NSG 3160 Exam 2
Health Assessment
Galen College of Nursing
2026/2027 |Newly Released
50 Verified questions & Answers with Detailed Rationales
Graded A+
Q1: A 78-year-old patient is admitted to the unit with sudden onset of confusion. The nurse
performs a mental status assessment and notes that the patient is alert but oriented only to
person. She is unable to answer questions about the date or why she is in the hospital. Which
component of the mental status exam (MSE) does this represent?
A. Appearance.
B. Perception.
C. Cognition. [CORRECT]
D. Content of thought.
Correct Answer: C
Rationale: Orientation (person, place, time, situation) is a key component of the cognitive
domain of the mental status exam. This patient is disoriented to place and time, indicating a
cognitive deficit, which is common in delirium or dementia.
Board Pearl: COGNITION = Orientation (Person, Place, Time, Situation) + Memory.
Q2: The nurse is caring for a patient with a history of schizophrenia. During the mental status
assessment, the nurse asks the patient to interpret the saying "People in glass houses shouldn't
throw stones." The patient responds, "Glass is fragile, so windows break." Which alteration in
thought process is this patient demonstrating?
A. Concrete thinking. [CORRECT]
B. Circumstantiality.
C. Clang association.
D. Neologism.
Correct Answer: A
,Rationale: Concrete thinking is the literal interpretation of proverbs or metaphors. The patient
focuses on the literal quality of "glass" rather than the abstract meaning of the saying. This is a
sign often seen in schizophrenia or cognitive impairment.
Board Pearl: Proverbs require abstract thinking; a literal answer indicates concrete thinking.
Q3: The nurse enters a patient’s room and notes that the patient’s eyelids are drooping
bilaterally, covering half of the pupils. Their posture is slumped, and their clothing is stained
from lunch. Which assessment would the nurse prioritize based on the "ABCT" mnemonic?
A. Assessing Behavior. [CORRECT]
B. Assessing Cognition.
C. Assessing Perception.
D. Assessing Affect.
Correct Answer: A
Rationale: While A and B are important, "B" for Behavior in the ABCT mnemonic refers to the
patient's general appearance, hygiene, dress, and posture. The slumped posture and stained
clothes are immediate cues to general self-care status and depression.
Board Pearl: ABCT - B is Behavior: Look at their dress, hygiene, and posture first.
Q4: Select all that apply. The nurse is assessing a patient's thought processes. Which of the
following are recognized forms of thought disturbances? (Select 3)
A. Flight of ideas. [CORRECT]
B. Tangentiality. [CORRECT]
C. Echopraxia. [CORRECT]
D. Euphoria.
E. Insight.
Correct Answer: A, B, C
Rationale: Flight of ideas is rapid speech with jumping between topics. Tangentiality is
wandering away from the point but not coming back. Echopraxia is the meaningless repetition of
words or phrases, a speech disturbance. Euphoria is an affect (mood), and insight is a judgment,
not a thought process disturbance.
Board Pearl: Thought process disorders involve how they speak (Speed, logic, repetition).
Q5: During an interview, the nurse asks a patient, "What brings you to the hospital today?" The
patient stops speaking mid-sentence, looks at the wall, and begins talking about a bird they saw
earlier. This is an example of:
A. Flight of ideas.
B. Loose association. [CORRECT]
C. Clang association.
D. Circumstantiality.
Correct Answer: B
, Rationale: Loose associations involve jumping from one topic to another with no logical
connection. The shift from "why I am here" to "a bird I saw" is a classic example of
disorganized thought processes seen in mania or psychosis.
Board Pearl: Loose associations = Topic jumping with no logical link.
Q6: The nurse is performing a visual acuity test using a Snellen chart. The patient covers the left
eye and reads the 20/20 line correctly. When covering the right eye, the patient reads the 20/40
line. How does the nurse document this finding?
A. Right eye: 20/20; Left eye: 20/40.
B. Right eye: 20/40; Left eye: 20/20. [CORRECT]
C. Binocular vision: 20/20.
D. Uncorrected vision: 20/40.
Correct Answer: B
Rationale: Snellen notation is written as the distance the patient is from the chart (20) over the
distance a person with normal vision can read the line. The right eye (OD - Ocular Dexter) read
the 40-foot line, while the left eye (OS - Ocular Sinister) read the 20-foot line.
Board Pearl: 20/40 means the patient sees at 20 feet what a normal eye sees at 40 feet.
Q7: An older adult patient reports needing to hold newspapers farther away to read the print. The
nurse recognizes this as a normal age-related change known as:
A. Presbyopia. [CORRECT]
B. Myopia.
C. Hyperopia.
D. Arcus senilis.
Correct Answer: A
Rationale: Presbyopia is the loss of the lens's ability to accommodate, typically beginning after
age 40. It causes difficulty focusing on near objects (like reading), which is why "cheater
readers" are needed.
Board Pearl: Presbyopia = "Old eyes" (Need glasses for reading).
Q8: The nurse is assessing the extraocular movements of a patient who sustained a head injury.
Which cranial nerves are being tested by asking the patient to follow the nurse's finger through
the six cardinal fields of gaze?
A. II (Optic), III (Oculomotor), IV (Trochlear), VI (Abducens). [CORRECT]
B. I (Olfactory), II (Optic), III (Oculomotor).
C. III (Oculomotor), V (Trigeminal), VII (Facial).
D. VI (Abducens), VII (Facial), VIII (Acoustic).
Correct Answer: A
Rationale: The "six cardinal fields" test assesses the function of CN II, III, IV, and VI. These
nerves innervate the muscles that control eye movement.
Board Pearl: The 6 Gaze Test = Cranial Nerves II, III, IV, VI.
