NUR 2092/NUR2092 Exam 4 V3 | Health
Assessment Q&A with Rationale |
Rasmussen University
1. During a breast examination, the nurse notes a small, hard, non-tender lump in the upper
outer quadrant. Which anatomical structure is most commonly associated with breast cancer
in this area?
A. Areola
B. Nipple
C. Tail of Spence
D. Lower inner quadrant
Answer: C
Rationale: The Tail of Spence is the superior lateral corner of breast tissue that projects up
and laterally into the axilla. It is the most common site for breast cancer to occur because it
contains a high concentration of lymph nodes. Nurses must ensure this area is palpated
thoroughly during every clinical breast exam.
2. When assessing the neurological system, the nurse asks the patient to stand with feet
together and eyes closed. The patient begins to sway and loses balance. This is a positive sign
for which test?
A. Gait Test
,B. Romberg Test
C. Babinski Sign
D. Stereognosis
Answer: B
Rationale: A positive Romberg sign occurs when a patient loses balance after closing their
eyes while standing with feet together. This indicates a problem with proprioception,
vestibular function, or cerebellar function. The test should always be performed with the
nurse standing nearby to prevent the patient from falling.
3. A 65-year-old male patient reports difficulty starting his urine stream and a frequent need
to urinate at night. The nurse suspects which condition?
A. Testicular Torsion
B. Epispadias
C. Benign Prostatic Hyperplasia (BPH)
D. Prostatitis
Answer: C
Rationale: Benign Prostatic Hyperplasia involves an enlarged prostate that constricts the
urethra, leading to urinary hesitancy and nocturia. This condition is very common in aging
men and is typically non-malignant. Assessment usually includes a digital rectal exam to
determine the size and consistency of the prostate gland.
, 4. The nurse is assessing a patient for Carpal Tunnel Syndrome. Which maneuver involves the
patient holding their hands back-to-back while flexing the wrists 90 degrees for 60 seconds?
A. Tinel Sign
B. Bulge Sign
C. Phalen Test
D. Lasegue Test
Answer: C
Rationale: The Phalen test reproduces numbness and burning in a person with carpal
tunnel syndrome by compressing the median nerve. The patient must hold the position for
at least 60 seconds to elicit a response. A positive result is indicated by paresthesia in the
distribution of the median nerve.
5. A patient exhibits an exaggerated posterior curvature of the thoracic spine. The nurse
documents this finding as:
A. Scoliosis
B. Kyphosis
C. Lordosis
D. Ankylosis
Answer: B
Assessment Q&A with Rationale |
Rasmussen University
1. During a breast examination, the nurse notes a small, hard, non-tender lump in the upper
outer quadrant. Which anatomical structure is most commonly associated with breast cancer
in this area?
A. Areola
B. Nipple
C. Tail of Spence
D. Lower inner quadrant
Answer: C
Rationale: The Tail of Spence is the superior lateral corner of breast tissue that projects up
and laterally into the axilla. It is the most common site for breast cancer to occur because it
contains a high concentration of lymph nodes. Nurses must ensure this area is palpated
thoroughly during every clinical breast exam.
2. When assessing the neurological system, the nurse asks the patient to stand with feet
together and eyes closed. The patient begins to sway and loses balance. This is a positive sign
for which test?
A. Gait Test
,B. Romberg Test
C. Babinski Sign
D. Stereognosis
Answer: B
Rationale: A positive Romberg sign occurs when a patient loses balance after closing their
eyes while standing with feet together. This indicates a problem with proprioception,
vestibular function, or cerebellar function. The test should always be performed with the
nurse standing nearby to prevent the patient from falling.
3. A 65-year-old male patient reports difficulty starting his urine stream and a frequent need
to urinate at night. The nurse suspects which condition?
A. Testicular Torsion
B. Epispadias
C. Benign Prostatic Hyperplasia (BPH)
D. Prostatitis
Answer: C
Rationale: Benign Prostatic Hyperplasia involves an enlarged prostate that constricts the
urethra, leading to urinary hesitancy and nocturia. This condition is very common in aging
men and is typically non-malignant. Assessment usually includes a digital rectal exam to
determine the size and consistency of the prostate gland.
, 4. The nurse is assessing a patient for Carpal Tunnel Syndrome. Which maneuver involves the
patient holding their hands back-to-back while flexing the wrists 90 degrees for 60 seconds?
A. Tinel Sign
B. Bulge Sign
C. Phalen Test
D. Lasegue Test
Answer: C
Rationale: The Phalen test reproduces numbness and burning in a person with carpal
tunnel syndrome by compressing the median nerve. The patient must hold the position for
at least 60 seconds to elicit a response. A positive result is indicated by paresthesia in the
distribution of the median nerve.
5. A patient exhibits an exaggerated posterior curvature of the thoracic spine. The nurse
documents this finding as:
A. Scoliosis
B. Kyphosis
C. Lordosis
D. Ankylosis
Answer: B
