NSG 3160 Exam 4 V3 | NSG 3160 Health
Assessment | Actual Q&A with Rationale (NSG3160
Exam 4) | Galen
1. During a neurological assessment, the nurse asks the patient to stand with feet together
and eyes closed. The patient begins to sway significantly and almost falls. How should the
nurse document this finding?
A. Negative Romberg test
B. Positive Babinski sign
C. Positive Romberg test
D. Negative Stereognosis
Correct Answer: C
Explanation: A positive Romberg test occurs when a patient loses balance after closing
their eyes, which indicates a problem with vestibular or proprioceptive function. The nurse
must stand nearby during this test to ensure patient safety and prevent falls. This specific
test helps differentiate between cerebellar ataxia and sensory ataxia.
2. When assessing a patient’s musculoskeletal system, the nurse notes a lateral curvature of
the thoracic and lumbar spine. Which condition is the nurse observing?
A. Kyphosis
B. Lordosis
,C. Scoliosis
D. Ankylosis
Correct Answer: C
Explanation: Scoliosis is characterized by a lateral or S-shaped curvature of the spine,
most commonly diagnosed during adolescence. It is typically assessed using the Adam’s
Forward Bend test to observe for rib asymmetry. Kyphosis refers to an exaggerated
outward curvature of the thoracic spine, often called ‘hunchback’.
3. A nurse is performing a physical assessment on a patient with suspected carpal tunnel
syndrome. Which of the following tests should the nurse perform? (Select All That Apply)
A. Phalen’s test
B. Tinel’s sign
C. Bulge sign
D. Lachman test
E. McMurray test
F. Allen’s test
Correct Answer: AB
Explanation: Phalen’s test involves holding the wrists in acute flexion for 60 seconds to
see if numbness or tingling occurs. Tinel’s sign is performed by percussing over the median
, nerve at the wrist to elicit a ‘pins and needles’ sensation. These tests are specifically used to
assess for median nerve compression associated with carpal tunnel syndrome.
4. The nurse is testing a patient’s visual acuity using a Snellen chart. The patient is able to
read the 20/40 line with the right eye. What does this finding indicate?
A. The patient can read at 40 feet what a normal eye can read at 20 feet.
B. The patient has 20% vision in the right eye.
C. The patient can read at 20 feet what a normal eye can read at 40 feet.
D. The patient is legally blind in the right eye.
Correct Answer: C
Explanation: The numerator (20) represents the distance the patient is standing from the
chart, while the denominator (40) represents the distance at which a normal eye could
read that same line. Therefore, 20/40 vision means the patient’s vision is worse than
normal. Legal blindness is generally defined as 20/200 or worse in the better eye with
correction.
5. When assessing the deep tendon reflexes (DTRs) of a patient, the nurse notes that the
responses are very brisk and hyperactive with clonus. How should the nurse grade these
reflexes?
A. 1+
B. 2+
C. 3+
Assessment | Actual Q&A with Rationale (NSG3160
Exam 4) | Galen
1. During a neurological assessment, the nurse asks the patient to stand with feet together
and eyes closed. The patient begins to sway significantly and almost falls. How should the
nurse document this finding?
A. Negative Romberg test
B. Positive Babinski sign
C. Positive Romberg test
D. Negative Stereognosis
Correct Answer: C
Explanation: A positive Romberg test occurs when a patient loses balance after closing
their eyes, which indicates a problem with vestibular or proprioceptive function. The nurse
must stand nearby during this test to ensure patient safety and prevent falls. This specific
test helps differentiate between cerebellar ataxia and sensory ataxia.
2. When assessing a patient’s musculoskeletal system, the nurse notes a lateral curvature of
the thoracic and lumbar spine. Which condition is the nurse observing?
A. Kyphosis
B. Lordosis
,C. Scoliosis
D. Ankylosis
Correct Answer: C
Explanation: Scoliosis is characterized by a lateral or S-shaped curvature of the spine,
most commonly diagnosed during adolescence. It is typically assessed using the Adam’s
Forward Bend test to observe for rib asymmetry. Kyphosis refers to an exaggerated
outward curvature of the thoracic spine, often called ‘hunchback’.
3. A nurse is performing a physical assessment on a patient with suspected carpal tunnel
syndrome. Which of the following tests should the nurse perform? (Select All That Apply)
A. Phalen’s test
B. Tinel’s sign
C. Bulge sign
D. Lachman test
E. McMurray test
F. Allen’s test
Correct Answer: AB
Explanation: Phalen’s test involves holding the wrists in acute flexion for 60 seconds to
see if numbness or tingling occurs. Tinel’s sign is performed by percussing over the median
, nerve at the wrist to elicit a ‘pins and needles’ sensation. These tests are specifically used to
assess for median nerve compression associated with carpal tunnel syndrome.
4. The nurse is testing a patient’s visual acuity using a Snellen chart. The patient is able to
read the 20/40 line with the right eye. What does this finding indicate?
A. The patient can read at 40 feet what a normal eye can read at 20 feet.
B. The patient has 20% vision in the right eye.
C. The patient can read at 20 feet what a normal eye can read at 40 feet.
D. The patient is legally blind in the right eye.
Correct Answer: C
Explanation: The numerator (20) represents the distance the patient is standing from the
chart, while the denominator (40) represents the distance at which a normal eye could
read that same line. Therefore, 20/40 vision means the patient’s vision is worse than
normal. Legal blindness is generally defined as 20/200 or worse in the better eye with
correction.
5. When assessing the deep tendon reflexes (DTRs) of a patient, the nurse notes that the
responses are very brisk and hyperactive with clonus. How should the nurse grade these
reflexes?
A. 1+
B. 2+
C. 3+
