NRS 420 Exam 3 V1 | NRS 420 Health Assessment |
Actual Q&A with Rationale (NRS420 Exam 3) |
Grand Canyon University
1. The nurse is assessing a patient for a suspected stroke. To evaluate the function of Cranial
Nerve VII (Facial), which actions should the nurse ask the patient to perform? (Select all that
apply)
A. Smile and frown
B. Puff out cheeks
C. Clench the teeth
D. Close eyes tightly against resistance
E. Lift eyebrows
F. Stick out the tongue
Correct Answer: A, B, D, E
Explanation: Cranial Nerve VII, the facial nerve, is responsible for the muscles of facial
expression. Asking the patient to smile, frown, puff cheeks, and lift eyebrows specifically
tests the motor component of this nerve. Option C tests the trigeminal nerve (CN V), and
option F tests the hypoglossal nerve (CN XII).
,2. During a musculoskeletal assessment, the nurse asks the patient to move their arm away
from the midline of the body. How should the nurse document this movement?
A. Adduction
B. Circumduction
C. Abduction
D. Extension
Correct Answer: C
Explanation: Abduction is the movement of a limb or other part away from the midline of
the body or from another part. Adduction is the opposite, moving toward the midline.
Accurate terminology is essential for communicating physical findings in the health record.
3. When assessing the deep tendon reflexes of a patient, the nurse notes a very brisk
response with rhythmic oscillations (clonus). What grade should the nurse assign to this
finding?
A. 1+
B. 4+
C. 3+
D. 2+
Correct Answer: B
, Explanation: Reflexes are graded on a scale of 0 to 4+, where 2+ is the normal expected
finding. A grade of 4+ is characterized by very brisk, hyperactive responses with clonus,
which is often indicative of upper motor neuron disease. Grade 1+ is diminished, and 3+ is
brisker than average but not necessarily indicative of disease.
4. A patient presents with a suspicious skin lesion. Which characteristics of the lesion would
suggest a high risk for melanoma according to the ABCDE rule? (Select all that apply)
A. Asymmetrical shape
B. Border irregularity
C. Color variation within the lesion
D. Diameter less than 6 mm
E. Evolving size or shape
Correct Answer: A, B, C, E
Explanation: The ABCDE acronym stands for Asymmetry, Border irregularity, Color
variation, Diameter greater than 6 mm, and Evolving. Any lesion showing these signs
should be documented and reported for further biopsy or dermatological evaluation. Early
detection of these changes is critical for the prognosis of malignant melanoma.
5. The nurse is performing a breast assessment on a female patient. In which quadrant are
most breast tumors found?
A. Upper outer quadrant
B. Lower inner quadrant
Actual Q&A with Rationale (NRS420 Exam 3) |
Grand Canyon University
1. The nurse is assessing a patient for a suspected stroke. To evaluate the function of Cranial
Nerve VII (Facial), which actions should the nurse ask the patient to perform? (Select all that
apply)
A. Smile and frown
B. Puff out cheeks
C. Clench the teeth
D. Close eyes tightly against resistance
E. Lift eyebrows
F. Stick out the tongue
Correct Answer: A, B, D, E
Explanation: Cranial Nerve VII, the facial nerve, is responsible for the muscles of facial
expression. Asking the patient to smile, frown, puff cheeks, and lift eyebrows specifically
tests the motor component of this nerve. Option C tests the trigeminal nerve (CN V), and
option F tests the hypoglossal nerve (CN XII).
,2. During a musculoskeletal assessment, the nurse asks the patient to move their arm away
from the midline of the body. How should the nurse document this movement?
A. Adduction
B. Circumduction
C. Abduction
D. Extension
Correct Answer: C
Explanation: Abduction is the movement of a limb or other part away from the midline of
the body or from another part. Adduction is the opposite, moving toward the midline.
Accurate terminology is essential for communicating physical findings in the health record.
3. When assessing the deep tendon reflexes of a patient, the nurse notes a very brisk
response with rhythmic oscillations (clonus). What grade should the nurse assign to this
finding?
A. 1+
B. 4+
C. 3+
D. 2+
Correct Answer: B
, Explanation: Reflexes are graded on a scale of 0 to 4+, where 2+ is the normal expected
finding. A grade of 4+ is characterized by very brisk, hyperactive responses with clonus,
which is often indicative of upper motor neuron disease. Grade 1+ is diminished, and 3+ is
brisker than average but not necessarily indicative of disease.
4. A patient presents with a suspicious skin lesion. Which characteristics of the lesion would
suggest a high risk for melanoma according to the ABCDE rule? (Select all that apply)
A. Asymmetrical shape
B. Border irregularity
C. Color variation within the lesion
D. Diameter less than 6 mm
E. Evolving size or shape
Correct Answer: A, B, C, E
Explanation: The ABCDE acronym stands for Asymmetry, Border irregularity, Color
variation, Diameter greater than 6 mm, and Evolving. Any lesion showing these signs
should be documented and reported for further biopsy or dermatological evaluation. Early
detection of these changes is critical for the prognosis of malignant melanoma.
5. The nurse is performing a breast assessment on a female patient. In which quadrant are
most breast tumors found?
A. Upper outer quadrant
B. Lower inner quadrant
