NSG 3160 Exam 2 /Actual NSG 3160 Exam 2 Health
Assessment Exam Actual Test Bank 2026/2027 Practice
Questions And Study Guide Complete Accurate Exam
Real Questions And Correct Verified Answers With
Detailed Rationales (Reliable Answers) Currently Updated
1. The nurse just received report on the neurological unit. Which of the
following findings would be of most concern?
A. Patient with chronic dementia A&O×1
B. Patient with a head injury who does not remember what was happening
before or during the injury
C. Patient reporting headache, denies any injury, no external abnormalities
noted
D. Patient reporting generalized weakness
Correct Answer: B. Patient with a head injury who does not remember
what was happening before or during the injury
Rationale: A patient with a head injury who cannot remember events before
or during the injury is experiencing retrograde amnesia, which is concerning
and indicates potential neurological compromise. While dementia (A) is
,chronic, and headache with no injury (C) or generalized weakness (D) are
concerning, the acute head injury with memory loss represents an acute
change that requires immediate attention.
2. Patient reports having a head injury while out with friends and reporting
ETOH intake. Which of the following statements would concern you the
most?
A. "I was being goofy and tripped."
B. "My legs feel unsteady."
C. "I am having trouble focusing."
D. "It is hard to swallow when taking a drink."
Correct Answer: D. "It is hard to swallow when taking a drink."
Rationale: Difficulty swallowing (dysphagia) is a priority finding as it
indicates potential brainstem involvement or cranial nerve dysfunction, which
can compromise the airway (ABCs). This is more concerning than unsteady
gait, trouble focusing, or the mechanism of injury.
3. Which of the following statements made by the student nurse requires
further education?
A. "One method to assess cranial nerve V would be to have the person puff
their cheeks. Then press on their cheeks to ensure the air escapes equally
bilaterally."
, B. "To assess the acoustic, or vestibulocochlear, nerve would be to
administer the whisper test. An expected finding is for the patient to
correctly repeat at least four of the six phrases."
C. "When assessing the pupil, if the patient has an increased ICP there will
be a sudden, unilateral, dilated, and nonreactive change in the pupils."
D. "To assess cranial nerve XII, ask the patient to protrude their tongue,
ensuring no tremors or wasting are present, and that the tongue is midline."
Correct Answer: C. "When assessing the pupil, if the patient has an
increased ICP there will be a sudden, unilateral, dilated, and nonreactive
change in the pupils."
Rationale: Increased intracranial pressure (ICP) typically causes a bilateral,
not unilateral, change in pupils. A sudden, unilateral, dilated, and nonreactive
pupil is more characteristic of cranial nerve III (oculomotor nerve)
compression, which can occur with herniation syndromes. The student's
statement about ICP requires further education as it inaccurately describes the
pupillary findings associated with increased ICP.
4. While practicing the Romberg Test, which of the following statements, if
made by the student nurse, would show understanding of this test?
A. "An expected finding for this test is negative. If negative, the patient
will not sway, or become unbalanced and fall."
B. "An expected finding for this test is positive. If positive, the patient will
not sway, or become unbalanced and fall."
, C. "An unexpected finding for this test is negative. If negative, the patient
will not sway, or become unbalanced and fall."
D. "An unexpected finding for this test is positive. If positive, the patient
will not sway, or become unbalanced and fall."
Correct Answer: A. "An expected finding for this test is negative. If
negative, the patient will not sway, or become unbalanced and fall."
Rationale: The Romberg test assesses balance and proprioception. A negative
(normal) finding means the patient can stand with feet together, arms at sides,
and eyes closed for approximately 20 seconds without swaying or falling. A
positive finding indicates an inability to maintain balance, suggesting
cerebellar or vestibular dysfunction.
5. Mental status is defined as:
A. A patient's emotional and cognitive function
B. The patient's conscious, mood, and affect
C. General Intelligence
D. Patient's perception
Correct Answer: A. A patient's emotional and cognitive function
Rationale: Mental status refers to a person's emotional and cognitive
functioning, including aspects such as consciousness, orientation, mood,
affect, thought processes, memory, attention, and judgment. Therefore, A is
the most comprehensive definition. Options B, C, and D describe individual
components of mental status rather than the overall concept.
