NSG121/NSG 121 Exam 4 V1 | Health
Assessment Q&A with Rationale | Herzing
University
1. A nurse is assessing a client’s cranial nerves. Which action should the nurse ask the client to
perform to assess the motor function of the facial nerve (Cranial Nerve VII)?
A. Stick out the tongue and move it from side to side
B. Shrug the shoulders against resistance
C. Follow a finger through the six cardinal fields of gaze
D. Smile, frown, and puff out the cheeks
Correct Answer: D
Rationale: Cranial Nerve VII, the facial nerve, is responsible for the motor movement of
facial expressions. The nurse observes for symmetry while the client smiles, frowns, and
puffs out their cheeks to ensure the nerve is intact. Asymmetry in these movements could
indicate a neurological deficit such as Bell’s palsy or a stroke.
2. While assessing the musculoskeletal system, a nurse notes that a client can move their arm
against gravity but cannot overcome any added resistance. How should the nurse document
this muscle strength?
A. 2/5
B. 4/5
,C. 3/5
D. 5/5
Correct Answer: C
Rationale: Muscle strength is graded on a scale of 0 to 5, where a grade of 3 indicates full
range of motion against gravity but not against resistance. A grade of 4 would mean the
client can resist some pressure, while a grade of 5 is normal strength. Documentation of
these findings is essential for tracking the client’s physical rehabilitation progress.
3. A nurse is performing a neurological assessment on a client and asks them to stand with
feet together and eyes closed. The client begins to sway significantly and almost falls. What
should the nurse document this as?
A. Positive Romberg test
B. Positive Babinski sign
C. Negative Romberg test
D. Negative Phalen’s sign
Correct Answer: A
Rationale: A positive Romberg test occurs when a client loses balance after closing their
eyes while standing with feet together. This test assesses cerebellar function and the
client’s sense of proprioception. The nurse must stand close to the client during this test to
prevent injury from falling.
, 4. Which part of the brain is primarily responsible for the coordination of voluntary
movements, equilibrium, and muscle tone?
A. Hypothalamus
B. Cerebellum
C. Cerebrum
D. Brainstem
Correct Answer: B
Rationale: The cerebellum is the portion of the brain that coordinates voluntary
movements and maintains posture and equilibrium. It does not initiate movement but
smooths out the actions of the muscles. Dysfunction in the cerebellum often manifests as
ataxia or uncoordinated gait.
5. During a breast examination, in which quadrant are most breast tumors found?
A. Upper inner quadrant
B. Upper outer quadrant
C. Lower inner quadrant
D. Lower outer quadrant
Correct Answer: B
Rationale: The upper outer quadrant, which includes the Tail of Spence, is the most
common site for breast tumors. This area contains a high concentration of glandular tissue
Assessment Q&A with Rationale | Herzing
University
1. A nurse is assessing a client’s cranial nerves. Which action should the nurse ask the client to
perform to assess the motor function of the facial nerve (Cranial Nerve VII)?
A. Stick out the tongue and move it from side to side
B. Shrug the shoulders against resistance
C. Follow a finger through the six cardinal fields of gaze
D. Smile, frown, and puff out the cheeks
Correct Answer: D
Rationale: Cranial Nerve VII, the facial nerve, is responsible for the motor movement of
facial expressions. The nurse observes for symmetry while the client smiles, frowns, and
puffs out their cheeks to ensure the nerve is intact. Asymmetry in these movements could
indicate a neurological deficit such as Bell’s palsy or a stroke.
2. While assessing the musculoskeletal system, a nurse notes that a client can move their arm
against gravity but cannot overcome any added resistance. How should the nurse document
this muscle strength?
A. 2/5
B. 4/5
,C. 3/5
D. 5/5
Correct Answer: C
Rationale: Muscle strength is graded on a scale of 0 to 5, where a grade of 3 indicates full
range of motion against gravity but not against resistance. A grade of 4 would mean the
client can resist some pressure, while a grade of 5 is normal strength. Documentation of
these findings is essential for tracking the client’s physical rehabilitation progress.
3. A nurse is performing a neurological assessment on a client and asks them to stand with
feet together and eyes closed. The client begins to sway significantly and almost falls. What
should the nurse document this as?
A. Positive Romberg test
B. Positive Babinski sign
C. Negative Romberg test
D. Negative Phalen’s sign
Correct Answer: A
Rationale: A positive Romberg test occurs when a client loses balance after closing their
eyes while standing with feet together. This test assesses cerebellar function and the
client’s sense of proprioception. The nurse must stand close to the client during this test to
prevent injury from falling.
, 4. Which part of the brain is primarily responsible for the coordination of voluntary
movements, equilibrium, and muscle tone?
A. Hypothalamus
B. Cerebellum
C. Cerebrum
D. Brainstem
Correct Answer: B
Rationale: The cerebellum is the portion of the brain that coordinates voluntary
movements and maintains posture and equilibrium. It does not initiate movement but
smooths out the actions of the muscles. Dysfunction in the cerebellum often manifests as
ataxia or uncoordinated gait.
5. During a breast examination, in which quadrant are most breast tumors found?
A. Upper inner quadrant
B. Upper outer quadrant
C. Lower inner quadrant
D. Lower outer quadrant
Correct Answer: B
Rationale: The upper outer quadrant, which includes the Tail of Spence, is the most
common site for breast tumors. This area contains a high concentration of glandular tissue
