NSG 3160 Exam 4 V1 | NSG 3160 Health
Assessment | Actual Q&A with Rationale (NSG3160
Exam 4) | Galen
1. A nurse is assessing a patient’s cranial nerves. To assess the function of Cranial Nerve II
(Optic), which of the following assessments should the nurse perform?
A. Assess the patient’s ability to identify familiar smells.
B. Check visual acuity using a Snellen chart.
C. Observe the patient’s eye movements in six cardinal directions.
D. Test the corneal reflex using a cotton wisp.
Correct Answer: B
Explanation: Cranial Nerve II is the optic nerve, responsible for vision. The Snellen chart is
the standard tool used to measure visual acuity at a distance. Testing the other options
would assess cranial nerves I, III, IV, VI, or V respectively.
2. During a musculoskeletal assessment, a nurse finds that a patient has full range of motion
against gravity but not against resistance. How should the nurse document this muscle
strength?
A. 2/5
B. 3/5
C. 4/5
,D. 5/5
Correct Answer: B
Explanation: A grade of 3/5 indicates that the muscle can move through the full range of
motion against the force of gravity but fails when resistance is applied. A 2/5 indicates full
ROM with gravity eliminated, while 4/5 indicates full ROM against some resistance. The
documentation must accurately reflect these standardized levels to track patient progress.
3. The nurse is assessing the patient’s cerebellar function. Which of the following tests are
appropriate to include? (Select all that apply)
A. Romberg test
B. Heel-to-shin test
C. Rapid alternating movements
D. Graphesthesia
E. Finger-to-nose test
F. Patellar reflex
Correct Answer: A, B, C, E
Explanation: Cerebellar function is primarily concerned with coordination and balance.
The Romberg, heel-to-shin, rapid alternating movements, and finger-to-nose tests all
specifically evaluate these areas. Graphesthesia is a sensory cortex test, and the patellar
reflex evaluates the spinal reflex arc.
, 4. Where is the most common site for breast tumors to occur?
A. Lower inner quadrant
B. Upper inner quadrant
C. Lower outer quadrant
D. Upper outer quadrant
Correct Answer: D
Explanation: The upper outer quadrant of the breast, which includes the Tail of Spence, is
the most common site for breast cancer. This area contains a high concentration of
glandular tissue. Nurses should ensure this region is thoroughly palpated during every
clinical breast examination.
5. When assessing the neurological status of an adult, the nurse strokes the lateral aspect of
the sole of the foot. The patient’s toes fan out and the big toe moves upward. How should
the nurse interpret this finding?
A. A normal plantar reflex
B. A negative Babinski sign
C. A positive Babinski sign, which is abnormal
D. A positive Romberg sign
Correct Answer: C
Assessment | Actual Q&A with Rationale (NSG3160
Exam 4) | Galen
1. A nurse is assessing a patient’s cranial nerves. To assess the function of Cranial Nerve II
(Optic), which of the following assessments should the nurse perform?
A. Assess the patient’s ability to identify familiar smells.
B. Check visual acuity using a Snellen chart.
C. Observe the patient’s eye movements in six cardinal directions.
D. Test the corneal reflex using a cotton wisp.
Correct Answer: B
Explanation: Cranial Nerve II is the optic nerve, responsible for vision. The Snellen chart is
the standard tool used to measure visual acuity at a distance. Testing the other options
would assess cranial nerves I, III, IV, VI, or V respectively.
2. During a musculoskeletal assessment, a nurse finds that a patient has full range of motion
against gravity but not against resistance. How should the nurse document this muscle
strength?
A. 2/5
B. 3/5
C. 4/5
,D. 5/5
Correct Answer: B
Explanation: A grade of 3/5 indicates that the muscle can move through the full range of
motion against the force of gravity but fails when resistance is applied. A 2/5 indicates full
ROM with gravity eliminated, while 4/5 indicates full ROM against some resistance. The
documentation must accurately reflect these standardized levels to track patient progress.
3. The nurse is assessing the patient’s cerebellar function. Which of the following tests are
appropriate to include? (Select all that apply)
A. Romberg test
B. Heel-to-shin test
C. Rapid alternating movements
D. Graphesthesia
E. Finger-to-nose test
F. Patellar reflex
Correct Answer: A, B, C, E
Explanation: Cerebellar function is primarily concerned with coordination and balance.
The Romberg, heel-to-shin, rapid alternating movements, and finger-to-nose tests all
specifically evaluate these areas. Graphesthesia is a sensory cortex test, and the patellar
reflex evaluates the spinal reflex arc.
, 4. Where is the most common site for breast tumors to occur?
A. Lower inner quadrant
B. Upper inner quadrant
C. Lower outer quadrant
D. Upper outer quadrant
Correct Answer: D
Explanation: The upper outer quadrant of the breast, which includes the Tail of Spence, is
the most common site for breast cancer. This area contains a high concentration of
glandular tissue. Nurses should ensure this region is thoroughly palpated during every
clinical breast examination.
5. When assessing the neurological status of an adult, the nurse strokes the lateral aspect of
the sole of the foot. The patient’s toes fan out and the big toe moves upward. How should
the nurse interpret this finding?
A. A normal plantar reflex
B. A negative Babinski sign
C. A positive Babinski sign, which is abnormal
D. A positive Romberg sign
Correct Answer: C
