NRS 420 Exam 4 V1 | NRS 420 Health Assessment |
Actual Q&A with Rationale (NRS420 Exam 4) |
Grand Canyon University
1. When assessing a patient for a suspected stroke, the nurse asks the patient to smile, frown,
and puff out their cheeks. Which cranial nerve is being evaluated?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve XII (Hypoglossal)
C. Cranial Nerve IX (Glossopharyngeal)
D. Cranial Nerve VII (Facial)
Correct Answer: D
Explanation: Assessment of facial symmetry during movements like smiling or puffing
cheeks tests the motor function of the facial nerve. Asymmetry may indicate a central
nervous system lesion such as a stroke or a peripheral nerve issue like Bell’s palsy. The
nurse must document any drooping or air escape from the cheeks as abnormal findings.
2. A pregnant patient in her third trimester presents with an exaggerated inward curvature of
the lower spine. How should the nurse document this finding?
A. Lordosis
B. Scoliosis
C. Kyphosis
,D. Ankylosis
Correct Answer: A
Explanation: Lordosis is an abnormal increase in the lumbar curvature of the spine,
commonly seen in pregnancy and obesity. This compensatory mechanism helps maintain
the center of gravity as the abdominal weight increases. It is distinct from kyphosis, which
involves the thoracic spine, and scoliosis, which is a lateral curvature.
3. The nurse is conducting a health history for a 50-year-old female patient. Which of the
following factors increase the patient’s risk for developing breast cancer? (Select All That
Apply)
A. Early menarche (before age 12)
B. Late menopause (after age 55)
C. Nulliparity or first child after age 30
D. Family history of breast cancer in a first-degree relative
E. Regular physical activity of 150 minutes per week
F. High intake of fiber and cruciferous vegetables
Correct Answer: A, B, C, D
Explanation: Increased exposure to estrogen through early menarche or late menopause
significantly elevates breast cancer risk. Nulliparity or delayed childbearing also
, contributes to higher cumulative estrogen levels over a lifetime. Genetic predisposition,
evidenced by first-degree relative history, remains one of the strongest clinical predictors.
4. To assess for a possible meniscus tear in the knee, the nurse should perform which
specialized physical examination technique?
A. Phalen’s Test
B. McMurray’s Test
C. Lasegue’s Test
D. Tinel’s Sign
Correct Answer: B
Explanation: McMurray’s test is performed by rotating the leg with the knee flexed to
check for clicks or pain, which indicates a torn meniscus. If the nurse hears or feels a ‘click,’
the test is considered positive for injury. This maneuver helps differentiate meniscal
damage from collateral ligament tears.
5. During a neurological assessment, the nurse asks the patient to stand with feet together
and eyes closed. The patient begins to sway and loses balance. This is a positive sign for
which test?
A. Babinski Test
B. Weber Test
C. Allen Test
Actual Q&A with Rationale (NRS420 Exam 4) |
Grand Canyon University
1. When assessing a patient for a suspected stroke, the nurse asks the patient to smile, frown,
and puff out their cheeks. Which cranial nerve is being evaluated?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve XII (Hypoglossal)
C. Cranial Nerve IX (Glossopharyngeal)
D. Cranial Nerve VII (Facial)
Correct Answer: D
Explanation: Assessment of facial symmetry during movements like smiling or puffing
cheeks tests the motor function of the facial nerve. Asymmetry may indicate a central
nervous system lesion such as a stroke or a peripheral nerve issue like Bell’s palsy. The
nurse must document any drooping or air escape from the cheeks as abnormal findings.
2. A pregnant patient in her third trimester presents with an exaggerated inward curvature of
the lower spine. How should the nurse document this finding?
A. Lordosis
B. Scoliosis
C. Kyphosis
,D. Ankylosis
Correct Answer: A
Explanation: Lordosis is an abnormal increase in the lumbar curvature of the spine,
commonly seen in pregnancy and obesity. This compensatory mechanism helps maintain
the center of gravity as the abdominal weight increases. It is distinct from kyphosis, which
involves the thoracic spine, and scoliosis, which is a lateral curvature.
3. The nurse is conducting a health history for a 50-year-old female patient. Which of the
following factors increase the patient’s risk for developing breast cancer? (Select All That
Apply)
A. Early menarche (before age 12)
B. Late menopause (after age 55)
C. Nulliparity or first child after age 30
D. Family history of breast cancer in a first-degree relative
E. Regular physical activity of 150 minutes per week
F. High intake of fiber and cruciferous vegetables
Correct Answer: A, B, C, D
Explanation: Increased exposure to estrogen through early menarche or late menopause
significantly elevates breast cancer risk. Nulliparity or delayed childbearing also
, contributes to higher cumulative estrogen levels over a lifetime. Genetic predisposition,
evidenced by first-degree relative history, remains one of the strongest clinical predictors.
4. To assess for a possible meniscus tear in the knee, the nurse should perform which
specialized physical examination technique?
A. Phalen’s Test
B. McMurray’s Test
C. Lasegue’s Test
D. Tinel’s Sign
Correct Answer: B
Explanation: McMurray’s test is performed by rotating the leg with the knee flexed to
check for clicks or pain, which indicates a torn meniscus. If the nurse hears or feels a ‘click,’
the test is considered positive for injury. This maneuver helps differentiate meniscal
damage from collateral ligament tears.
5. During a neurological assessment, the nurse asks the patient to stand with feet together
and eyes closed. The patient begins to sway and loses balance. This is a positive sign for
which test?
A. Babinski Test
B. Weber Test
C. Allen Test
