NSG 3160 Exam 3 V3 | NSG 3160 Health
Assessment | Actual Q&A with Rationale (NSG3160
Exam 3) | Galen
1. The nurse is performing a neurological assessment on an adult patient and observes the
patient’s toes flare out and the big toe dorsiflexes when the sole of the foot is stroked. How
should the nurse document this finding?
A. Negative Babinski sign, which is normal
B. Positive Babinski sign, which is abnormal
C. Positive Romberg sign, which is normal
D. Negative Brudzinski sign, which is abnormal
Correct Answer: B
Explanation: A positive Babinski sign is characterized by dorsiflexion of the big toe and
fanning of the other toes. In adults, this is an abnormal finding and indicates an upper
motor neuron lesion such as a stroke or trauma. This reflex is only considered normal in
infants up to approximately 24 months of age.
2. A patient reports a sharp, catching pain in the knee when walking. To assess for a meniscus
tear, which maneuver should the nurse perform?
A. Phalen’s test
B. Bulge sign
,C. McMurray test
D. Lasegue’s test
Correct Answer: C
Explanation: The McMurray test is specifically designed to evaluate for a torn meniscus in
the knee. The nurse performs this by rotating the leg in and out while extending the knee
from a flexed position. A click or pain during this maneuver indicates a positive result and
potential meniscal injury.
3. When assessing the breast of a 55-year-old female, which findings would the nurse identify
as requiring immediate further investigation? (Select all that apply)
A. Peau d’orange appearance of the skin
B. Recent nipple inversion or retraction
C. Symmetrical venous patterns on both breasts
D. A fixed, non-tender, irregular mass
E. Bloody nipple discharge
F. Breast tissue that feels firm and granular
Correct Answer: A, B, D, E
Explanation: Peau d’orange is a classic sign of advanced breast cancer and lymphatic
obstruction. Nipple retraction and fixed irregular masses are highly suspicious for
, malignancy and require diagnostic imaging. Bloody discharge is never normal and
warrants an urgent referral to a specialist for further evaluation.
4. A nurse is assessing a patient for carpal tunnel syndrome. Which maneuver involves the
patient holding their wrists in acute flexion for 60 seconds?
A. Tinel’s sign
B. Phalen’s test
C. Allen’s test
D. Thomas test
Correct Answer: B
Explanation: Phalen’s test is a diagnostic procedure used to identify median nerve
compression. The patient is asked to press the backs of their hands together while flexing
the wrists at a 90-degree angle. Numbness or tingling produced within 60 seconds
indicates a positive test result.
5. During a musculoskeletal exam, the nurse asks the patient to move their arm away from
the midline of the body. The nurse is assessing for which type of movement?
A. Abduction
B. Adduction
C. Flexion
D. Pronation
Assessment | Actual Q&A with Rationale (NSG3160
Exam 3) | Galen
1. The nurse is performing a neurological assessment on an adult patient and observes the
patient’s toes flare out and the big toe dorsiflexes when the sole of the foot is stroked. How
should the nurse document this finding?
A. Negative Babinski sign, which is normal
B. Positive Babinski sign, which is abnormal
C. Positive Romberg sign, which is normal
D. Negative Brudzinski sign, which is abnormal
Correct Answer: B
Explanation: A positive Babinski sign is characterized by dorsiflexion of the big toe and
fanning of the other toes. In adults, this is an abnormal finding and indicates an upper
motor neuron lesion such as a stroke or trauma. This reflex is only considered normal in
infants up to approximately 24 months of age.
2. A patient reports a sharp, catching pain in the knee when walking. To assess for a meniscus
tear, which maneuver should the nurse perform?
A. Phalen’s test
B. Bulge sign
,C. McMurray test
D. Lasegue’s test
Correct Answer: C
Explanation: The McMurray test is specifically designed to evaluate for a torn meniscus in
the knee. The nurse performs this by rotating the leg in and out while extending the knee
from a flexed position. A click or pain during this maneuver indicates a positive result and
potential meniscal injury.
3. When assessing the breast of a 55-year-old female, which findings would the nurse identify
as requiring immediate further investigation? (Select all that apply)
A. Peau d’orange appearance of the skin
B. Recent nipple inversion or retraction
C. Symmetrical venous patterns on both breasts
D. A fixed, non-tender, irregular mass
E. Bloody nipple discharge
F. Breast tissue that feels firm and granular
Correct Answer: A, B, D, E
Explanation: Peau d’orange is a classic sign of advanced breast cancer and lymphatic
obstruction. Nipple retraction and fixed irregular masses are highly suspicious for
, malignancy and require diagnostic imaging. Bloody discharge is never normal and
warrants an urgent referral to a specialist for further evaluation.
4. A nurse is assessing a patient for carpal tunnel syndrome. Which maneuver involves the
patient holding their wrists in acute flexion for 60 seconds?
A. Tinel’s sign
B. Phalen’s test
C. Allen’s test
D. Thomas test
Correct Answer: B
Explanation: Phalen’s test is a diagnostic procedure used to identify median nerve
compression. The patient is asked to press the backs of their hands together while flexing
the wrists at a 90-degree angle. Numbness or tingling produced within 60 seconds
indicates a positive test result.
5. During a musculoskeletal exam, the nurse asks the patient to move their arm away from
the midline of the body. The nurse is assessing for which type of movement?
A. Abduction
B. Adduction
C. Flexion
D. Pronation
