NSG 3160 Exam 3 V1 | NSG 3160 Health
Assessment | Actual Q&A with Rationale (NSG3160
Exam 3) | Galen
1. A nurse is performing a neurological assessment on a patient. Which cranial nerves should
be tested to assess the motor function of the eyes? (Select All That Apply)
A. Cranial Nerve II (Optic)
B. Cranial Nerve III (Oculomotor)
C. Cranial Nerve IV (Trochlear)
D. Cranial Nerve V (Trigeminal)
E. Cranial Nerve VI (Abducens)
Correct Answer: B, C, E
Explanation: Cranial nerves III, IV, and VI are responsible for the extraocular movements
of the eyes. The oculomotor nerve (III) controls most eye movements and pupillary
constriction, while the trochlear (IV) and abducens (VI) control specific downward/inward
and outward movements respectively. Cranial nerve II is sensory for vision, and V is
responsible for facial sensation and mastication.
2. During a musculoskeletal examination, the nurse asks the patient to hold both hands back-
to-back while flexing the wrists 90 degrees for 60 seconds. What is the nurse assessing for?
A. Tinel’s sign for ulnar nerve compression
,B. Allen’s test for arterial blood flow
C. Phalen’s test for carpal tunnel syndrome
D. Finkelstein’s test for De Quervain’s tenosynovitis
Correct Answer: C
Explanation: This maneuver is known as Phalen’s test, which is used to screen for carpal
tunnel syndrome. A positive result occurs if the patient experiences numbness and burning,
suggesting median nerve compression. This test is highly specific for evaluating patients
reporting paresthesia in the thumb and first two fingers.
3. When assessing deep tendon reflexes, the nurse notes that the patient’s patellar reflex is
very brisk, hyperactive, with intermittent clonus. How should the nurse document this
finding?
A. 1+
B. 2+
C. 4+
D. 3+
Correct Answer: C
Explanation: A grade of 4+ indicates a reflex that is very brisk, hyperactive, and often
associated with clonus, which is indicative of upper motor neuron disease. A 2+ grade is
considered normal or average, while 1+ is diminished and 3+ is brisker than average.
, Accurate documentation of reflex intensity is vital for monitoring neurological status
changes.
4. A nurse is performing a breast examination. Which of the following findings would be
considered a sign of potential malignancy? (Select All That Apply)
A. A fixed, nontender mass with irregular borders
B. Skin dimpling or retraction
C. A soft, mobile, tender mass
D. Nipple discharge in a lactating woman
E. Peau d’orange appearance of the skin
Correct Answer: A, B, E
Explanation: Fixed, nontender masses with irregular borders are classic clinical signs of
breast cancer. Skin dimpling and the peau d’orange appearance (which looks like an orange
peel) suggest lymphatic obstruction common in advanced cases. Soft, mobile, and tender
masses are more frequently associated with benign fibrocystic changes.
5. The nurse is assessing a patient’s coordination using the Romberg test. Which of the
following actions is correct?
A. Ask the patient to walk heel-to-toe in a straight line
B. Ask the patient to run the heel of one foot down the shin of the opposite leg
Assessment | Actual Q&A with Rationale (NSG3160
Exam 3) | Galen
1. A nurse is performing a neurological assessment on a patient. Which cranial nerves should
be tested to assess the motor function of the eyes? (Select All That Apply)
A. Cranial Nerve II (Optic)
B. Cranial Nerve III (Oculomotor)
C. Cranial Nerve IV (Trochlear)
D. Cranial Nerve V (Trigeminal)
E. Cranial Nerve VI (Abducens)
Correct Answer: B, C, E
Explanation: Cranial nerves III, IV, and VI are responsible for the extraocular movements
of the eyes. The oculomotor nerve (III) controls most eye movements and pupillary
constriction, while the trochlear (IV) and abducens (VI) control specific downward/inward
and outward movements respectively. Cranial nerve II is sensory for vision, and V is
responsible for facial sensation and mastication.
2. During a musculoskeletal examination, the nurse asks the patient to hold both hands back-
to-back while flexing the wrists 90 degrees for 60 seconds. What is the nurse assessing for?
A. Tinel’s sign for ulnar nerve compression
,B. Allen’s test for arterial blood flow
C. Phalen’s test for carpal tunnel syndrome
D. Finkelstein’s test for De Quervain’s tenosynovitis
Correct Answer: C
Explanation: This maneuver is known as Phalen’s test, which is used to screen for carpal
tunnel syndrome. A positive result occurs if the patient experiences numbness and burning,
suggesting median nerve compression. This test is highly specific for evaluating patients
reporting paresthesia in the thumb and first two fingers.
3. When assessing deep tendon reflexes, the nurse notes that the patient’s patellar reflex is
very brisk, hyperactive, with intermittent clonus. How should the nurse document this
finding?
A. 1+
B. 2+
C. 4+
D. 3+
Correct Answer: C
Explanation: A grade of 4+ indicates a reflex that is very brisk, hyperactive, and often
associated with clonus, which is indicative of upper motor neuron disease. A 2+ grade is
considered normal or average, while 1+ is diminished and 3+ is brisker than average.
, Accurate documentation of reflex intensity is vital for monitoring neurological status
changes.
4. A nurse is performing a breast examination. Which of the following findings would be
considered a sign of potential malignancy? (Select All That Apply)
A. A fixed, nontender mass with irregular borders
B. Skin dimpling or retraction
C. A soft, mobile, tender mass
D. Nipple discharge in a lactating woman
E. Peau d’orange appearance of the skin
Correct Answer: A, B, E
Explanation: Fixed, nontender masses with irregular borders are classic clinical signs of
breast cancer. Skin dimpling and the peau d’orange appearance (which looks like an orange
peel) suggest lymphatic obstruction common in advanced cases. Soft, mobile, and tender
masses are more frequently associated with benign fibrocystic changes.
5. The nurse is assessing a patient’s coordination using the Romberg test. Which of the
following actions is correct?
A. Ask the patient to walk heel-to-toe in a straight line
B. Ask the patient to run the heel of one foot down the shin of the opposite leg
