NURS 190 | NURS190 Exam 3: Physical Assessment
- WCU Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is performing a neurological assessment on a patient and asks them to stand with
feet together and eyes closed. The patient begins to sway significantly and loses balance.
How should the nurse document this finding?
A. Presence of crepitus
B. Negative Babinski sign
C. Normal cerebellar function
D. Positive Romberg test
Correct Answer: D
Rationale: A positive Romberg test occurs when a patient is unable to maintain balance
with their eyes closed, indicating an issue with vestibular or proprioceptive function. This
test specifically evaluates the patient’s ability to maintain an upright position without
visual cues. Normal cerebellar function would result in minimal swaying, which is
documented as a negative result. Loss of balance suggests that the sensory inputs to the
cerebellum are not being processed correctly. Identifying this finding is critical for
assessing a patient’s risk for falls and neurological deficits.
2. When assessing a patient’s musculoskeletal system, the nurse notes a grating sound and
sensation when the patient moves their knee. What is the correct term for this finding?
A. Atrophy
B. Joint effusion
C. Contracture
D. Crepitus
Correct Answer: D
Rationale: Crepitus is a dry, crackling, or grating sound or sensation produced by air in
subcutaneous tissue or by bone rubbing against bone. It is commonly found in joints
affected by arthritis or following a fracture where bone fragments rub together. Unlike
joint effusion, which involves fluid accumulation, crepitus is a mechanical sensation
detected during range of motion. Atrophy refers to the wasting away of muscle tissue,
which is a different clinical observation. Documenting crepitus helps the healthcare
provider determine the extent of joint degeneration or injury.
,3. A nurse is assessing a patient’s skin and notices a lesion that is asymmetrical, has irregular
borders, and multiple colors. Which condition does the nurse suspect?
A. Basal cell carcinoma
B. Melanoma
C. Squamous cell carcinoma
D. Actinic keratosis
Correct Answer: B
Rationale: Melanoma is often identified using the ABCDE rule, where ‘A’ stands for
asymmetry and ‘B’ for border irregularity. The presence of ‘C’ for color variations, such as
shades of brown, black, or red, is a significant warning sign for malignancy. Basal cell
carcinoma typically presents as a pearly or waxy bump rather than an asymmetrical
multicolored lesion. Early detection of these characteristics is essential because melanoma
is the most aggressive form of skin cancer. The nurse must document these findings
precisely to facilitate an urgent referral for a biopsy.
4. During a neurological exam, the nurse asks the patient to smile, frown, and puff out their
cheeks. Which cranial nerve is being assessed?
A. CN V (Trigeminal)
B. CN VII (Facial)
C. CN IX (Glossopharyngeal)
D. CN XII (Hypoglossal)
Correct Answer: B
Rationale: Cranial Nerve VII, the facial nerve, is responsible for controlling the muscles of
facial expression and taste on the anterior two-thirds of the tongue. By asking the patient to
perform various facial movements, the nurse can evaluate the motor integrity of this nerve
on both sides of the face. Asymmetry during these tasks might indicate a lower motor
neuron lesion, such as Bell’s palsy, or a central nervous system issue. CN V is primarily
involved in facial sensation and mastication, which are different functions. This assessment
is a standard part of a comprehensive neurological screening to ensure symmetrical motor
function.
5. The nurse is assessing a patient’s muscle strength and finds that the patient can move their
arm against gravity but not against any resistance. What grade should the nurse assign?
A. Grade 1
B. Grade 3
C. Grade 2
D. Grade 4
, Correct Answer: B
Rationale: A muscle strength grade of 3 signifies that the patient has full range of motion
against gravity but lacks the strength to overcome manual resistance. Grade 2 is assigned
when a patient can only move their limb with gravity eliminated, such as sliding it across a
table. Grade 4 would indicate that the patient can move against some resistance, though not
the maximum amount expected for their age. Using this standardized 0-5 scale allows for
consistent communication among healthcare team members regarding a patient’s physical
progress. It is important to document this baseline to monitor recovery from injury or
neurological insult.
6. Which assessment technique should the nurse use to evaluate the patient’s Cranial Nerve
XI (Spinal Accessory)?
A. Assess the gag reflex using a tongue depressor.
B. Observe the patient’s ability to swallow a sip of water.
C. Test the patient’s ability to identify familiar smells.
D. Ask the patient to shrug their shoulders against resistance.
Correct Answer: D
Rationale: Cranial Nerve XI, the spinal accessory nerve, provides motor innervation to the
trapezius and sternocleidomastoid muscles. To test this nerve, the nurse asks the patient to
shrug their shoulders and turn their head side-to-side against the nurse’s resistance.
Weakness or asymmetry during this movement may suggest nerve damage or localized
muscle trauma. Testing the gag reflex is associated with CN IX and CN X, not the spinal
accessory nerve. Ensuring the integrity of CN XI is important for assessing the patient’s
upper body mobility and coordination.
7. A nurse is inspecting a patient’s skin and finds a pressure ulcer that has partial-thickness
loss of dermis and presents as a shallow open ulcer with a red-pink wound bed. What stage is
this ulcer?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Correct Answer: B
Rationale: A Stage 2 pressure ulcer is characterized by partial-thickness skin loss involving
the epidermis, dermis, or both. It usually appears as a shallow open ulcer or a
ruptured/intact serum-filled blister without slough or bruising. Stage 1 involves non-
blanchable redness of intact skin, while Stage 3 involves full-thickness tissue loss where
subcutaneous fat may be visible. Understanding these stages is vital for implementing the
- WCU Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is performing a neurological assessment on a patient and asks them to stand with
feet together and eyes closed. The patient begins to sway significantly and loses balance.
