NUR 101/NUR101 Exam 4 V3 | Health Assessment
Q&A with Rationale | Fortis College
1. A nurse is performing a neurological assessment on a client and asks them to shrug their
shoulders against resistance. Which cranial nerve is being evaluated?
A. Cranial Nerve X (Vagus)
B. Cranial Nerve XII (Hypoglossal)
C. Cranial Nerve XI (Spinal Accessory)
D. Cranial Nerve IX (Glossopharyngeal)
Correct Answer: C
Explanation: Cranial Nerve XI, the spinal accessory nerve, controls the trapezius and
sternocleidomastoid muscles. Testing shoulder shrugging and head turning against
resistance is the standard method for assessing its motor function. Weakness or
asymmetry in these movements may indicate nerve damage or muscle pathology.
2. During a musculoskeletal assessment, the nurse notes that a client has an exaggerated
lumbar curve. How should the nurse document this finding?
A. Kyphosis
B. Lordosis
C. Scoliosis
D. Ankylosis
,Correct Answer: B
Explanation: Lordosis is an inward curvature of the lumbar spine, often seen in pregnant
women or individuals with obesity. Kyphosis refers to the ‘hunchback’ appearance of the
thoracic spine, while scoliosis is a lateral deviation. Accurate documentation of spinal
alignment is essential for identifying potential mobility and pain issues.
3. When assessing the deep tendon reflexes (DTRs) of a client, the nurse observes a very brisk
response with rhythmic oscillations (clonus). What grade should the nurse assign?
A. 1+
B. 2+
C. 3+
D. 4+
Correct Answer: D
Explanation: A reflex grade of 4+ indicates a very brisk, hyperactive response often
associated with clonus. A normal reflex response is typically graded as 2+, while 1+ is
diminished and 3+ is brisker than average but not necessarily indicative of disease.
Hyperreflexia can be a sign of upper motor neuron lesions or electrolyte imbalances.
4. Which assessment technique is most appropriate for a nurse to use when checking for the
presence of fluid in the knee joint?
A. Phalen’s test
B. McMurray’s test
, C. Tinels sign
D. Bulge sign
Correct Answer: D
Explanation: The bulge sign is used to assess for small amounts of fluid in the knee joint by
milking fluid toward the suprapatellar pouch. Phalen’s and Tinel’s signs are specific to
assessing carpal tunnel syndrome in the wrist. McMurray’s test is utilized to evaluate for
meniscal tears rather than simple fluid effusion.
5. The nurse asks the client to stand with feet together and arms at the sides, then close their
eyes. The client begins to sway significantly and almost falls. This is a positive:
A. Babinski sign
B. Homan’s sign
C. Allen test
D. Romberg test
Correct Answer: D
Explanation: A positive Romberg test occurs when a client loses balance after closing their
eyes, indicating a problem with proprioception or vestibular function. While slight swaying
is normal, significant loss of balance is abnormal and requires safety precautions during the
exam. This test differentiates between cerebellar ataxia and sensory ataxia.
Q&A with Rationale | Fortis College
1. A nurse is performing a neurological assessment on a client and asks them to shrug their
shoulders against resistance. Which cranial nerve is being evaluated?
A. Cranial Nerve X (Vagus)
B. Cranial Nerve XII (Hypoglossal)
C. Cranial Nerve XI (Spinal Accessory)
D. Cranial Nerve IX (Glossopharyngeal)
Correct Answer: C
Explanation: Cranial Nerve XI, the spinal accessory nerve, controls the trapezius and
sternocleidomastoid muscles. Testing shoulder shrugging and head turning against
resistance is the standard method for assessing its motor function. Weakness or
asymmetry in these movements may indicate nerve damage or muscle pathology.
2. During a musculoskeletal assessment, the nurse notes that a client has an exaggerated
lumbar curve. How should the nurse document this finding?
A. Kyphosis
B. Lordosis
C. Scoliosis
D. Ankylosis
,Correct Answer: B
Explanation: Lordosis is an inward curvature of the lumbar spine, often seen in pregnant
women or individuals with obesity. Kyphosis refers to the ‘hunchback’ appearance of the
thoracic spine, while scoliosis is a lateral deviation. Accurate documentation of spinal
alignment is essential for identifying potential mobility and pain issues.
3. When assessing the deep tendon reflexes (DTRs) of a client, the nurse observes a very brisk
response with rhythmic oscillations (clonus). What grade should the nurse assign?
A. 1+
B. 2+
C. 3+
D. 4+
Correct Answer: D
Explanation: A reflex grade of 4+ indicates a very brisk, hyperactive response often
associated with clonus. A normal reflex response is typically graded as 2+, while 1+ is
diminished and 3+ is brisker than average but not necessarily indicative of disease.
Hyperreflexia can be a sign of upper motor neuron lesions or electrolyte imbalances.
4. Which assessment technique is most appropriate for a nurse to use when checking for the
presence of fluid in the knee joint?
A. Phalen’s test
B. McMurray’s test
, C. Tinels sign
D. Bulge sign
Correct Answer: D
Explanation: The bulge sign is used to assess for small amounts of fluid in the knee joint by
milking fluid toward the suprapatellar pouch. Phalen’s and Tinel’s signs are specific to
assessing carpal tunnel syndrome in the wrist. McMurray’s test is utilized to evaluate for
meniscal tears rather than simple fluid effusion.
5. The nurse asks the client to stand with feet together and arms at the sides, then close their
eyes. The client begins to sway significantly and almost falls. This is a positive:
A. Babinski sign
B. Homan’s sign
C. Allen test
D. Romberg test
Correct Answer: D
Explanation: A positive Romberg test occurs when a client loses balance after closing their
eyes, indicating a problem with proprioception or vestibular function. While slight swaying
is normal, significant loss of balance is abnormal and requires safety precautions during the
exam. This test differentiates between cerebellar ataxia and sensory ataxia.
