NUR 101/NUR101 Exam 4 V1 | Health Assessment
Q&A with Rationale | Fortis College
1. When performing a musculoskeletal assessment, the nurse asks the patient to move their
arm away from the midline of the body. Which movement is the nurse evaluating?
A. Abduction
B. Adduction
C. Flexion
D. Extension
Correct Answer: A
Explanation: Abduction is the movement of a limb or other part away from the midline of
the body or from another part. Adduction is the opposite movement, bringing the limb
toward the midline. The nurse must correctly identify these terms to document range of
motion accurately during a physical exam.
2. A patient presents with suspected carpal tunnel syndrome. Which assessment technique
should the nurse use to elicit numbness and burning?
A. Tinel’s sign
B. McMurray test
C. Bulge sign
D. Phalen’s test
,Correct Answer: D
Explanation: Phalen’s test is performed by having the patient hold their hands back-to-
back while flexing the wrists at 90 degrees for 60 seconds. A positive result occurs when
the patient experiences numbness and burning in the distribution of the median nerve.
Tinel’s sign involves percussion over the median nerve at the wrist, whereas the other tests
are for the knee.
3. During a neurological exam, the nurse asks the patient to follow a finger as it moves
through the six cardinal positions of gaze. Which cranial nerves are being assessed?
A. II, III, IV
B. III, IV, VI
C. V, VII, VIII
D. I, II, V
Correct Answer: B
Explanation: Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) control the
extraocular muscles responsible for eye movement. Assessing the six cardinal positions of
gaze allows the nurse to determine if these nerves are functioning synchronously. Deficits
in these movements may indicate neurological impairment or muscle weakness.
4. When assessing the deep tendon reflexes of a patient, the nurse notes a very brisk
response with clonus. How should the nurse document this finding?
A. 1+
, B. 4+
C. 3+
D. 2+
Correct Answer: B
Explanation: Deep tendon reflexes are graded on a 4-point scale where 2+ is considered
normal. A grade of 4+ indicates a very brisk, hyperactive response with clonus, which is
often associated with upper motor neuron disease. The nurse must differentiate between
normal and pathological responses to provide an accurate neurological profile.
5. A nurse is performing a breast examination on a female patient. Which area of the breast
should the nurse emphasize, as it is the most common site for breast tumors?
A. Upper outer quadrant
B. Lower inner quadrant
C. Upper inner quadrant
D. Lower outer quadrant
Correct Answer: A
Explanation: The upper outer quadrant, which includes the tail of Spence, is the most
common site for malignant breast tumors. The nurse should ensure thorough palpation of
this area during every clinical breast exam. Recognizing this anatomical predisposition
helps in the early detection of potential malignancies.
Q&A with Rationale | Fortis College
1. When performing a musculoskeletal assessment, the nurse asks the patient to move their
arm away from the midline of the body. Which movement is the nurse evaluating?
A. Abduction
B. Adduction
C. Flexion
D. Extension
Correct Answer: A
Explanation: Abduction is the movement of a limb or other part away from the midline of
the body or from another part. Adduction is the opposite movement, bringing the limb
toward the midline. The nurse must correctly identify these terms to document range of
motion accurately during a physical exam.
2. A patient presents with suspected carpal tunnel syndrome. Which assessment technique
should the nurse use to elicit numbness and burning?
A. Tinel’s sign
B. McMurray test
C. Bulge sign
D. Phalen’s test
,Correct Answer: D
Explanation: Phalen’s test is performed by having the patient hold their hands back-to-
back while flexing the wrists at 90 degrees for 60 seconds. A positive result occurs when
the patient experiences numbness and burning in the distribution of the median nerve.
Tinel’s sign involves percussion over the median nerve at the wrist, whereas the other tests
are for the knee.
3. During a neurological exam, the nurse asks the patient to follow a finger as it moves
through the six cardinal positions of gaze. Which cranial nerves are being assessed?
A. II, III, IV
B. III, IV, VI
C. V, VII, VIII
D. I, II, V
Correct Answer: B
Explanation: Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) control the
extraocular muscles responsible for eye movement. Assessing the six cardinal positions of
gaze allows the nurse to determine if these nerves are functioning synchronously. Deficits
in these movements may indicate neurological impairment or muscle weakness.
4. When assessing the deep tendon reflexes of a patient, the nurse notes a very brisk
response with clonus. How should the nurse document this finding?
A. 1+
, B. 4+
C. 3+
D. 2+
Correct Answer: B
Explanation: Deep tendon reflexes are graded on a 4-point scale where 2+ is considered
normal. A grade of 4+ indicates a very brisk, hyperactive response with clonus, which is
often associated with upper motor neuron disease. The nurse must differentiate between
normal and pathological responses to provide an accurate neurological profile.
5. A nurse is performing a breast examination on a female patient. Which area of the breast
should the nurse emphasize, as it is the most common site for breast tumors?
A. Upper outer quadrant
B. Lower inner quadrant
C. Upper inner quadrant
D. Lower outer quadrant
Correct Answer: A
Explanation: The upper outer quadrant, which includes the tail of Spence, is the most
common site for malignant breast tumors. The nurse should ensure thorough palpation of
this area during every clinical breast exam. Recognizing this anatomical predisposition
helps in the early detection of potential malignancies.