How should the nurse document this finding?
A. Presence of crepitus
B. Negative Babinski sign
C. Normal cerebellar function
D. Positive Romberg test
Correct Answer: D
Rationale: A positive Romberg test occurs when a patient is unable to maintain balance
with their eyes closed, indicating an issue with vestibular or proprioceptive function. This
test specifically evaluates the patient’s ability to maintain an upright position without
visual cues. Normal cerebellar function would result in minimal swaying, which is
documented as a negative result. Loss of balance suggests that the sensory inputs to the
cerebellum are not being processed correctly. Identifying this finding is critical for
assessing a patient’s risk for falls and neurological deficits.
2. When assessing a patient’s musculoskeletal system, the nurse notes a grating sound and
sensation when the patient moves their knee. What is the correct term for this finding?
A. Atrophy
B. Joint effusion
C. Contracture
D. Crepitus
Correct Answer: D
Rationale: Crepitus is a dry, crackling, or grating sound or sensation produced by air in
subcutaneous tissue or by bone rubbing against bone. It is commonly found in joints
affected by arthritis or following a fracture where bone fragments rub together. Unlike
joint effusion, which involves fluid accumulation, crepitus is a mechanical sensation
detected during range of motion. Atrophy refers to the wasting away of muscle tissue,
which is a different clinical observation. Documenting crepitus helps the healthcare
provider determine the extent of joint degeneration or injury.
,3. A nurse is assessing a patient’s skin and notices a lesion that is asymmetrical, has irregular
borders, and multiple colors. Which condition does the nurse suspect?
A. Basal cell carcinoma
B. Melanoma
C. Squamous cell carcinoma
D. Actinic keratosis
Correct Answer: B
Rationale: Melanoma is often identified using the ABCDE rule, where ‘A’ stands for
asymmetry and ‘B’ for border irregularity. The presence of ‘C’ for color variations, such as
shades of brown, black, or red, is a significant warning sign for malignancy. Basal cell
carcinoma typically presents as a pearly or waxy bump rather than an asymmetrical
multicolored lesion. Early detection of these characteristics is essential because melanoma
is the most aggressive form of skin cancer. The nurse must document these findings
precisely to facilitate an urgent referral for a biopsy.
4. During a neurological exam, the nurse asks the patient to smile, frown, and puff out their
cheeks. Which cranial nerve is being assessed?
A. CN V (Trigeminal)
B. CN VII (Facial)
C. CN IX (Glossopharyngeal)
D. CN XII (Hypoglossal)
Correct Answer: B
Rationale: Cranial Nerve VII, the facial nerve, is responsible for controlling the muscles of
facial expression and taste on the anterior two-thirds of the tongue. By asking the patient to
perform various facial movements, the nurse can evaluate the motor integrity of this nerve
on both sides of the face. Asymmetry during these tasks might indicate a lower motor
neuron lesion, such as Bell’s palsy, or a central nervous system issue. CN V is primarily
involved in facial sensation and mastication, which are different functions. This assessment
is a standard part of a comprehensive neurological screening to ensure symmetrical motor
function.
5. The nurse is assessing a patient’s muscle strength and finds that the patient can move their
arm against gravity but not against any resistance. What grade should the nurse assign?
A. Grade 1
B. Grade 3
C. Grade 2
D. Grade 4
, Correct Answer: B
Rationale: A muscle strength grade of 3 signifies that the patient has full range of motion
against gravity but lacks the strength to overcome manual resistance. Grade 2 is assigned
when a patient can only move their limb with gravity eliminated, such as sliding it across a
table. Grade 4 would indicate that the patient can move against some resistance, though not
the maximum amount expected for their age. Using this standardized 0-5 scale allows for
consistent communication among healthcare team members regarding a patient’s physical
progress. It is important to document this baseline to monitor recovery from injury or
neurological insult.
6. Which assessment technique should the nurse use to evaluate the patient’s Cranial Nerve
XI (Spinal Accessory)?
A. Assess the gag reflex using a tongue depressor.
B. Observe the patient’s ability to swallow a sip of water.
C. Test the patient’s ability to identify familiar smells.
D. Ask the patient to shrug their shoulders against resistance.
Correct Answer: D
Rationale: Cranial Nerve XI, the spinal accessory nerve, provides motor innervation to the
trapezius and sternocleidomastoid muscles. To test this nerve, the nurse asks the patient to
shrug their shoulders and turn their head side-to-side against the nurse’s resistance.
Weakness or asymmetry during this movement may suggest nerve damage or localized
muscle trauma. Testing the gag reflex is associated with CN IX and CN X, not the spinal
accessory nerve. Ensuring the integrity of CN XI is important for assessing the patient’s
upper body mobility and coordination.
7. A nurse is inspecting a patient’s skin and finds a pressure ulcer that has partial-thickness
loss of dermis and presents as a shallow open ulcer with a red-pink wound bed. What stage is
this ulcer?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Correct Answer: B
Rationale: A Stage 2 pressure ulcer is characterized by partial-thickness skin loss involving
the epidermis, dermis, or both. It usually appears as a shallow open ulcer or a
ruptured/intact serum-filled blister without slough or bruising. Stage 1 involves non-
blanchable redness of intact skin, while Stage 3 involves full-thickness tissue loss where
subcutaneous fat may be visible. Understanding these stages is vital for implementing the
