?
A. McMurray test
B. Tinel sign
C. Bulge sign
D. Phalen test
Answer: D
Assessment | Actual Q&A with Rationale
(NSG351 Exam 4) | James Madison
University
1. A nurse is assessing a patient’s range of motion and notes a limitation in movement. Which
instrument should the nurse use to provide a precise measurement of the joint angle?
A. Tape measure
B. Reflex hammer
C. Goniometer
D. Monofilament
Answer: C
Rationale: A goniometer is a specialized tool used to measure the precise degrees of joint
motion. It is essential when a patient presents with limited range of motion to establish a
baseline. Accurate measurement helps in tracking the progress of rehabilitation or the
progression of a disease.
2. When grading muscle strength, the nurse observes that the patient can move their arm
against gravity but not against any added resistance. How should the nurse document this
finding?
A. 1/5
,B. 3/5
C. 2/5
D. 4/5
Answer: B
Rationale: A grade of 3/5 indicates that the muscle can complete a full range of motion
against gravity but fails when resistance is applied. This scale is standardized from 0 to 5,
where 5 is normal strength. Documentation must be accurate to ensure the clinical team
understands the patient’s functional limitations.
3. A school nurse is screening adolescents for scoliosis. Which instruction should the nurse
provide to the student during the assessment?
A. “Lean back as far as you can.”
B. “Bend forward at the waist toward your toes.”
C. “Walk across the room in a straight line.”
D. “Stand on one leg with your eyes closed.”
Answer: B
Rationale: The Adams Forward Bend test is the standard screening method for detecting
scoliosis in adolescents. By bending forward, any rib hump or spinal curvature becomes
more prominent to the observer. The nurse looks for asymmetry in the ribs, scapula, or
waistline during this maneuver.
, 4. An older adult patient presents with an exaggerated posterior curvature of the thoracic
spine. What term should the nurse use to document this finding?
A. Lordosis
B. Kyphosis
C. Scoliosis
D. Ankylosis
Answer: B
Rationale: Kyphosis is commonly referred to as a ‘hunchback’ and involves an abnormal
outward curvature of the thoracic spine. It is frequently seen in older adults due to
osteoporosis or disc degeneration. Lordosis, conversely, is an inward curvature of the
lumbar spine.
5. During a musculoskeletal exam, a patient reports numbness and tingling in the thumb and
first two fingers. The nurse asks the patient to hold their hands back-to-back for 60 seconds.
What is this test called?
A. McMurray test
B. Tinel sign
C. Bulge sign
D. Phalen test
Answer: D
