NSG 3160 Exam 4 V2 | NSG 3160 Health
Assessment | Actual Q&A with Rationale (NSG3160
Exam 4) | Galen
1. The nurse is assessing the cranial nerves of a patient following a head injury. Which of the
following findings would indicate an impairment of the Oculomotor Nerve (CN III)? Select all
that apply.
A. Ptosis of the upper eyelid
B. Constriction of the pupil in response to light
C. Failure of the eye to move upward or inward
D. Absence of the blink reflex
E. Dilation of the pupil (Mydriasis)
F. Loss of visual acuity
Correct Answer: A, C, E
Explanation: Cranial Nerve III (Oculomotor) is responsible for most extraocular muscle
movements, opening of the eyelids, and pupillary constriction. Ptosis indicates a weakness
in the levator palpebrae muscle, which is controlled by CN III. Impairment often results in a
fixed, dilated pupil or the inability to move the eye in specific directions.
,2. When assessing a patient for carpal tunnel syndrome, the nurse asks the patient to hold
both hands back-to-back while flexing the wrists 90 degrees for 60 seconds. What is the name
of this diagnostic test?
A. Tinel Sign
B. Phalen Test
C. McMurray Test
D. Lasegue Test
Correct Answer: B
Explanation: The Phalen test involves acute flexion of the wrists for 60 seconds to
compress the median nerve. A positive result is indicated by numbness and burning in the
distribution of the median nerve. This test is a standard physical assessment tool for
diagnosing carpal tunnel syndrome.
3. During a musculoskeletal assessment, the nurse asks the patient to move their leg away
from the midline of the body. How should the nurse document this movement?
A. Adduction
B. Abduction
C. Circumduction
D. Inversion
Correct Answer: B
, Explanation: Abduction is the movement of a limb away from the midline of the body.
Conversely, adduction is the movement toward the midline. Accurate documentation of
range of motion is essential for tracking musculoskeletal health and recovery.
4. The nurse is performing a neurological assessment on a client and notes a positive Babinski
sign. Which of the following describes a positive Babinski sign in an adult?
A. The great toe dorsiflexes and the other toes fan out.
B. The toes curl downward in response to plantar stimulation.
C. The patient experiences sudden muscle weakness.
D. The knee jerks forward when the patellar tendon is struck.
Correct Answer: A
Explanation: A positive Babinski sign occurs when the great toe moves upward
(dorsiflexion) and the other toes fan out. While this is a normal reflex in infants, it indicates
upper motor neuron disease in adults. This finding warrants further neurological
investigation to identify the underlying cause.
5. A patient presents with ‘the worst headache of my life’ and neck stiffness. Which of the
following physical assessment maneuvers should the nurse prioritize to check for meningeal
irritation? Select all that apply.
A. Brudzinski sign
B. Kernig sign
C. Romberg test
Assessment | Actual Q&A with Rationale (NSG3160
Exam 4) | Galen
1. The nurse is assessing the cranial nerves of a patient following a head injury. Which of the
following findings would indicate an impairment of the Oculomotor Nerve (CN III)? Select all
that apply.
A. Ptosis of the upper eyelid
B. Constriction of the pupil in response to light
C. Failure of the eye to move upward or inward
D. Absence of the blink reflex
E. Dilation of the pupil (Mydriasis)
F. Loss of visual acuity
Correct Answer: A, C, E
Explanation: Cranial Nerve III (Oculomotor) is responsible for most extraocular muscle
movements, opening of the eyelids, and pupillary constriction. Ptosis indicates a weakness
in the levator palpebrae muscle, which is controlled by CN III. Impairment often results in a
fixed, dilated pupil or the inability to move the eye in specific directions.
,2. When assessing a patient for carpal tunnel syndrome, the nurse asks the patient to hold
both hands back-to-back while flexing the wrists 90 degrees for 60 seconds. What is the name
of this diagnostic test?
A. Tinel Sign
B. Phalen Test
C. McMurray Test
D. Lasegue Test
Correct Answer: B
Explanation: The Phalen test involves acute flexion of the wrists for 60 seconds to
compress the median nerve. A positive result is indicated by numbness and burning in the
distribution of the median nerve. This test is a standard physical assessment tool for
diagnosing carpal tunnel syndrome.
3. During a musculoskeletal assessment, the nurse asks the patient to move their leg away
from the midline of the body. How should the nurse document this movement?
A. Adduction
B. Abduction
C. Circumduction
D. Inversion
Correct Answer: B
, Explanation: Abduction is the movement of a limb away from the midline of the body.
Conversely, adduction is the movement toward the midline. Accurate documentation of
range of motion is essential for tracking musculoskeletal health and recovery.
4. The nurse is performing a neurological assessment on a client and notes a positive Babinski
sign. Which of the following describes a positive Babinski sign in an adult?
A. The great toe dorsiflexes and the other toes fan out.
B. The toes curl downward in response to plantar stimulation.
C. The patient experiences sudden muscle weakness.
D. The knee jerks forward when the patellar tendon is struck.
Correct Answer: A
Explanation: A positive Babinski sign occurs when the great toe moves upward
(dorsiflexion) and the other toes fan out. While this is a normal reflex in infants, it indicates
upper motor neuron disease in adults. This finding warrants further neurological
investigation to identify the underlying cause.
5. A patient presents with ‘the worst headache of my life’ and neck stiffness. Which of the
following physical assessment maneuvers should the nurse prioritize to check for meningeal
irritation? Select all that apply.
A. Brudzinski sign
B. Kernig sign
C. Romberg test
