NRS 420 Exam 4 V2 | NRS 420 Health Assessment |
Actual Q&A with Rationale (NRS420 Exam 4) |
Grand Canyon University
1. A nurse is performing a neurological assessment on a patient following a motor vehicle
accident. Which findings would lead the nurse to conclude there is impairment of Cranial
Nerves III, IV, or VI? (Select All That Apply)
A. Ptosis of the upper eyelid
B. Lateral deviation of the eye at rest
C. Loss of smell sensation
D. Nystagmus during the six cardinal positions of gaze
E. Consensual pupillary constriction
F. Inability to move the eyes downward and inward
Correct Answer: A, B, D, F
Explanation: Cranial nerves III (Oculomotor), IV (Trochlear), and VI (Abducens) control
the extraocular muscles and pupillary response. Ptosis, nystagmus, and strabismus
(deviation) are clinical indicators of dysfunction in these specific nerves. Testing these
nerves is critical for identifying brainstem injuries or increased intracranial pressure in
trauma patients.
,2. During a musculoskeletal exam, the nurse asks a patient to move their arm away from the
midline of the body. The nurse should document this movement as:
A. Abduction
B. Adduction
C. Circumduction
D. Flexion
Correct Answer: A
Explanation: Abduction is defined as the movement of a limb or other part away from the
midline of the body or from another part. Adduction is the opposite, moving the limb
toward the midline. Accurate documentation of range of motion is essential for tracking
progress in physical therapy or identifying joint restrictions.
3. The nurse is assessing a 65-year-old male patient reporting difficulty starting his urinary
stream. Which condition is most likely associated with this symptom?
A. Benign Prostatic Hyperplasia (BPH)
B. Inguinal hernia
C. Testicular torsion
D. Orchitis
Correct Answer: A
, Explanation: Benign Prostatic Hyperplasia (BPH) is a common condition in older men
where the enlarging prostate gland compresses the urethra. This compression leads to
symptoms like hesitancy, weak stream, and nocturia. Unlike BPH, testicular torsion is an
acute emergency characterized by sudden pain and swelling.
4. A patient is unable to differentiate between a key and a coin placed in their hand while
their eyes are closed. How should the nurse document this finding?
A. Astereognosis
B. Positive Romberg sign
C. Negative Graphesthesia
D. Anosmia
Correct Answer: A
Explanation: Stereognosis is the ability to recognize objects by feeling their form, size, and
weight while the eyes are closed. The inability to do so is called astereognosis, which may
indicate a lesion in the sensory cortex or posterior column. Graphesthesia refers
specifically to the ability to ‘read’ a number traced on the skin.
5. When assessing for carpal tunnel syndrome, the nurse asks the patient to hold both hands
back-to-back while flexing the wrists 90 degrees for 60 seconds. What is the name of this
test?
A. Tinel sign
B. Lasegue test
Actual Q&A with Rationale (NRS420 Exam 4) |
Grand Canyon University
1. A nurse is performing a neurological assessment on a patient following a motor vehicle
accident. Which findings would lead the nurse to conclude there is impairment of Cranial
Nerves III, IV, or VI? (Select All That Apply)
A. Ptosis of the upper eyelid
B. Lateral deviation of the eye at rest
C. Loss of smell sensation
D. Nystagmus during the six cardinal positions of gaze
E. Consensual pupillary constriction
F. Inability to move the eyes downward and inward
Correct Answer: A, B, D, F
Explanation: Cranial nerves III (Oculomotor), IV (Trochlear), and VI (Abducens) control
the extraocular muscles and pupillary response. Ptosis, nystagmus, and strabismus
(deviation) are clinical indicators of dysfunction in these specific nerves. Testing these
nerves is critical for identifying brainstem injuries or increased intracranial pressure in
trauma patients.
,2. During a musculoskeletal exam, the nurse asks a patient to move their arm away from the
midline of the body. The nurse should document this movement as:
A. Abduction
B. Adduction
C. Circumduction
D. Flexion
Correct Answer: A
Explanation: Abduction is defined as the movement of a limb or other part away from the
midline of the body or from another part. Adduction is the opposite, moving the limb
toward the midline. Accurate documentation of range of motion is essential for tracking
progress in physical therapy or identifying joint restrictions.
3. The nurse is assessing a 65-year-old male patient reporting difficulty starting his urinary
stream. Which condition is most likely associated with this symptom?
A. Benign Prostatic Hyperplasia (BPH)
B. Inguinal hernia
C. Testicular torsion
D. Orchitis
Correct Answer: A
, Explanation: Benign Prostatic Hyperplasia (BPH) is a common condition in older men
where the enlarging prostate gland compresses the urethra. This compression leads to
symptoms like hesitancy, weak stream, and nocturia. Unlike BPH, testicular torsion is an
acute emergency characterized by sudden pain and swelling.
4. A patient is unable to differentiate between a key and a coin placed in their hand while
their eyes are closed. How should the nurse document this finding?
A. Astereognosis
B. Positive Romberg sign
C. Negative Graphesthesia
D. Anosmia
Correct Answer: A
Explanation: Stereognosis is the ability to recognize objects by feeling their form, size, and
weight while the eyes are closed. The inability to do so is called astereognosis, which may
indicate a lesion in the sensory cortex or posterior column. Graphesthesia refers
specifically to the ability to ‘read’ a number traced on the skin.
5. When assessing for carpal tunnel syndrome, the nurse asks the patient to hold both hands
back-to-back while flexing the wrists 90 degrees for 60 seconds. What is the name of this
test?
A. Tinel sign
B. Lasegue test
