NSG121/NSG 121 Exam 3 V3 | Health
Assessment Q&A with Rationale | Herzing
University
1. During a neurological assessment, 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 IX (Glossopharyngeal)
C. Cranial Nerve VII (Facial)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: C
Rationale: Cranial nerve VII, the facial nerve, is responsible for the motor movement of
facial expressions such as smiling and puffing cheeks. The trigeminal nerve (CN V)
primarily handles facial sensation and mastication muscles. Testing symmetric movement
of facial features is a standard nursing practice to assess for potential deficits or palsies.
2. A nurse is assessing a 75-year-old patient and notes an exaggerated curvature of the
thoracic spine. How should the nurse document this finding?
A. Lordosis
B. Scoliosis
C. Kyphosis
,D. Ankylosis
Correct Answer: C
Rationale: Kyphosis is a common postural change in older adults, characterized by an
outward curvature of the thoracic spine. Lordosis refers to the inward curvature of the
lumbar spine, often seen in pregnancy or obesity. Proper documentation of spinal
alignment is essential for identifying changes in musculoskeletal health over time.
3. When performing a musculoskeletal exam, the nurse notes a grating sound and sensation
when the patient moves their knee. This is documented as:
A. Subluxation
B. Contracture
C. Effusion
D. Crepitus
Correct Answer: D
Rationale: Crepitus is an audible or palpable crunching or grating sound that accompanies
joint movement. It occurs when articular surfaces in the joints are roughened, which is
frequently seen in conditions like osteoarthritis. The nurse must differentiate this from
normal ‘popping’ sounds to accurately assess joint integrity.
4. To assess the function of the cerebellar system, which test should the nurse perform?
A. Weber test
, B. Stereognosis test
C. Babinski reflex
D. Finger-to-nose test
Correct Answer: D
Rationale: The finger-to-nose test evaluates voluntary movement and coordination, which
are functions of the cerebellum. Inability to perform this smoothly may indicate cerebellar
disease or alcohol intoxication. Other cerebellar tests include rapid alternating movements
and the heel-to-shin test.
5. A patient has a deep tendon reflex (DTR) that is very brisk and shows clonus. The nurse
should grade this as:
A. 1+
B. 2+
C. 4+
D. 3+
Correct Answer: C
Rationale: A grade of 4+ indicates a reflex that is very brisk, hyperactive, and often
associated with clonus, which may signify upper motor neuron disease. Grade 2+ is
considered normal or average, while 1+ is diminished. The nurse uses the percussion
hammer to elicit these responses systematically across the body.
Assessment Q&A with Rationale | Herzing
University
1. During a neurological assessment, 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 IX (Glossopharyngeal)
C. Cranial Nerve VII (Facial)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: C
Rationale: Cranial nerve VII, the facial nerve, is responsible for the motor movement of
facial expressions such as smiling and puffing cheeks. The trigeminal nerve (CN V)
primarily handles facial sensation and mastication muscles. Testing symmetric movement
of facial features is a standard nursing practice to assess for potential deficits or palsies.
2. A nurse is assessing a 75-year-old patient and notes an exaggerated curvature of the
thoracic spine. How should the nurse document this finding?
A. Lordosis
B. Scoliosis
C. Kyphosis
,D. Ankylosis
Correct Answer: C
Rationale: Kyphosis is a common postural change in older adults, characterized by an
outward curvature of the thoracic spine. Lordosis refers to the inward curvature of the
lumbar spine, often seen in pregnancy or obesity. Proper documentation of spinal
alignment is essential for identifying changes in musculoskeletal health over time.
3. When performing a musculoskeletal exam, the nurse notes a grating sound and sensation
when the patient moves their knee. This is documented as:
A. Subluxation
B. Contracture
C. Effusion
D. Crepitus
Correct Answer: D
Rationale: Crepitus is an audible or palpable crunching or grating sound that accompanies
joint movement. It occurs when articular surfaces in the joints are roughened, which is
frequently seen in conditions like osteoarthritis. The nurse must differentiate this from
normal ‘popping’ sounds to accurately assess joint integrity.
4. To assess the function of the cerebellar system, which test should the nurse perform?
A. Weber test
, B. Stereognosis test
C. Babinski reflex
D. Finger-to-nose test
Correct Answer: D
Rationale: The finger-to-nose test evaluates voluntary movement and coordination, which
are functions of the cerebellum. Inability to perform this smoothly may indicate cerebellar
disease or alcohol intoxication. Other cerebellar tests include rapid alternating movements
and the heel-to-shin test.
5. A patient has a deep tendon reflex (DTR) that is very brisk and shows clonus. The nurse
should grade this as:
A. 1+
B. 2+
C. 4+
D. 3+
Correct Answer: C
Rationale: A grade of 4+ indicates a reflex that is very brisk, hyperactive, and often
associated with clonus, which may signify upper motor neuron disease. Grade 2+ is
considered normal or average, while 1+ is diminished. The nurse uses the percussion
hammer to elicit these responses systematically across the body.
