NR 305 Health Assessment in Nursing - Exam 3 Practice 2026
|Chamberlain College
1. When assessing the Glascow Coma Scale (GCS), what are the three
components evaluated?
A. Balance, gait, and coordination
B. Pupillary reaction, blood pressure, and heart rate
C. Orientation, memory, and cognitive ability
D. Verbal response, motor response, and eye opening
Answer: D
Rationale: The GCS measures the level of consciousness based on Eye opening, Verbal
response, and Motor response.
2. Which cranial nerve is being tested when a nurse asks the patient to identify
a scent like coffee or vanilla?
A. CN II
B. CN I
C. CN III
D. CN IV
Answer: B
Rationale: CN I (Olfactory) is responsible for the sense of smell.
,3. A nurse observes a patient’s gait and notes it is uncoordinated and
staggering. How should this be documented?
A. Spastic gait
B. Steppage gait
C. Ataxic gait
D. Festinating gait
Answer: C
Rationale: Ataxia refers to a lack of muscle coordination during voluntary movements,
such as walking.
4. Testing the Trigeminal Nerve (CN V) involves which of the following actions?
A. Asking the patient to smile and puff out cheeks
B. Testing the gag reflex
C. Asking the patient to shrug their shoulders
D. Palpating the masseter muscles while the patient clenches their teeth
Answer: D
Rationale: CN V has a motor component involving the muscles of mastication (masseter
and temporal).
5. What does a ‘positive’ Romberg test indicate?
A. The patient lost balance and stepped out when eyes were closed
B. The patient was able to stand still with eyes closed
C. The patient has intact deep tendon reflexes
D. The patient has normal hearing
Answer: A
Rationale: A positive Romberg test occurs when the patient loses balance with eyes closed,
indicating a problem with proprioception or vestibular function.
, 6. The ‘Tail of Spence’ is located in which quadrant of the breast?
A. Lower Inner Quadrant
B. Upper Inner Quadrant
C. Upper Outer Quadrant
D. Lower Outer Quadrant
Answer: C
Rationale: The Tail of Spence is an extension of the tissue of the upper outer quadrant of
the breast into the axilla.
7. During a breast examination, the nurse notes skin that looks like an orange
peel (peau d’orange). This is often associated with:
A. Normal aging
B. Hormonal changes
C. Edema from blocked lymphatic drainage
D. Fibrocystic breast disease
Answer: C
Rationale: Peau d’orange is a sign of skin edema, which can indicate underlying
malignancy blocking lymphatic vessels.
8. When is the best time for a premenopausal woman to perform a Breast Self-
Examination (BSE)?
A. On the first day of her period
B. Mid-cycle during ovulation
C. 4 to 7 days after the first day of the menstrual period
D. On the same date every month regardless of cycle
Answer: C
Rationale: After the period, hormone levels drop, making the breasts less tender and
easier to palpate for lumps.
|Chamberlain College
1. When assessing the Glascow Coma Scale (GCS), what are the three
components evaluated?
A. Balance, gait, and coordination
B. Pupillary reaction, blood pressure, and heart rate
C. Orientation, memory, and cognitive ability
D. Verbal response, motor response, and eye opening
Answer: D
Rationale: The GCS measures the level of consciousness based on Eye opening, Verbal
response, and Motor response.
2. Which cranial nerve is being tested when a nurse asks the patient to identify
a scent like coffee or vanilla?
A. CN II
B. CN I
C. CN III
D. CN IV
Answer: B
Rationale: CN I (Olfactory) is responsible for the sense of smell.
,3. A nurse observes a patient’s gait and notes it is uncoordinated and
staggering. How should this be documented?
A. Spastic gait
B. Steppage gait
C. Ataxic gait
D. Festinating gait
Answer: C
Rationale: Ataxia refers to a lack of muscle coordination during voluntary movements,
such as walking.
4. Testing the Trigeminal Nerve (CN V) involves which of the following actions?
A. Asking the patient to smile and puff out cheeks
B. Testing the gag reflex
C. Asking the patient to shrug their shoulders
D. Palpating the masseter muscles while the patient clenches their teeth
Answer: D
Rationale: CN V has a motor component involving the muscles of mastication (masseter
and temporal).
5. What does a ‘positive’ Romberg test indicate?
A. The patient lost balance and stepped out when eyes were closed
B. The patient was able to stand still with eyes closed
C. The patient has intact deep tendon reflexes
D. The patient has normal hearing
Answer: A
Rationale: A positive Romberg test occurs when the patient loses balance with eyes closed,
indicating a problem with proprioception or vestibular function.
, 6. The ‘Tail of Spence’ is located in which quadrant of the breast?
A. Lower Inner Quadrant
B. Upper Inner Quadrant
C. Upper Outer Quadrant
D. Lower Outer Quadrant
Answer: C
Rationale: The Tail of Spence is an extension of the tissue of the upper outer quadrant of
the breast into the axilla.
7. During a breast examination, the nurse notes skin that looks like an orange
peel (peau d’orange). This is often associated with:
A. Normal aging
B. Hormonal changes
C. Edema from blocked lymphatic drainage
D. Fibrocystic breast disease
Answer: C
Rationale: Peau d’orange is a sign of skin edema, which can indicate underlying
malignancy blocking lymphatic vessels.
8. When is the best time for a premenopausal woman to perform a Breast Self-
Examination (BSE)?
A. On the first day of her period
B. Mid-cycle during ovulation
C. 4 to 7 days after the first day of the menstrual period
D. On the same date every month regardless of cycle
Answer: C
Rationale: After the period, hormone levels drop, making the breasts less tender and
easier to palpate for lumps.