Health Assessment
Galen College of Nursing
2026/2027 |Newly Released
50 Verified questions & Answers with Detailed Rationales
Graded A+
Q1: A 78-year-old patient is admitted to the unit with sudden onset of confusion. The nurse
performs a mental status assessment and notes that the patient is alert but oriented only to
person. She is unable to answer questions about the date or why she is in the hospital. Which
component of the mental status exam (MSE) does this represent?
A. Appearance.
B. Perception.
C. Cognition. [CORRECT]
D. Content of thought.
Correct Answer: C
Rationale: Orientation (person, place, time, situation) is a key component of the cognitive
domain of the mental status exam. This patient is disoriented to place and time, indicating a
cognitive deficit, which is common in delirium or dementia.
Board Pearl: COGNITION = Orientation (Person, Place, Time, Situation) + Memory.
Q2: The nurse is caring for a patient with a history of schizophrenia. During the mental status
assessment, the nurse asks the patient to interpret the saying "People in glass houses shouldn't
throw stones." The patient responds, "Glass is fragile, so windows break." Which alteration in
thought process is this patient demonstrating?
A. Concrete thinking. [CORRECT]
B. Circumstantiality.
C. Clang association.
D. Neologism.
Correct Answer: A
,Rationale: Concrete thinking is the literal interpretation of proverbs or metaphors. The patient
focuses on the literal quality of "glass" rather than the abstract meaning of the saying. This is a
sign often seen in schizophrenia or cognitive impairment.
Board Pearl: Proverbs require abstract thinking; a literal answer indicates concrete thinking.
Q3: The nurse enters a patient’s room and notes that the patient’s eyelids are drooping
bilaterally, covering half of the pupils. Their posture is slumped, and their clothing is stained
from lunch. Which assessment would the nurse prioritize based on the "ABCT" mnemonic?
A. Assessing Behavior. [CORRECT]
B. Assessing Cognition.
C. Assessing Perception.
D. Assessing Affect.
Correct Answer: A
Rationale: While A and B are important, "B" for Behavior in the ABCT mnemonic refers to the
patient's general appearance, hygiene, dress, and posture. The slumped posture and stained
clothes are immediate cues to general self-care status and depression.
Board Pearl: ABCT - B is Behavior: Look at their dress, hygiene, and posture first.
Q4: Select all that apply. The nurse is assessing a patient's thought processes. Which of the
following are recognized forms of thought disturbances? (Select 3)
A. Flight of ideas. [CORRECT]
B. Tangentiality. [CORRECT]
C. Echopraxia. [CORRECT]
D. Euphoria.
E. Insight.
Correct Answer: A, B, C
Rationale: Flight of ideas is rapid speech with jumping between topics. Tangentiality is
wandering away from the point but not coming back. Echopraxia is the meaningless repetition of
words or phrases, a speech disturbance. Euphoria is an affect (mood), and insight is a judgment,
not a thought process disturbance.
Board Pearl: Thought process disorders involve how they speak (Speed, logic, repetition).
Q5: During an interview, the nurse asks a patient, "What brings you to the hospital today?" The
patient stops speaking mid-sentence, looks at the wall, and begins talking about a bird they saw
earlier. This is an example of:
A. Flight of ideas.
B. Loose association. [CORRECT]
C. Clang association.
D. Circumstantiality.
Correct Answer: B
, Rationale: Loose associations involve jumping from one topic to another with no logical
connection. The shift from "why I am here" to "a bird I saw" is a classic example of
disorganized thought processes seen in mania or psychosis.
Board Pearl: Loose associations = Topic jumping with no logical link.
Q6: The nurse is performing a visual acuity test using a Snellen chart. The patient covers the left
eye and reads the 20/20 line correctly. When covering the right eye, the patient reads the 20/40
line. How does the nurse document this finding?
A. Right eye: 20/20; Left eye: 20/40.
B. Right eye: 20/40; Left eye: 20/20. [CORRECT]
C. Binocular vision: 20/20.
D. Uncorrected vision: 20/40.
Correct Answer: B
Rationale: Snellen notation is written as the distance the patient is from the chart (20) over the
distance a person with normal vision can read the line. The right eye (OD - Ocular Dexter) read
the 40-foot line, while the left eye (OS - Ocular Sinister) read the 20-foot line.
Board Pearl: 20/40 means the patient sees at 20 feet what a normal eye sees at 40 feet.
Q7: An older adult patient reports needing to hold newspapers farther away to read the print. The
nurse recognizes this as a normal age-related change known as:
A. Presbyopia. [CORRECT]
B. Myopia.
C. Hyperopia.
D. Arcus senilis.
Correct Answer: A
Rationale: Presbyopia is the loss of the lens's ability to accommodate, typically beginning after
age 40. It causes difficulty focusing on near objects (like reading), which is why "cheater
readers" are needed.
Board Pearl: Presbyopia = "Old eyes" (Need glasses for reading).
Q8: The nurse is assessing the extraocular movements of a patient who sustained a head injury.
Which cranial nerves are being tested by asking the patient to follow the nurse's finger through
the six cardinal fields of gaze?
A. II (Optic), III (Oculomotor), IV (Trochlear), VI (Abducens). [CORRECT]
B. I (Olfactory), II (Optic), III (Oculomotor).
C. III (Oculomotor), V (Trigeminal), VII (Facial).
D. VI (Abducens), VII (Facial), VIII (Acoustic).
Correct Answer: A
Rationale: The "six cardinal fields" test assesses the function of CN II, III, IV, and VI. These
nerves innervate the muscles that control eye movement.
Board Pearl: The 6 Gaze Test = Cranial Nerves II, III, IV, VI.
