EXAM 4 STUDY GUIDE: NURS-160,
2025/2026 WITH CORRECT/ACCURATE
ANSWERS
Glascow Coma Scale (GCS) - CORRECT ANSWERS- Only useful to
assess patients with altered conciousness
3-15 point scale
High score of 15 and low score of 3
What are the three parts of the Glascow coma scale - CORRECT
ANSWERS- 1. Eye response
2. Verbal response
3. Motor response
Mr. Brown was playing soccer and hurt his right knee. It appears
swollen. What is the first assessment you should make?
a. Palpate for crepitus in the knee.
b. Compare the swollen knee with the other knee.
c. Assess active ROM in the knee.
d. Feel the knee for warmth. - CORRECT ANSWERS- B. Compare
the swollen knee with the other knee.
,Rationale: The first step is inspection. The first thing to do is to
compare one knee with the other for symmetry. All the other
answers are procedures for assessing joints, which may be
indicated but do not represent the first step that the nurse should
take.
What is the earliest and most sensitive indicator if altered
cerebral function?
a. unequal pupils
b. paralysis of one side of the body
c. change in level of consciousness
d. loss of deep tendon reflexes - CORRECT ANSWERS- Change in
level of consciousness
When PERRLA is normal, which cranial nerve is responsible?
a. optic CN II
b. oculomotor CN III
c. trochlear CN IV
d. abducens CN IV - CORRECT ANSWERS- Oculomotor CN III
Health related patient reaching in relation to neurological
assessment includes what?
a. pupillary response
,b. injury prevention
c. stroke protection
d. sensory perception - CORRECT ANSWERS- Injury Prevention
Stroke protection
Rational: Risk assessment and health-related patient teaching
include stroke prevention and injury prevention.
Do women that have had mastectomies need to perform self-
breast exams? - CORRECT ANSWERS- Yes - the cancer could
come back
What is one topic pertinent to abdominal health promotion? -
CORRECT ANSWERS- Food-borne illness (3 areas of focus
involving the GI system include: colorectal illness, and hepatitis)
Mrs. Jones presents at the emergency department complaining of
severe pain in her abdomen. She has a history of a liver
transplant. What would the nurse know NOT to do? - CORRECT
ANSWERS- Palpate the abdomen
CVA Risks - CORRECT ANSWERS- Age
Gender
Family History
Race
, Previous CVA or TIA's
Diabetes, A fib (atrial fibrillation)
HTN
Hyperlipidemia
Smoking
Obesity
Alcohol
What is CVA - CORRECT ANSWERS- cerebrovascular accident
(stroke); caused by plaque, clot, bleeding in vessels of brain
-stroke in right side of the brain will have motor and sensory
deficits on the left side of the body
-stroke in the left side of the brain will have right-sided motor and
sensory deficit
dysphasia - CORRECT ANSWERS- generation of speech, and
sometimes its comprehension
receptive aphasia - CORRECT ANSWERS- Wernicke's area,
unable. to understand language, spoken or written
expressive aphasia - CORRECT ANSWERS- Broca's area of brain,
loss of the ability to produce language.
2025/2026 WITH CORRECT/ACCURATE
ANSWERS
Glascow Coma Scale (GCS) - CORRECT ANSWERS- Only useful to
assess patients with altered conciousness
3-15 point scale
High score of 15 and low score of 3
What are the three parts of the Glascow coma scale - CORRECT
ANSWERS- 1. Eye response
2. Verbal response
3. Motor response
Mr. Brown was playing soccer and hurt his right knee. It appears
swollen. What is the first assessment you should make?
a. Palpate for crepitus in the knee.
b. Compare the swollen knee with the other knee.
c. Assess active ROM in the knee.
d. Feel the knee for warmth. - CORRECT ANSWERS- B. Compare
the swollen knee with the other knee.
,Rationale: The first step is inspection. The first thing to do is to
compare one knee with the other for symmetry. All the other
answers are procedures for assessing joints, which may be
indicated but do not represent the first step that the nurse should
take.
What is the earliest and most sensitive indicator if altered
cerebral function?
a. unequal pupils
b. paralysis of one side of the body
c. change in level of consciousness
d. loss of deep tendon reflexes - CORRECT ANSWERS- Change in
level of consciousness
When PERRLA is normal, which cranial nerve is responsible?
a. optic CN II
b. oculomotor CN III
c. trochlear CN IV
d. abducens CN IV - CORRECT ANSWERS- Oculomotor CN III
Health related patient reaching in relation to neurological
assessment includes what?
a. pupillary response
,b. injury prevention
c. stroke protection
d. sensory perception - CORRECT ANSWERS- Injury Prevention
Stroke protection
Rational: Risk assessment and health-related patient teaching
include stroke prevention and injury prevention.
Do women that have had mastectomies need to perform self-
breast exams? - CORRECT ANSWERS- Yes - the cancer could
come back
What is one topic pertinent to abdominal health promotion? -
CORRECT ANSWERS- Food-borne illness (3 areas of focus
involving the GI system include: colorectal illness, and hepatitis)
Mrs. Jones presents at the emergency department complaining of
severe pain in her abdomen. She has a history of a liver
transplant. What would the nurse know NOT to do? - CORRECT
ANSWERS- Palpate the abdomen
CVA Risks - CORRECT ANSWERS- Age
Gender
Family History
Race
, Previous CVA or TIA's
Diabetes, A fib (atrial fibrillation)
HTN
Hyperlipidemia
Smoking
Obesity
Alcohol
What is CVA - CORRECT ANSWERS- cerebrovascular accident
(stroke); caused by plaque, clot, bleeding in vessels of brain
-stroke in right side of the brain will have motor and sensory
deficits on the left side of the body
-stroke in the left side of the brain will have right-sided motor and
sensory deficit
dysphasia - CORRECT ANSWERS- generation of speech, and
sometimes its comprehension
receptive aphasia - CORRECT ANSWERS- Wernicke's area,
unable. to understand language, spoken or written
expressive aphasia - CORRECT ANSWERS- Broca's area of brain,
loss of the ability to produce language.
