NSG 6020 Advanced Health
Assessment: Complete -Question Final
Exam Practice Bank with Evidence-
Based Rationales
Q1. A 65-year-old patient remarks that she just can't believe that her
breasts sag so much. She states it must be from lack of exercise. What
explanation should the nurse offer her?
Answer: After menopause, the glandular and fat tissue atrophies, causing
breast size and elasticity to diminish, resulting in breasts that sag.
Rationale: Postmenopausal hormonal changes lead to atrophy of glandular
tissue and loss of elasticity, not lack of exercise .
Q2. The mother of a 10-year-old boy asks the nurse to discuss the
recognition of puberty. The nurse should reply by saying:
Answer: The first sign of puberty is enlargement of the testes.
Rationale: In males, testicular enlargement precedes penile growth and
pubic hair development, typically beginning between ages 9-14 .
Q3. The brain and spinal cord are included in which of the following?
Answer: Central nervous system.
Rationale: The CNS consists of the brain and spinal cord; the PNS includes
cranial nerves and peripheral nerves .
,Q4. The cranial nerves, 31 pairs of spinal nerves, and branches make up
which of the following?
Answer: Peripheral nervous system.
Rationale: The PNS connects the CNS to limbs and organs .
Q5. A rotational sensation of spinning is considered to be which of the
following?
Answer: Vertigo.
Rationale: Vertigo is the illusion of rotational movement; distinguish from
lightheadedness or disequilibrium .
Q6. A sensation of numbness and/or tingling of the extremities is
referred to as which of the following?
Answer: Paresthesia.
Rationale: Paresthesia is an abnormal sensation without an obvious
stimulus .
Q7. Lightly touching the cornea with a cotton ball would be examining
which cranial nerve?
Answer: CN V (Trigeminal) - corneal reflex.
Rationale: The afferent limb of the corneal reflex is CN V1 (ophthalmic
branch) .
Q8. During an examination, the nurse notes severe nystagmus in both
eyes of a patient. Which conclusion is correct?
Answer: This may indicate disease of the cerebellum or brainstem.
,Rationale: Nystagmus can indicate cerebellar or brainstem pathology .
Q9. How is balance evaluated?
Answer: Romberg test, fast recovery of balance when shoved, eyes closed
standing on one foot, hopping in place.
Rationale: Balance integrates vestibular, visual, and proprioceptive input .
Q10. What is the Romberg test?
Answer: Ask patient (with eyes open then closed) to stand, feet together,
arms at side. Loss of balance is a positive Romberg sign.
Rationale: Stand close, prepared to catch the patient. Sensory ataxia
worsens with eyes closed; cerebellar ataxia present regardless .
Q11. What does a positive Romberg sign mean?
Answer: Indicates cerebellar ataxia, vestibular dysfunction, or sensory loss.
Rationale: Sensory ataxia worsens with eyes closed; cerebellar ataxia is
present regardless of eye closure .
Q12. How do you evaluate sensory function?
Answer: Evaluate both primary and cortical discriminatory sensation by
having the patient identify various sensory stimuli at hands, lower arms,
abdomen, feet, and lower legs.
Rationale: Test with the patient's eyes closed, side to side .
Q13. Explain the two-point discrimination test.
Answer: Use two sharp objects and alternate touching skin with one or
both points at various locations.
, Rationale: Tests cortical sensory function; parietal lobe lesions affect
discrimination .
Q14. Explain the extinction phenomenon.
Answer: Simultaneously touch two areas on each side of body (cheek and
hand) with sharp edge. Ask patient to tell how many stimuli and where.
Rationale: Extinction indicates contralateral parietal lobe lesion .
Q15. Explain graphesthesia.
Answer: Draw a letter in the palm of the patient's hand and have them
identify it.
Rationale: Tests cortical sensory integration .
Q16. What are the deep tendon reflexes?
Answer: Biceps, brachioradial, triceps, patellar, Achilles, and clonus.
Rationale: DTRs evaluate specific spinal segment levels .
Q17. What do absent reflexes reflect?
Answer: Indicate neuropathy or lower motor neuron disorder.
Rationale: LMN lesions cause hyporeflexia or areflexia .
Q18. What do hyperactive reflexes suggest?
Answer: Upper motor neuron lesions.
Rationale: UMN lesions cause hyperreflexia due to loss of inhibitory
control .
