NUR 101/NUR101 Exam 3 V3 | Health Assessment
Q&A with Rationale | Fortis College
1. When assessing a patient’s cranial nerves, the nurse asks the patient to smile, frown, and
puff out their cheeks. Which cranial nerve is being evaluated?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve VII (Facial)
C. Cranial Nerve X (Vagus)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: B
Explanation: Cranial Nerve VII is responsible for the motor function of facial expressions.
Asking the patient to perform these actions allows the nurse to observe for symmetry and
strength. Asymmetry could indicate a condition such as Bell’s palsy or a stroke.
2. A nurse is performing a musculoskeletal assessment and asks the patient to move their
arm away from the midline of the body. How should the nurse document this movement?
A. Adduction
B. Abduction
C. Flexion
D. Extension
,Correct Answer: B
Explanation: Abduction is the movement of a limb away from the midline of the body.
Adduction refers to moving a limb toward the midline. Accurate documentation of range of
motion is essential for tracking musculoskeletal health and recovery.
3. During an eye assessment, the nurse notes that the patient’s pupils constrict when looking
at a near object after looking at a distant object. What is this phenomenon called?
A. Consensual reaction
B. Nystagmus
C. Direct reaction
D. Accommodation
Correct Answer: D
Explanation: Accommodation is the process by which the eye’s lens changes shape to
focus on near objects, resulting in pupillary constriction. This test is a standard part of the
PERRLA assessment. It demonstrates the coordination of the ciliary muscles and the optic
nerve.
4. The nurse is assessing a patient for carpal tunnel syndrome using the Phalen test. Which
patient action indicates a positive result?
A. Sharp pain when the nurse taps over the median nerve at the wrist.
B. Numbness and burning when the backs of the hands are pressed together for 60
seconds.
, C. Inability to make a fist without pain in the palm.
D. Weakness when trying to abduct the thumb against resistance.
Correct Answer: B
Explanation: The Phalen test involves holding the wrists in acute flexion for 60 seconds to
compress the median nerve. A positive result is characterized by numbness or tingling in
the distribution of the median nerve. This is a common diagnostic physical exam finding for
carpal tunnel syndrome.
5. A patient is reported to have 20/40 vision after a Snellen chart test. How should the nurse
interpret these findings?
A. The patient can see at 20 feet what a normal eye sees at 40 feet.
B. The patient can see at 40 feet what a normal eye sees at 20 feet.
C. The patient’s vision is twice as good as normal vision.
D. The patient has perfect vision in the right eye but poor vision in the left eye.
Correct Answer: A
Explanation: In Snellen chart results, the top number represents the distance from the
chart (20 feet). The bottom number represents the distance at which a person with normal
vision could read the same line. A result of 20/40 indicates the patient’s vision is poorer
than standard 20/20 vision.
Q&A with Rationale | Fortis College
1. When assessing a patient’s cranial nerves, the nurse asks the patient to smile, frown, and
puff out their cheeks. Which cranial nerve is being evaluated?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve VII (Facial)
C. Cranial Nerve X (Vagus)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: B
Explanation: Cranial Nerve VII is responsible for the motor function of facial expressions.
Asking the patient to perform these actions allows the nurse to observe for symmetry and
strength. Asymmetry could indicate a condition such as Bell’s palsy or a stroke.
2. A nurse is performing a musculoskeletal assessment and asks the patient to move their
arm away from the midline of the body. How should the nurse document this movement?
A. Adduction
B. Abduction
C. Flexion
D. Extension
,Correct Answer: B
Explanation: Abduction is the movement of a limb away from the midline of the body.
Adduction refers to moving a limb toward the midline. Accurate documentation of range of
motion is essential for tracking musculoskeletal health and recovery.
3. During an eye assessment, the nurse notes that the patient’s pupils constrict when looking
at a near object after looking at a distant object. What is this phenomenon called?
A. Consensual reaction
B. Nystagmus
C. Direct reaction
D. Accommodation
Correct Answer: D
Explanation: Accommodation is the process by which the eye’s lens changes shape to
focus on near objects, resulting in pupillary constriction. This test is a standard part of the
PERRLA assessment. It demonstrates the coordination of the ciliary muscles and the optic
nerve.
4. The nurse is assessing a patient for carpal tunnel syndrome using the Phalen test. Which
patient action indicates a positive result?
A. Sharp pain when the nurse taps over the median nerve at the wrist.
B. Numbness and burning when the backs of the hands are pressed together for 60
seconds.
, C. Inability to make a fist without pain in the palm.
D. Weakness when trying to abduct the thumb against resistance.
Correct Answer: B
Explanation: The Phalen test involves holding the wrists in acute flexion for 60 seconds to
compress the median nerve. A positive result is characterized by numbness or tingling in
the distribution of the median nerve. This is a common diagnostic physical exam finding for
carpal tunnel syndrome.
5. A patient is reported to have 20/40 vision after a Snellen chart test. How should the nurse
interpret these findings?
A. The patient can see at 20 feet what a normal eye sees at 40 feet.
B. The patient can see at 40 feet what a normal eye sees at 20 feet.
C. The patient’s vision is twice as good as normal vision.
D. The patient has perfect vision in the right eye but poor vision in the left eye.
Correct Answer: A
Explanation: In Snellen chart results, the top number represents the distance from the
chart (20 feet). The bottom number represents the distance at which a person with normal
vision could read the same line. A result of 20/40 indicates the patient’s vision is poorer
than standard 20/20 vision.
