NSG 351 Exam 4 V1 | NSG 351 Health
Assessment | Actual Q&A with Rationale
(NSG351 Exam 4) | James Madison
University
1. When assessing the Glasgow Coma Scale (GCS) of a patient after a head injury, which three
areas does the nurse evaluate?
A. Pupillary response, motor response, and verbal response
B. Verbal response, orientation, and pupillary response
C. Eye opening, sensory response, and motor response
D. Eye opening, motor response, and verbal response
Answer: D
Rationale: The Glasgow Coma Scale is a standardized objective tool used to assess a
patient’s level of consciousness. It evaluates three specific categories: eye opening, motor
response, and verbal response. A maximum score of 15 indicates a fully alert person, while
a score of 7 or less reflects a coma state.
2. The nurse is testing a patient’s cranial nerve VII (Facial). Which assessment technique is
most appropriate?
A. Assess the patient’s ability to identify familiar odors
B. Ask the patient to smile, frown, and puff out their cheeks
,C. Assess visual acuity using a Snellen chart
D. Test the gag reflex using a tongue blade
Answer: B
Rationale: Cranial nerve VII, the facial nerve, is responsible for the motor symmetry of
facial expressions. The nurse assesses this by asking the patient to perform movements
such as smiling, frowning, and puffing the cheeks. Asymmetry in these movements may
indicate a neurological deficit or Bell’s palsy.
3. During a musculoskeletal assessment, the nurse asks the patient to move their arm away
from the midline of the body. This movement is called:
A. Abduction
B. Flexion
C. Adduction
D. Extension
Answer: A
Rationale: Abduction is the movement of a limb away from the midline of the body in the
frontal plane. This is a common range of motion measurement used during a physical
examination of the shoulder and hip. Adduction, conversely, is the movement toward the
midline of the body.
, 4. A patient presents with ‘morning stiffness’ in the joints that improves with movement
throughout the day. Which condition does the nurse suspect?
A. Osteoarthritis
B. Gouty arthritis
C. Osteoporosis
D. Rheumatoid arthritis
Answer: D
Rationale: Rheumatoid arthritis is a systemic inflammatory disease characterized by
symmetric joint involvement and significant morning stiffness. This stiffness typically lasts
longer than 30 to 60 minutes and improves with activity. In contrast, osteoarthritis
stiffness usually resolves within 30 minutes of waking.
5. When performing the Romberg test, what is the primary concern for the nurse to ensure
patient safety?
A. Check for rapid alternating movements
B. Stand close to the patient to prevent a fall
C. Monitor the patient’s blood pressure
D. Ask the patient to keep their eyes open the entire time
Answer: B
Assessment | Actual Q&A with Rationale
(NSG351 Exam 4) | James Madison
University
1. When assessing the Glasgow Coma Scale (GCS) of a patient after a head injury, which three
areas does the nurse evaluate?
A. Pupillary response, motor response, and verbal response
B. Verbal response, orientation, and pupillary response
C. Eye opening, sensory response, and motor response
D. Eye opening, motor response, and verbal response
Answer: D
Rationale: The Glasgow Coma Scale is a standardized objective tool used to assess a
patient’s level of consciousness. It evaluates three specific categories: eye opening, motor
response, and verbal response. A maximum score of 15 indicates a fully alert person, while
a score of 7 or less reflects a coma state.
2. The nurse is testing a patient’s cranial nerve VII (Facial). Which assessment technique is
most appropriate?
A. Assess the patient’s ability to identify familiar odors
B. Ask the patient to smile, frown, and puff out their cheeks
,C. Assess visual acuity using a Snellen chart
D. Test the gag reflex using a tongue blade
Answer: B
Rationale: Cranial nerve VII, the facial nerve, is responsible for the motor symmetry of
facial expressions. The nurse assesses this by asking the patient to perform movements
such as smiling, frowning, and puffing the cheeks. Asymmetry in these movements may
indicate a neurological deficit or Bell’s palsy.
3. During a musculoskeletal assessment, the nurse asks the patient to move their arm away
from the midline of the body. This movement is called:
A. Abduction
B. Flexion
C. Adduction
D. Extension
Answer: A
Rationale: Abduction is the movement of a limb away from the midline of the body in the
frontal plane. This is a common range of motion measurement used during a physical
examination of the shoulder and hip. Adduction, conversely, is the movement toward the
midline of the body.
, 4. A patient presents with ‘morning stiffness’ in the joints that improves with movement
throughout the day. Which condition does the nurse suspect?
A. Osteoarthritis
B. Gouty arthritis
C. Osteoporosis
D. Rheumatoid arthritis
Answer: D
Rationale: Rheumatoid arthritis is a systemic inflammatory disease characterized by
symmetric joint involvement and significant morning stiffness. This stiffness typically lasts
longer than 30 to 60 minutes and improves with activity. In contrast, osteoarthritis
stiffness usually resolves within 30 minutes of waking.
5. When performing the Romberg test, what is the primary concern for the nurse to ensure
patient safety?
A. Check for rapid alternating movements
B. Stand close to the patient to prevent a fall
C. Monitor the patient’s blood pressure
D. Ask the patient to keep their eyes open the entire time
Answer: B
