NSG121/NSG 121 Exam 4 V2 | Health
Assessment Q&A with Rationale | Herzing
University
1. When assessing a client’s cranial nerves, the nurse asks the client to smile, frown, and puff
out their cheeks. Which cranial nerve is being evaluated?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve VIII (Acoustic)
C. Cranial Nerve VII (Facial)
D. Cranial Nerve IX (Glossopharyngeal)
Correct Answer: C
Rationale: Cranial Nerve VII, the facial nerve, is responsible for the motor activity of facial
expressions. By asking the patient to smile, frown, and puff their cheeks, the nurse can
observe for symmetry and strength of these muscles. Asymmetry could indicate a
neurological deficit such as a stroke or Bell’s palsy.
2. The nurse is performing a Romberg test on a client. Which instruction should the nurse
provide?
A. Stand with feet together and eyes open, then close eyes and hold for 20 seconds.
B. Walk in a straight line placing the heel of one foot directly in front of the toe of the other.
C. Touch your nose with your index finger and then touch my finger.
,D. Hop on one foot for 10 seconds without losing balance.
Correct Answer: A
Rationale: The Romberg test is used to assess cerebellar function and balance by checking
for proprioception. The client is asked to stand with feet together and arms at their side,
first with eyes open and then with eyes closed. A positive Romberg sign is noted if the
client loses balance or sways significantly while the eyes are closed.
3. Which finding is considered normal when assessing the plantar reflex in an adult?
A. Plantar flexion of all toes
B. Dorsiflexion of the big toe with fanning of other toes
C. No movement of the toes
D. Extension of the foot at the ankle
Correct Answer: A
Rationale: In an adult, the normal response to the plantar reflex test is the downward
curling or plantar flexion of the toes. A Babinski sign, which is the upward movement of the
big toe, is abnormal in adults and indicates upper motor neuron disease. This reflex is
normal only in infants up to approximately 24 months of age.
4. During a musculoskeletal assessment, the nurse asks the client to move their arm away
from the midline of the body. How should the nurse document this movement?
A. Adduction
, B. Flexion
C. Abduction
D. Extension
Correct Answer: C
Rationale: Abduction is defined as the movement of a limb or other part away from the
midline of the body. This is a standard range of motion assessment for joints like the
shoulder and hip. In contrast, adduction refers to moving the limb toward the midline.
5. A nurse is assessing a client’s muscle strength and notes that the client can move their limb
through a full range of motion against gravity but not against resistance. How would this be
graded?
A. 1/5
B. 2/5
C. 3/5
D. 4/5
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 only. Grade 4 indicates full range of motion against gravity
with some resistance. Grade 5 is considered normal strength, meaning the client can resist
full pressure from the examiner.
Assessment Q&A with Rationale | Herzing
University
1. When assessing a client’s cranial nerves, the nurse asks the client to smile, frown, and puff
out their cheeks. Which cranial nerve is being evaluated?
A. Cranial Nerve V (Trigeminal)
B. Cranial Nerve VIII (Acoustic)
C. Cranial Nerve VII (Facial)
D. Cranial Nerve IX (Glossopharyngeal)
Correct Answer: C
Rationale: Cranial Nerve VII, the facial nerve, is responsible for the motor activity of facial
expressions. By asking the patient to smile, frown, and puff their cheeks, the nurse can
observe for symmetry and strength of these muscles. Asymmetry could indicate a
neurological deficit such as a stroke or Bell’s palsy.
2. The nurse is performing a Romberg test on a client. Which instruction should the nurse
provide?
A. Stand with feet together and eyes open, then close eyes and hold for 20 seconds.
B. Walk in a straight line placing the heel of one foot directly in front of the toe of the other.
C. Touch your nose with your index finger and then touch my finger.
,D. Hop on one foot for 10 seconds without losing balance.
Correct Answer: A
Rationale: The Romberg test is used to assess cerebellar function and balance by checking
for proprioception. The client is asked to stand with feet together and arms at their side,
first with eyes open and then with eyes closed. A positive Romberg sign is noted if the
client loses balance or sways significantly while the eyes are closed.
3. Which finding is considered normal when assessing the plantar reflex in an adult?
A. Plantar flexion of all toes
B. Dorsiflexion of the big toe with fanning of other toes
C. No movement of the toes
D. Extension of the foot at the ankle
Correct Answer: A
Rationale: In an adult, the normal response to the plantar reflex test is the downward
curling or plantar flexion of the toes. A Babinski sign, which is the upward movement of the
big toe, is abnormal in adults and indicates upper motor neuron disease. This reflex is
normal only in infants up to approximately 24 months of age.
4. During a musculoskeletal assessment, the nurse asks the client to move their arm away
from the midline of the body. How should the nurse document this movement?
A. Adduction
, B. Flexion
C. Abduction
D. Extension
Correct Answer: C
Rationale: Abduction is defined as the movement of a limb or other part away from the
midline of the body. This is a standard range of motion assessment for joints like the
shoulder and hip. In contrast, adduction refers to moving the limb toward the midline.
5. A nurse is assessing a client’s muscle strength and notes that the client can move their limb
through a full range of motion against gravity but not against resistance. How would this be
graded?
A. 1/5
B. 2/5
C. 3/5
D. 4/5
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 only. Grade 4 indicates full range of motion against gravity
with some resistance. Grade 5 is considered normal strength, meaning the client can resist
full pressure from the examiner.