Assessment: Complete -Question Final
Exam Practice Bank with Evidence-
Based Rationales
Q1. A 65-year-old patient remarks that she just can't believe that her
breasts sag so much. She states it must be from lack of exercise. What
explanation should the nurse offer her?
Answer: After menopause, the glandular and fat tissue atrophies, causing
breast size and elasticity to diminish, resulting in breasts that sag.
Rationale: Postmenopausal hormonal changes lead to atrophy of glandular
tissue and loss of elasticity, not lack of exercise .
Q2. The mother of a 10-year-old boy asks the nurse to discuss the
recognition of puberty. The nurse should reply by saying:
Answer: The first sign of puberty is enlargement of the testes.
Rationale: In males, testicular enlargement precedes penile growth and
pubic hair development, typically beginning between ages 9-14 .
Q3. The brain and spinal cord are included in which of the following?
Answer: Central nervous system.
Rationale: The CNS consists of the brain and spinal cord; the PNS includes
cranial nerves and peripheral nerves .
,Q4. The cranial nerves, 31 pairs of spinal nerves, and branches make up
which of the following?
Answer: Peripheral nervous system.
Rationale: The PNS connects the CNS to limbs and organs .
Q5. A rotational sensation of spinning is considered to be which of the
following?
Answer: Vertigo.
Rationale: Vertigo is the illusion of rotational movement; distinguish from
lightheadedness or disequilibrium .
Q6. A sensation of numbness and/or tingling of the extremities is
referred to as which of the following?
Answer: Paresthesia.
Rationale: Paresthesia is an abnormal sensation without an obvious
stimulus .
Q7. Lightly touching the cornea with a cotton ball would be examining
which cranial nerve?
Answer: CN V (Trigeminal) - corneal reflex.
Rationale: The afferent limb of the corneal reflex is CN V1 (ophthalmic
branch) .
Q8. During an examination, the nurse notes severe nystagmus in both
eyes of a patient. Which conclusion is correct?
Answer: This may indicate disease of the cerebellum or brainstem.
,Rationale: Nystagmus can indicate cerebellar or brainstem pathology .
Q9. How is balance evaluated?
Answer: Romberg test, fast recovery of balance when shoved, eyes closed
standing on one foot, hopping in place.
Rationale: Balance integrates vestibular, visual, and proprioceptive input .
Q10. What is the Romberg test?
Answer: Ask patient (with eyes open then closed) to stand, feet together,
arms at side. Loss of balance is a positive Romberg sign.
Rationale: Stand close, prepared to catch the patient. Sensory ataxia
worsens with eyes closed; cerebellar ataxia present regardless .
Q11. What does a positive Romberg sign mean?
Answer: Indicates cerebellar ataxia, vestibular dysfunction, or sensory loss.
Rationale: Sensory ataxia worsens with eyes closed; cerebellar ataxia is
present regardless of eye closure .
Q12. How do you evaluate sensory function?
Answer: Evaluate both primary and cortical discriminatory sensation by
having the patient identify various sensory stimuli at hands, lower arms,
abdomen, feet, and lower legs.
Rationale: Test with the patient's eyes closed, side to side .
Q13. Explain the two-point discrimination test.
Answer: Use two sharp objects and alternate touching skin with one or
both points at various locations.
, Rationale: Tests cortical sensory function; parietal lobe lesions affect
discrimination .
Q14. Explain the extinction phenomenon.
Answer: Simultaneously touch two areas on each side of body (cheek and
hand) with sharp edge. Ask patient to tell how many stimuli and where.
Rationale: Extinction indicates contralateral parietal lobe lesion .
Q15. Explain graphesthesia.
Answer: Draw a letter in the palm of the patient's hand and have them
identify it.
Rationale: Tests cortical sensory integration .
Q16. What are the deep tendon reflexes?
Answer: Biceps, brachioradial, triceps, patellar, Achilles, and clonus.
Rationale: DTRs evaluate specific spinal segment levels .
Q17. What do absent reflexes reflect?
Answer: Indicate neuropathy or lower motor neuron disorder.
Rationale: LMN lesions cause hyporeflexia or areflexia .
Q18. What do hyperactive reflexes suggest?
Answer: Upper motor neuron lesions.
Rationale: UMN lesions cause hyperreflexia due to loss of inhibitory
control .
