NSG 3160 Exam 4 V2 | NSG 3160 Health
Assessment | Actual Q&A with Rationale (NSG3160
Exam 4) | Galen
1. A nurse is performing a neurological assessment on a client. To assess the function of
Cranial Nerve VII (Facial), which actions should the nurse ask the client to perform? (Select All
That Apply)
A. Smile and frown
B. Close eyes tightly
C. Puff out cheeks
D. Stick out the tongue
E. Lift shoulders against resistance
F. Show teeth
Correct Answer: A, B, C, F
Explanation: Cranial Nerve VII (Facial) is responsible for the motor movement of the
muscles of facial expression. Asking the client to smile, frown, close eyes tightly, and puff
out their cheeks assesses the symmetry and strength of these muscles. Sticking out the
tongue involves CN XII (Hypoglossal), and lifting shoulders involves CN XI (Spinal
Accessory).
,2. When assessing the deep tendon reflexes (DTRs) of a client, the nurse notes that the
reflexes are very brisk, hyperactive, and include clonus. How should the nurse document this
finding?
A. 1+
B. 2+
C. 4+
D. 3+
Correct Answer: C
Explanation: The standard scale for grading reflexes ranges from 0 to 4+. A grade of 4+ is
used for very brisk, hyperactive reflexes that are often associated with disease and clonus.
A grade of 2+ is considered normal or average, while 1+ indicates a diminished response.
3. A patient presents with suspected carpal tunnel syndrome. Which assessment technique
involves having the patient hold both hands back-to-back while flexing the wrists 90 degrees
for 60 seconds?
A. Tinel’s sign
B. McMurray’s test
C. Phalen’s test
D. Lachman test
Correct Answer: C
, Explanation: Phalen’s test specifically assesses for median nerve compression
characteristic of carpal tunnel syndrome by flexing the wrists back-to-back. If numbness
and burning occur within 60 seconds, the test is considered positive. Tinel’s sign involves
percussion over the median nerve at the wrist, not flexion.
4. During a musculoskeletal exam, the nurse asks the client to move their arm away from the
midline of the body. This movement is documented as:
A. Adduction
B. Flexion
C. Abduction
D. Extension
Correct Answer: C
Explanation: Abduction is the movement of a limb or other part away from the midline of
the body or from another part. Adduction is the opposite movement, bringing the limb
toward the midline. Accurate terminology is essential for professional documentation of
range of motion.
5. Which of the following are components of the Glasgow Coma Scale (GCS)? (Select All That
Apply)
A. Eye opening
B. Pupillary response
C. Verbal response
Assessment | Actual Q&A with Rationale (NSG3160
Exam 4) | Galen
1. A nurse is performing a neurological assessment on a client. To assess the function of
Cranial Nerve VII (Facial), which actions should the nurse ask the client to perform? (Select All
That Apply)
A. Smile and frown
B. Close eyes tightly
C. Puff out cheeks
D. Stick out the tongue
E. Lift shoulders against resistance
F. Show teeth
Correct Answer: A, B, C, F
Explanation: Cranial Nerve VII (Facial) is responsible for the motor movement of the
muscles of facial expression. Asking the client to smile, frown, close eyes tightly, and puff
out their cheeks assesses the symmetry and strength of these muscles. Sticking out the
tongue involves CN XII (Hypoglossal), and lifting shoulders involves CN XI (Spinal
Accessory).
,2. When assessing the deep tendon reflexes (DTRs) of a client, the nurse notes that the
reflexes are very brisk, hyperactive, and include clonus. How should the nurse document this
finding?
A. 1+
B. 2+
C. 4+
D. 3+
Correct Answer: C
Explanation: The standard scale for grading reflexes ranges from 0 to 4+. A grade of 4+ is
used for very brisk, hyperactive reflexes that are often associated with disease and clonus.
A grade of 2+ is considered normal or average, while 1+ indicates a diminished response.
3. A patient presents with suspected carpal tunnel syndrome. Which assessment technique
involves having the patient hold both hands back-to-back while flexing the wrists 90 degrees
for 60 seconds?
A. Tinel’s sign
B. McMurray’s test
C. Phalen’s test
D. Lachman test
Correct Answer: C
, Explanation: Phalen’s test specifically assesses for median nerve compression
characteristic of carpal tunnel syndrome by flexing the wrists back-to-back. If numbness
and burning occur within 60 seconds, the test is considered positive. Tinel’s sign involves
percussion over the median nerve at the wrist, not flexion.
4. During a musculoskeletal exam, the nurse asks the client to move their arm away from the
midline of the body. This movement is documented as:
A. Adduction
B. Flexion
C. Abduction
D. Extension
Correct Answer: C
Explanation: Abduction is the movement of a limb or other part away from the midline of
the body or from another part. Adduction is the opposite movement, bringing the limb
toward the midline. Accurate terminology is essential for professional documentation of
range of motion.
5. Which of the following are components of the Glasgow Coma Scale (GCS)? (Select All That
Apply)
A. Eye opening
B. Pupillary response
C. Verbal response
