NURS 5220 Exam 4 V2 | NURS 5220
Advanced Health Assessment and
Diagnostic Reasoning Review | Actual
Q&A with Rationale (NURS5220 Exam 4) |
The University of Texas at Arlington
1. A 72-year-old female presents for a routine check-up. Which of the following findings
during the ‘Get Up and Go’ test would most strongly indicate a need for further fall risk
intervention?
A. Completion of the task in exactly 8 seconds.
B. Completion of the task taking more than 12 seconds.
C. Standing up without using the arms of the chair.
D. Walking at a steady, rhythmic pace during the 3-meter turn.
Answer: B
Rationale: The Get Up and Go test is a clinical tool used to assess a patient’s mobility and
balance. A score of 12 seconds or more is generally considered a marker for increased risk
of falling in community-dwelling older adults. This assessment helps the clinician
determine if physical therapy or home safety modifications are required to prevent injury.
2. During a pelvic examination of a pregnant patient in her first trimester, the provider notes
a bluish discoloration of the cervix and vaginal mucosa. This is documented as:
A. Chadwick’s sign
,B. Goodell’s sign
C. Hegar’s sign
D. Ladit’s sign
Answer: A
Rationale: Chadwick’s sign is a presumptive sign of pregnancy characterized by a violet-
blue color of the vaginal mucosa and cervix. This physiological change is caused by
increased vascularity and congestion in the pelvic area during early gestation. It typically
becomes apparent around the 6th to 8th week of pregnancy.
3. When assessing a 9-month-old infant, which developmental milestone is considered age-
appropriate according to the Denver II developmental screening tool?
A. Building a tower of two cubes.
B. Walking without assistance for five steps.
C. Understanding and following two-step commands.
D. Picking up a small piece of food using a pincer grasp.
Answer: D
Rationale: The pincer grasp, involving the use of the thumb and forefinger to pick up small
objects, is a key fine motor milestone for 9-month-old infants. Walking and building towers
are milestones that usually appear between 12 and 18 months of age. Language
comprehension for multi-step commands develops much later in the toddler years.
, 4. A patient exhibits a positive Romberg test. This finding primarily suggests a deficit in which
of the following areas?
A. Cerebellar coordination
B. Upper motor neuron strength
C. Proprioception and vestibular function
D. Frontal lobe executive function
Answer: C
Rationale: A positive Romberg sign occurs when a patient can maintain balance with eyes
open but loses balance when the eyes are closed. This indicates that the patient is relying
on visual cues to compensate for a loss of proprioception or vestibular input. If the patient
is unsteady even with eyes open, the issue is more likely related to cerebellar ataxia rather
than a positive Romberg sign.
5. Which of the following is considered an Instrumental Activity of Daily Living (IADL) rather
than a Basic Activity of Daily Living (ADL)?
A. Toileting and personal hygiene
B. Transferring from bed to a chair
C. Self-feeding prepared meals
D. Managing medications and finances
Answer: D
Advanced Health Assessment and
Diagnostic Reasoning Review | Actual
Q&A with Rationale (NURS5220 Exam 4) |
The University of Texas at Arlington
1. A 72-year-old female presents for a routine check-up. Which of the following findings
during the ‘Get Up and Go’ test would most strongly indicate a need for further fall risk
intervention?
A. Completion of the task in exactly 8 seconds.
B. Completion of the task taking more than 12 seconds.
C. Standing up without using the arms of the chair.
D. Walking at a steady, rhythmic pace during the 3-meter turn.
Answer: B
Rationale: The Get Up and Go test is a clinical tool used to assess a patient’s mobility and
balance. A score of 12 seconds or more is generally considered a marker for increased risk
of falling in community-dwelling older adults. This assessment helps the clinician
determine if physical therapy or home safety modifications are required to prevent injury.
2. During a pelvic examination of a pregnant patient in her first trimester, the provider notes
a bluish discoloration of the cervix and vaginal mucosa. This is documented as:
A. Chadwick’s sign
,B. Goodell’s sign
C. Hegar’s sign
D. Ladit’s sign
Answer: A
Rationale: Chadwick’s sign is a presumptive sign of pregnancy characterized by a violet-
blue color of the vaginal mucosa and cervix. This physiological change is caused by
increased vascularity and congestion in the pelvic area during early gestation. It typically
becomes apparent around the 6th to 8th week of pregnancy.
3. When assessing a 9-month-old infant, which developmental milestone is considered age-
appropriate according to the Denver II developmental screening tool?
A. Building a tower of two cubes.
B. Walking without assistance for five steps.
C. Understanding and following two-step commands.
D. Picking up a small piece of food using a pincer grasp.
Answer: D
Rationale: The pincer grasp, involving the use of the thumb and forefinger to pick up small
objects, is a key fine motor milestone for 9-month-old infants. Walking and building towers
are milestones that usually appear between 12 and 18 months of age. Language
comprehension for multi-step commands develops much later in the toddler years.
, 4. A patient exhibits a positive Romberg test. This finding primarily suggests a deficit in which
of the following areas?
A. Cerebellar coordination
B. Upper motor neuron strength
C. Proprioception and vestibular function
D. Frontal lobe executive function
Answer: C
Rationale: A positive Romberg sign occurs when a patient can maintain balance with eyes
open but loses balance when the eyes are closed. This indicates that the patient is relying
on visual cues to compensate for a loss of proprioception or vestibular input. If the patient
is unsteady even with eyes open, the issue is more likely related to cerebellar ataxia rather
than a positive Romberg sign.
5. Which of the following is considered an Instrumental Activity of Daily Living (IADL) rather
than a Basic Activity of Daily Living (ADL)?
A. Toileting and personal hygiene
B. Transferring from bed to a chair
C. Self-feeding prepared meals
D. Managing medications and finances
Answer: D
