NSG 3160 Exam 2 | NSG 3160 Health Assessment |
Actual Q&A with Rationale (NSG 3160 Exam 2) |
Galen
1. A nurse is performing a neurological assessment on a patient. What is the correct
sequence for the examination?
a) Cranial nerves, mental status, motor system, sensory system, reflexes
b) Mental status, cranial nerves, motor system, sensory system, reflexes
c) Motor system, sensory system, cranial nerves, mental status, reflexes
d) Reflexes, sensory system, motor system, cranial nerves, mental status
Correct Answer: b) Mental status, cranial nerves, motor system, sensory system,
reflexes
Rationale: The correct sequence for a complete neurologic examination is mental
status, cranial nerves, motor system, sensory system, and reflexes.
2. A patient presents with a complaint of a severe headache that they have never
had before. What should the nurse's priority action be?
a) Administer an analgesic medication as ordered.
b) Assess the patient's neurological status.
c) Ask the patient about the characteristics of their headache.
d) Immediately refer the patient to the emergency department.
Correct Answer: d) Immediately refer the patient to the emergency department.
Rationale: A sudden onset of a severe headache, especially if the patient has never had
one before, can be a sign of a serious medical condition such as a stroke or aneurysm.
The patient should be referred to the emergency department immediately for further
evaluation and treatment.
3. What is the most important factor in a neuro recheck?
a) Vital signs
b) Pupillary response
c) Level of consciousness (LOC)
d) Glasgow Coma Scale
Correct Answer: c) Level of consciousness (LOC)
Rationale: A change in LOC is the single most important factor in this examination.
,4. Which cranial nerve is responsible for smell?
a) CN I
b) CN II
c) CN V
d) CN VII
Correct Answer: a) CN I
Rationale: Cranial Nerve I, the olfactory nerve, is responsible for the sense of smell.
5. A nurse is testing a patient's biceps reflex. What is the expected response?
a) Extension of the forearm
b) Flexion of the forearm
c) Dorsiflexion of the foot
d) Plantar flexion of the foot
Correct Answer: b) Flexion of the forearm
Rationale: Striking the biceps tendon should cause contraction of the biceps muscle
and flexion of the forearm.
6. Which of the following is not a component of the mental status examination?
a) Appearance
b) Temperature
c) Behavior
d) Cognition
Correct Answer: b) Temperature
Rationale: Temperature is a vital sign and not a component of the mental status exam.
The components are health history, appearance, behavior, cognition, and thought
process.
7. The nurse is assessing a patient who has experienced a stroke. The patient is
unable to speak clearly but seems to understand what the nurse is saying. What
type of aphasia is this patient experiencing?
a) Global aphasia
b) Receptive aphasia
c) Expressive aphasia
d) Anomic aphasia
Correct Answer: c) Expressive aphasia
Rationale: Expressive aphasia is a neurological condition that affects a person's ability
, to speak fluently and to find the right words, despite having intact comprehension. This
is also known as Broca's Aphasia.
8. A patient who is experiencing a stroke may have difficulty swallowing. What is the
medical term for difficulty swallowing?
a) Aphasia
b) Dysarthria
c) Dysphagia
d) Aphagia
Correct Answer: c) Dysphagia
Rationale: Dysphagia is the medical term for difficulty swallowing.
9. A patient scores a 3 on the Glasgow Coma Scale. How would the nurse interpret
this score?
a) Mild head injury
b) Moderate head injury
c) Severe head injury
d) Comatose
Correct Answer: c) Severe head injury
Rationale: A score of 3-8 on the Glasgow Coma Scale indicates a severe head injury.
10. The Mini-Mental State Exam (MMSE) is used to screen for what condition?
a) Depression
b) Delirium
c) Dementia
d) Anxiety
Correct Answer: c) Dementia
Rationale: The Mini-Mental State Exam (MMSE) is a valid detector of organic disease
such as dementia, but lacks sensitivity to detect mild cognitive impairment. It is used to
screen for cognitive impairment, most commonly associated with dementia.