Assessment Exam Actual Test Bank 2026/2027 Practice
Questions And Study Guide Complete Accurate Exam
Real Questions And Correct Verified Answers With
Detailed Rationales (Reliable Answers) Currently Updated
1. The nurse just received report on the neurological unit. Which of the
following findings would be of most concern?
A. Patient with chronic dementia A&O×1
B. Patient with a head injury who does not remember what was happening
before or during the injury
C. Patient reporting headache, denies any injury, no external abnormalities
noted
D. Patient reporting generalized weakness
Correct Answer: B. Patient with a head injury who does not remember
what was happening before or during the injury
Rationale: A patient with a head injury who cannot remember events before
or during the injury is experiencing retrograde amnesia, which is concerning
and indicates potential neurological compromise. While dementia (A) is
,chronic, and headache with no injury (C) or generalized weakness (D) are
concerning, the acute head injury with memory loss represents an acute
change that requires immediate attention.
2. Patient reports having a head injury while out with friends and reporting
ETOH intake. Which of the following statements would concern you the
most?
A. "I was being goofy and tripped."
B. "My legs feel unsteady."
C. "I am having trouble focusing."
D. "It is hard to swallow when taking a drink."
Correct Answer: D. "It is hard to swallow when taking a drink."
Rationale: Difficulty swallowing (dysphagia) is a priority finding as it
indicates potential brainstem involvement or cranial nerve dysfunction, which
can compromise the airway (ABCs). This is more concerning than unsteady
gait, trouble focusing, or the mechanism of injury.
3. Which of the following statements made by the student nurse requires
further education?
A. "One method to assess cranial nerve V would be to have the person puff
their cheeks. Then press on their cheeks to ensure the air escapes equally
bilaterally."
, B. "To assess the acoustic, or vestibulocochlear, nerve would be to
administer the whisper test. An expected finding is for the patient to
correctly repeat at least four of the six phrases."
C. "When assessing the pupil, if the patient has an increased ICP there will
be a sudden, unilateral, dilated, and nonreactive change in the pupils."
D. "To assess cranial nerve XII, ask the patient to protrude their tongue,
ensuring no tremors or wasting are present, and that the tongue is midline."
Correct Answer: C. "When assessing the pupil, if the patient has an
increased ICP there will be a sudden, unilateral, dilated, and nonreactive
change in the pupils."
Rationale: Increased intracranial pressure (ICP) typically causes a bilateral,
not unilateral, change in pupils. A sudden, unilateral, dilated, and nonreactive
pupil is more characteristic of cranial nerve III (oculomotor nerve)
compression, which can occur with herniation syndromes. The student's
statement about ICP requires further education as it inaccurately describes the
pupillary findings associated with increased ICP.
4. While practicing the Romberg Test, which of the following statements, if
made by the student nurse, would show understanding of this test?
A. "An expected finding for this test is negative. If negative, the patient
will not sway, or become unbalanced and fall."
B. "An expected finding for this test is positive. If positive, the patient will
not sway, or become unbalanced and fall."
, C. "An unexpected finding for this test is negative. If negative, the patient
will not sway, or become unbalanced and fall."
D. "An unexpected finding for this test is positive. If positive, the patient
will not sway, or become unbalanced and fall."
Correct Answer: A. "An expected finding for this test is negative. If
negative, the patient will not sway, or become unbalanced and fall."
Rationale: The Romberg test assesses balance and proprioception. A negative
(normal) finding means the patient can stand with feet together, arms at sides,
and eyes closed for approximately 20 seconds without swaying or falling. A
positive finding indicates an inability to maintain balance, suggesting
cerebellar or vestibular dysfunction.
5. Mental status is defined as:
A. A patient's emotional and cognitive function
B. The patient's conscious, mood, and affect
C. General Intelligence
D. Patient's perception
Correct Answer: A. A patient's emotional and cognitive function
Rationale: Mental status refers to a person's emotional and cognitive
functioning, including aspects such as consciousness, orientation, mood,
affect, thought processes, memory, attention, and judgment. Therefore, A is
the most comprehensive definition. Options B, C, and D describe individual
components of mental status rather than the overall concept.
