NUR 101/NUR101 Exam 4 V2 | Health Assessment
Q&A with Rationale | Fortis College
1. During a neurological examination, the nurse asks the patient to stand with feet together
and eyes closed. The patient begins to sway and loses balance. How should the nurse
document this finding?
A. Positive Romberg sign
B. Negative Romberg sign
C. Positive Babinski reflex
D. Negative Babinski reflex
Correct Answer: A
Explanation: A positive Romberg sign occurs when a patient loses balance after closing
their eyes, indicating a problem with sensory ataxia or vestibular function. The nurse must
stand close to the patient during this test to ensure safety and prevent falls. This specific
test assesses the integrity of the posterior columns of the spinal cord.
2. When assessing the musculoskeletal system of an older adult, the nurse notes an
exaggerated posterior curvature of the thoracic spine. This condition is known as:
A. Lordosis
B. Scoliosis
C. Ankylosis
,D. Kyphosis
Correct Answer: D
Explanation: Kyphosis is an enhanced thoracic curve that is common in aging adults,
particularly those with osteoporosis. It is often referred to as ‘dowager’s hump’ when it is
severe. The nurse should assess for associated pain or respiratory restriction caused by
this postural change.
3. The nurse is assessing Cranial Nerve VII. Which action by the patient indicates that this
nerve is intact?
A. The patient tracks an object through the six cardinal fields of gaze.
B. The patient identifies a scent like coffee or soap.
C. The patient shrugs their shoulders against resistance.
D. The patient smiles, frowns, and puffs out their cheeks symmetrically.
Correct Answer: D
Explanation: Cranial Nerve VII is the Facial nerve, which controls motor functions of the
face such as smiling and frowning. Symmetry is the key finding to observe during this
assessment to rule out bells palsy or stroke. Sensory functions of this nerve involve taste on
the anterior two-thirds of the tongue, though motor function is more commonly tested.
4. A patient presents with a ‘pins and needles’ sensation in their hands. The nurse documents
this subjective finding as:
A. Paresthesia
, B. Anesthesia
C. Hyperesthesia
D. Hypoesthesia
Correct Answer: A
Explanation: Paresthesia is the medical term for abnormal sensations such as burning,
tingling, or numbness. This is a subjective finding reported by the patient rather than an
objective sign observed by the nurse. It often indicates peripheral nerve damage or
circulatory issues.
5. During a breast examination, the nurse notes that the skin of the left breast appears
thickened and the hair follicles are exaggerated, resembling the skin of an orange. This is
documented as:
A. Fibroadenoma
B. Mastitis
C. Paget’s disease
D. Peau d’orange
Correct Answer: D
Explanation: Peau d’orange is a French term meaning ‘orange peel skin’ and is a classic
sign of inflammatory breast cancer or lymphatic obstruction. The edema causes the skin to
Q&A with Rationale | Fortis College
1. During a neurological examination, the nurse asks the patient to stand with feet together
and eyes closed. The patient begins to sway and loses balance. How should the nurse
document this finding?
A. Positive Romberg sign
B. Negative Romberg sign
C. Positive Babinski reflex
D. Negative Babinski reflex
Correct Answer: A
Explanation: A positive Romberg sign occurs when a patient loses balance after closing
their eyes, indicating a problem with sensory ataxia or vestibular function. The nurse must
stand close to the patient during this test to ensure safety and prevent falls. This specific
test assesses the integrity of the posterior columns of the spinal cord.
2. When assessing the musculoskeletal system of an older adult, the nurse notes an
exaggerated posterior curvature of the thoracic spine. This condition is known as:
A. Lordosis
B. Scoliosis
C. Ankylosis
,D. Kyphosis
Correct Answer: D
Explanation: Kyphosis is an enhanced thoracic curve that is common in aging adults,
particularly those with osteoporosis. It is often referred to as ‘dowager’s hump’ when it is
severe. The nurse should assess for associated pain or respiratory restriction caused by
this postural change.
3. The nurse is assessing Cranial Nerve VII. Which action by the patient indicates that this
nerve is intact?
A. The patient tracks an object through the six cardinal fields of gaze.
B. The patient identifies a scent like coffee or soap.
C. The patient shrugs their shoulders against resistance.
D. The patient smiles, frowns, and puffs out their cheeks symmetrically.
Correct Answer: D
Explanation: Cranial Nerve VII is the Facial nerve, which controls motor functions of the
face such as smiling and frowning. Symmetry is the key finding to observe during this
assessment to rule out bells palsy or stroke. Sensory functions of this nerve involve taste on
the anterior two-thirds of the tongue, though motor function is more commonly tested.
4. A patient presents with a ‘pins and needles’ sensation in their hands. The nurse documents
this subjective finding as:
A. Paresthesia
, B. Anesthesia
C. Hyperesthesia
D. Hypoesthesia
Correct Answer: A
Explanation: Paresthesia is the medical term for abnormal sensations such as burning,
tingling, or numbness. This is a subjective finding reported by the patient rather than an
objective sign observed by the nurse. It often indicates peripheral nerve damage or
circulatory issues.
5. During a breast examination, the nurse notes that the skin of the left breast appears
thickened and the hair follicles are exaggerated, resembling the skin of an orange. This is
documented as:
A. Fibroadenoma
B. Mastitis
C. Paget’s disease
D. Peau d’orange
Correct Answer: D
Explanation: Peau d’orange is a French term meaning ‘orange peel skin’ and is a classic
sign of inflammatory breast cancer or lymphatic obstruction. The edema causes the skin to
