NUR 2092/NUR2092 Exam 4 V2 | Health
Assessment Q&A with Rationale |
Rasmussen University
1. A nurse is performing a neurological assessment on a patient and asks them 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. Positive Babinski sign
B. Positive Romberg test
C. Negative Ortolani sign
D. Positive Phalen’s test
Correct Answer: B
Expert Explanation: The Romberg test is a specific assessment used to evaluate cerebellar
function and balance. A positive result occurs when a patient loses balance after closing
their eyes, which suggests an issue with proprioception or vestibular function. The nurse
should stand close to the patient during this test to ensure safety and prevent falls.
2. When assessing the abdomen, which sequence of physical examination techniques should
the nurse follow?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
,C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Palpation, Inspection, Auscultation
Correct Answer: A
Expert Explanation: In abdominal assessment, auscultation is performed immediately
after inspection to avoid altering bowel sounds. Percussion and palpation can stimulate
peristalsis, leading to inaccurate auscultatory findings. Following this specific order
ensures the most reliable clinical data is collected from the patient.
3. A nurse is assessing a patient’s deep tendon reflexes and notes that the patellar reflex is
very brisk with intermittent clonus. What grade should the nurse assign to this reflex?
A. 1+
B. 2+
C. 4+
D. 3+
Correct Answer: C
Expert Explanation: A grade of 4+ indicates a reflex that is very brisk, hyperactive, and
often associated with clonus. Normal reflexes are typically graded as 2+, while 1+ is
diminished and 3+ is brisker than average but not necessarily pathological. Identifying a 4+
reflex is critical as it may indicate upper motor neuron disease.
, 4. Which cranial nerve is the nurse assessing when asking the patient to shrug their shoulders
against resistance?
A. Cranial Nerve VII (Facial)
B. Cranial Nerve IX (Glossopharyngeal)
C. Cranial Nerve XII (Hypoglossal)
D. Cranial Nerve XI (Spinal Accessory)
Correct Answer: D
Expert Explanation: Cranial Nerve XI, the spinal accessory nerve, controls the trapezius
and sternocleidomastoid muscles. To test this nerve, the nurse asks the patient to shrug
their shoulders and turn their head against resistance. Weakness or asymmetry in these
movements could indicate nerve damage or muscle dysfunction.
5. During a musculoskeletal exam, the nurse asks the patient to move their arm away from
the midline of the body. What is the correct term for this movement?
A. Adduction
B. Abduction
C. Flexion
D. Extension
Correct Answer: B
Assessment Q&A with Rationale |
Rasmussen University
1. A nurse is performing a neurological assessment on a patient and asks them 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. Positive Babinski sign
B. Positive Romberg test
C. Negative Ortolani sign
D. Positive Phalen’s test
Correct Answer: B
Expert Explanation: The Romberg test is a specific assessment used to evaluate cerebellar
function and balance. A positive result occurs when a patient loses balance after closing
their eyes, which suggests an issue with proprioception or vestibular function. The nurse
should stand close to the patient during this test to ensure safety and prevent falls.
2. When assessing the abdomen, which sequence of physical examination techniques should
the nurse follow?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
,C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Palpation, Inspection, Auscultation
Correct Answer: A
Expert Explanation: In abdominal assessment, auscultation is performed immediately
after inspection to avoid altering bowel sounds. Percussion and palpation can stimulate
peristalsis, leading to inaccurate auscultatory findings. Following this specific order
ensures the most reliable clinical data is collected from the patient.
3. A nurse is assessing a patient’s deep tendon reflexes and notes that the patellar reflex is
very brisk with intermittent clonus. What grade should the nurse assign to this reflex?
A. 1+
B. 2+
C. 4+
D. 3+
Correct Answer: C
Expert Explanation: A grade of 4+ indicates a reflex that is very brisk, hyperactive, and
often associated with clonus. Normal reflexes are typically graded as 2+, while 1+ is
diminished and 3+ is brisker than average but not necessarily pathological. Identifying a 4+
reflex is critical as it may indicate upper motor neuron disease.
, 4. Which cranial nerve is the nurse assessing when asking the patient to shrug their shoulders
against resistance?
A. Cranial Nerve VII (Facial)
B. Cranial Nerve IX (Glossopharyngeal)
C. Cranial Nerve XII (Hypoglossal)
D. Cranial Nerve XI (Spinal Accessory)
Correct Answer: D
Expert Explanation: Cranial Nerve XI, the spinal accessory nerve, controls the trapezius
and sternocleidomastoid muscles. To test this nerve, the nurse asks the patient to shrug
their shoulders and turn their head against resistance. Weakness or asymmetry in these
movements could indicate nerve damage or muscle dysfunction.
5. During a musculoskeletal exam, the nurse asks the patient to move their arm away from
the midline of the body. What is the correct term for this movement?
A. Adduction
B. Abduction
C. Flexion
D. Extension
Correct Answer: B
