NRS 420 Exam 4 V3 | NRS 420 Health Assessment |
Actual Q&A with Rationale (NRS420 Exam 4) |
Grand Canyon University
1. When assessing the neurological status of a patient, the nurse uses the Glasgow Coma
Scale (GCS). Which of the following components are measured in this assessment?
A. Eye opening response
B. Pupillary reaction
C. Verbal response
D. Motor response
E. Deep tendon reflexes
Correct Answer: A, C, D
Explanation: The Glasgow Coma Scale is a standardized tool used to assess consciousness
and brain injury severity. It specifically measures eye opening, verbal response, and motor
response. Other assessments like pupillary reaction and reflexes are part of a neuro exam
but not the GCS scoring system.
2. A nurse is evaluating a patient’s musculoskeletal system. Which of the following clinical
findings are characteristic of Rheumatoid Arthritis (RA)? Select all that apply.
A. Symmetric joint involvement
B. Pain that worsens throughout the day
,C. Morning stiffness lasting more than 60 minutes
D. Bouchard’s nodes
E. Ulnar drift
F. Swan-neck deformities
Correct Answer: A, C, E, F
Explanation: Rheumatoid arthritis is a systemic inflammatory disease characterized by
symmetric involvement and prolonged morning stiffness. Ulnar drift and swan-neck
deformities are classic late-stage manifestations of the disease. In contrast, Heberden’s and
Bouchard’s nodes are typically associated with Osteoarthritis, and OA pain usually worsens
with activity rather than improving.
3. The nurse is performing a physical assessment on a 75-year-old female and notes an
exaggerated posterior curvature of the thoracic spine. How should the nurse document this
finding?
A. Lordosis
B. Scoliosis
C. Spondylolisthesis
D. Kyphosis
Correct Answer: D
, Explanation: Kyphosis is an increased thoracic curvature, often referred to as a
‘hunchback,’ and is common in elderly populations due to osteoporosis. Lordosis refers to
an exaggerated lumbar curve, often seen in pregnancy or obesity. Scoliosis is a lateral
curvature of the spine that is typically assessed during adolescence.
4. During a neurological assessment, the nurse asks the patient to stand with feet together
and arms at the sides, first with eyes open and then with eyes closed. The patient begins to
sway significantly and loses balance when the eyes are closed. What is this finding called?
A. Negative Romberg sign
B. Negative Phalen’s test
C. Positive Babinski sign
D. Positive Romberg sign
Correct Answer: D
Explanation: A positive Romberg sign occurs when a patient can maintain balance with
eyes open but loses balance with eyes closed. This indicates a problem with sensory ataxia
or vestibular function, as the patient is relying solely on vision for balance. A negative test
is one where the patient maintains posture with minimal swaying.
5. The nurse is assessing the function of Cranial Nerve II (Optic Nerve). Which of the following
tools should be used for this assessment?
A. Penlight
B. Snellen Chart
Actual Q&A with Rationale (NRS420 Exam 4) |
Grand Canyon University
1. When assessing the neurological status of a patient, the nurse uses the Glasgow Coma
Scale (GCS). Which of the following components are measured in this assessment?
A. Eye opening response
B. Pupillary reaction
C. Verbal response
D. Motor response
E. Deep tendon reflexes
Correct Answer: A, C, D
Explanation: The Glasgow Coma Scale is a standardized tool used to assess consciousness
and brain injury severity. It specifically measures eye opening, verbal response, and motor
response. Other assessments like pupillary reaction and reflexes are part of a neuro exam
but not the GCS scoring system.
2. A nurse is evaluating a patient’s musculoskeletal system. Which of the following clinical
findings are characteristic of Rheumatoid Arthritis (RA)? Select all that apply.
A. Symmetric joint involvement
B. Pain that worsens throughout the day
,C. Morning stiffness lasting more than 60 minutes
D. Bouchard’s nodes
E. Ulnar drift
F. Swan-neck deformities
Correct Answer: A, C, E, F
Explanation: Rheumatoid arthritis is a systemic inflammatory disease characterized by
symmetric involvement and prolonged morning stiffness. Ulnar drift and swan-neck
deformities are classic late-stage manifestations of the disease. In contrast, Heberden’s and
Bouchard’s nodes are typically associated with Osteoarthritis, and OA pain usually worsens
with activity rather than improving.
3. The nurse is performing a physical assessment on a 75-year-old female and notes an
exaggerated posterior curvature of the thoracic spine. How should the nurse document this
finding?
A. Lordosis
B. Scoliosis
C. Spondylolisthesis
D. Kyphosis
Correct Answer: D
, Explanation: Kyphosis is an increased thoracic curvature, often referred to as a
‘hunchback,’ and is common in elderly populations due to osteoporosis. Lordosis refers to
an exaggerated lumbar curve, often seen in pregnancy or obesity. Scoliosis is a lateral
curvature of the spine that is typically assessed during adolescence.
4. During a neurological assessment, the nurse asks the patient to stand with feet together
and arms at the sides, first with eyes open and then with eyes closed. The patient begins to
sway significantly and loses balance when the eyes are closed. What is this finding called?
A. Negative Romberg sign
B. Negative Phalen’s test
C. Positive Babinski sign
D. Positive Romberg sign
Correct Answer: D
Explanation: A positive Romberg sign occurs when a patient can maintain balance with
eyes open but loses balance with eyes closed. This indicates a problem with sensory ataxia
or vestibular function, as the patient is relying solely on vision for balance. A negative test
is one where the patient maintains posture with minimal swaying.
5. The nurse is assessing the function of Cranial Nerve II (Optic Nerve). Which of the following
tools should be used for this assessment?
A. Penlight
B. Snellen Chart
