NR304/NR 304 Exam 4 V2 | Health
Assessment II Q&A with Rationale |
Chamberlain University
1. A nurse is assessing a patient’s cranial nerves. To assess the function of Cranial Nerve VII,
which action should the nurse ask the patient to perform?
A. Shrug the shoulders against resistance.
B. Stick out the tongue and move it side to side.
C. Follow a penlight through the six cardinal fields of gaze.
D. Smile, frown, and puff out the cheeks.
Correct Answer: D
Rationale: Cranial Nerve VII, the facial nerve, is responsible for the muscles of facial
expression. Asking the patient to smile, frown, and puff out the cheeks allows the nurse to
observe for symmetry and motor strength. Asymmetric movement may indicate Bell’s
palsy or central nervous system damage such as a stroke.
2. When grading muscle strength, the nurse notes that a patient has active motion against full
resistance without evident fatigue. How should the nurse document this finding?
A. 5/5
B. 4/5
C. 3/5
,D. 2/5
Correct Answer: A
Rationale: A muscle strength grade of 5/5 indicates normal strength where the patient can
maintain position against full resistance. Grade 4/5 indicates good strength against some
resistance, while Grade 3/5 signifies the patient can only move against gravity. Proper
documentation of muscle strength is vital for tracking recovery in musculoskeletal or
neurological rehabilitation.
3. The nurse is performing a Glasgow Coma Scale (GCS) assessment. The patient opens their
eyes to pain, makes incomprehensible sounds, and withdraws from pain. What is the
calculated GCS score?
A. 6
B. 12
C. 10
D. 8
Correct Answer: D
Rationale: The GCS is calculated by adding the scores for eye opening (2 for pain), verbal
response (2 for incomprehensible sounds), and motor response (4 for withdrawal from
pain), totaling 8. A score of 8 or less is often the clinical threshold for a comatose state and
may necessitate airway protection. Consistent monitoring using this scale allows for the
early detection of neurological deterioration.
, 4. During a musculoskeletal assessment, the nurse performs the Phalen test. A positive result
is indicative of which condition?
A. Rotator cuff tear
B. Meniscal tear
C. Osteoarthritis of the hip
D. Carpal tunnel syndrome
Correct Answer: D
Rationale: The Phalen test involves holding the wrists in acute flexion for 60 seconds to
compress the median nerve. If the patient experiences numbness or burning, it suggests
carpal tunnel syndrome. This assessment is a standard part of evaluating repetitive strain
injuries in the upper extremities.
5. Which cranial nerve is the nurse assessing when checking the patient’s pupillary light reflex
and accommodation?
A. Cranial Nerve II
B. Cranial Nerve VI
C. Cranial Nerve IV
D. Cranial Nerve III
Correct Answer: D
Assessment II Q&A with Rationale |
Chamberlain University
1. A nurse is assessing a patient’s cranial nerves. To assess the function of Cranial Nerve VII,
which action should the nurse ask the patient to perform?
A. Shrug the shoulders against resistance.
B. Stick out the tongue and move it side to side.
C. Follow a penlight through the six cardinal fields of gaze.
D. Smile, frown, and puff out the cheeks.
Correct Answer: D
Rationale: Cranial Nerve VII, the facial nerve, is responsible for the muscles of facial
expression. Asking the patient to smile, frown, and puff out the cheeks allows the nurse to
observe for symmetry and motor strength. Asymmetric movement may indicate Bell’s
palsy or central nervous system damage such as a stroke.
2. When grading muscle strength, the nurse notes that a patient has active motion against full
resistance without evident fatigue. How should the nurse document this finding?
A. 5/5
B. 4/5
C. 3/5
,D. 2/5
Correct Answer: A
Rationale: A muscle strength grade of 5/5 indicates normal strength where the patient can
maintain position against full resistance. Grade 4/5 indicates good strength against some
resistance, while Grade 3/5 signifies the patient can only move against gravity. Proper
documentation of muscle strength is vital for tracking recovery in musculoskeletal or
neurological rehabilitation.
3. The nurse is performing a Glasgow Coma Scale (GCS) assessment. The patient opens their
eyes to pain, makes incomprehensible sounds, and withdraws from pain. What is the
calculated GCS score?
A. 6
B. 12
C. 10
D. 8
Correct Answer: D
Rationale: The GCS is calculated by adding the scores for eye opening (2 for pain), verbal
response (2 for incomprehensible sounds), and motor response (4 for withdrawal from
pain), totaling 8. A score of 8 or less is often the clinical threshold for a comatose state and
may necessitate airway protection. Consistent monitoring using this scale allows for the
early detection of neurological deterioration.
, 4. During a musculoskeletal assessment, the nurse performs the Phalen test. A positive result
is indicative of which condition?
A. Rotator cuff tear
B. Meniscal tear
C. Osteoarthritis of the hip
D. Carpal tunnel syndrome
Correct Answer: D
Rationale: The Phalen test involves holding the wrists in acute flexion for 60 seconds to
compress the median nerve. If the patient experiences numbness or burning, it suggests
carpal tunnel syndrome. This assessment is a standard part of evaluating repetitive strain
injuries in the upper extremities.
5. Which cranial nerve is the nurse assessing when checking the patient’s pupillary light reflex
and accommodation?
A. Cranial Nerve II
B. Cranial Nerve VI
C. Cranial Nerve IV
D. Cranial Nerve III
Correct Answer: D