11. Which of the following is a subjective finding related to the head?
a) Head injury
b) Size of the skull
c) Symmetry of the face
Actual Q&A with Rationale (NSG 3160 Exam 2) |
Galen
1. A nurse is performing a neurological assessment on a patient. What is the correct
sequence for the examination?
a) Cranial nerves, mental status, motor system, sensory system, reflexes
b) Mental status, cranial nerves, motor system, sensory system, reflexes
c) Motor system, sensory system, cranial nerves, mental status, reflexes
d) Reflexes, sensory system, motor system, cranial nerves, mental status
Correct Answer: b) Mental status, cranial nerves, motor system, sensory system,
reflexes
Rationale: The correct sequence for a complete neurologic examination is mental
status, cranial nerves, motor system, sensory system, and reflexes.
2. A patient presents with a complaint of a severe headache that they have never
had before. What should the nurse's priority action be?
a) Administer an analgesic medication as ordered.
b) Assess the patient's neurological status.
c) Ask the patient about the characteristics of their headache.
d) Immediately refer the patient to the emergency department.
Correct Answer: d) Immediately refer the patient to the emergency department.
Rationale: A sudden onset of a severe headache, especially if the patient has never had
one before, can be a sign of a serious medical condition such as a stroke or aneurysm.
The patient should be referred to the emergency department immediately for further
evaluation and treatment.
3. What is the most important factor in a neuro recheck?
a) Vital signs
b) Pupillary response
c) Level of consciousness (LOC)
d) Glasgow Coma Scale
Correct Answer: c) Level of consciousness (LOC)
Rationale: A change in LOC is the single most important factor in this examination.
,4. Which cranial nerve is responsible for smell?
a) CN I
b) CN II
c) CN V
d) CN VII
Correct Answer: a) CN I
Rationale: Cranial Nerve I, the olfactory nerve, is responsible for the sense of smell.
5. A nurse is testing a patient's biceps reflex. What is the expected response?
a) Extension of the forearm
b) Flexion of the forearm
c) Dorsiflexion of the foot
d) Plantar flexion of the foot
Correct Answer: b) Flexion of the forearm
Rationale: Striking the biceps tendon should cause contraction of the biceps muscle
and flexion of the forearm.
6. Which of the following is not a component of the mental status examination?
a) Appearance
b) Temperature
c) Behavior
d) Cognition
Correct Answer: b) Temperature
Rationale: Temperature is a vital sign and not a component of the mental status exam.
The components are health history, appearance, behavior, cognition, and thought
process.
7. The nurse is assessing a patient who has experienced a stroke. The patient is
unable to speak clearly but seems to understand what the nurse is saying. What
type of aphasia is this patient experiencing?
a) Global aphasia
b) Receptive aphasia
c) Expressive aphasia
d) Anomic aphasia
Correct Answer: c) Expressive aphasia
Rationale: Expressive aphasia is a neurological condition that affects a person's ability
, to speak fluently and to find the right words, despite having intact comprehension. This
is also known as Broca's Aphasia.
8. A patient who is experiencing a stroke may have difficulty swallowing. What is the
medical term for difficulty swallowing?
a) Aphasia
b) Dysarthria
c) Dysphagia
d) Aphagia
Correct Answer: c) Dysphagia
Rationale: Dysphagia is the medical term for difficulty swallowing.
9. A patient scores a 3 on the Glasgow Coma Scale. How would the nurse interpret
this score?
a) Mild head injury
b) Moderate head injury
c) Severe head injury
d) Comatose
Correct Answer: c) Severe head injury
Rationale: A score of 3-8 on the Glasgow Coma Scale indicates a severe head injury.
10. The Mini-Mental State Exam (MMSE) is used to screen for what condition?
a) Depression
b) Delirium
c) Dementia
d) Anxiety
Correct Answer: c) Dementia
Rationale: The Mini-Mental State Exam (MMSE) is a valid detector of organic disease
such as dementia, but lacks sensitivity to detect mild cognitive impairment. It is used to
screen for cognitive impairment, most commonly associated with dementia.
11. Which of the following is a subjective finding related to the head?
a) Head injury
b) Size of the skull
c) Symmetry of the face
