NUR 3270/NUR3270 Exam 3 V1 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing the musculoskeletal system, 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. Flexion
C. Abduction
D. Extension
Answer: C
Rationale: Abduction is the movement of a limb away from the midline of the body. In
contrast, adduction refers to moving the limb toward the midline. Understanding these
terms is essential for documenting range of motion accurately during a physical
assessment.
2. During a neurological exam, the nurse asks the patient to stick out their tongue. Which
cranial nerve is being tested?
A. Cranial Nerve IX (Glossopharyngeal)
B. Cranial Nerve XII (Hypoglossal)
C. Cranial Nerve XI (Spinal Accessory)
,D. Cranial Nerve X (Vagus)
Answer: B
Rationale: Cranial Nerve XII, the hypoglossal nerve, is responsible for the motor function
of the tongue. The nurse observes for symmetry and tremors when the patient protrudes
the tongue. Damage to this nerve would cause the tongue to deviate toward the affected
side.
3. A nurse is performing a breast examination on a female patient. In which quadrant are
most breast tumors found?
A. Upper inner quadrant
B. Lower inner quadrant
C. Lower outer quadrant
D. Upper outer quadrant
Answer: D
Rationale: The upper outer quadrant, which includes the Tail of Spence, is the most
common site for breast cancer. This area contains a high concentration of glandular tissue
compared to other quadrants. Therefore, the nurse must ensure thorough palpation of this
specific region during every exam.
, 4. While assessing a patient for carpal tunnel syndrome, the nurse asks the patient to hold
their hands back-to-back while flexing the wrists 90 degrees for 60 seconds. What is this test
called?
A. Tinel’s sign
B. Phalen’s test
C. McMurray’s test
D. Bulge sign
Answer: B
Rationale: Phalen’s test is used to identify potential compression of the median nerve at
the wrist. A positive result occurs if the patient experiences numbness or burning within 60
seconds. This is a common bedside assessment tool for patients complaining of wrist pain
or tingling.
5. The nurse is testing a patient’s deep tendon reflexes and notes that the response is very
brisk and hyperactive with clonus. How should the nurse document this finding?
A. 1+
B. 2+
C. 4+
D. 3+
Answer: C
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing the musculoskeletal system, 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. Flexion
C. Abduction
D. Extension
Answer: C
Rationale: Abduction is the movement of a limb away from the midline of the body. In
contrast, adduction refers to moving the limb toward the midline. Understanding these
terms is essential for documenting range of motion accurately during a physical
assessment.
2. During a neurological exam, the nurse asks the patient to stick out their tongue. Which
cranial nerve is being tested?
A. Cranial Nerve IX (Glossopharyngeal)
B. Cranial Nerve XII (Hypoglossal)
C. Cranial Nerve XI (Spinal Accessory)
,D. Cranial Nerve X (Vagus)
Answer: B
Rationale: Cranial Nerve XII, the hypoglossal nerve, is responsible for the motor function
of the tongue. The nurse observes for symmetry and tremors when the patient protrudes
the tongue. Damage to this nerve would cause the tongue to deviate toward the affected
side.
3. A nurse is performing a breast examination on a female patient. In which quadrant are
most breast tumors found?
A. Upper inner quadrant
B. Lower inner quadrant
C. Lower outer quadrant
D. Upper outer quadrant
Answer: D
Rationale: The upper outer quadrant, which includes the Tail of Spence, is the most
common site for breast cancer. This area contains a high concentration of glandular tissue
compared to other quadrants. Therefore, the nurse must ensure thorough palpation of this
specific region during every exam.
, 4. While assessing a patient for carpal tunnel syndrome, the nurse asks the patient to hold
their hands back-to-back while flexing the wrists 90 degrees for 60 seconds. What is this test
called?
A. Tinel’s sign
B. Phalen’s test
C. McMurray’s test
D. Bulge sign
Answer: B
Rationale: Phalen’s test is used to identify potential compression of the median nerve at
the wrist. A positive result occurs if the patient experiences numbness or burning within 60
seconds. This is a common bedside assessment tool for patients complaining of wrist pain
or tingling.
5. The nurse is testing a patient’s deep tendon reflexes and notes that the response is very
brisk and hyperactive with clonus. How should the nurse document this finding?
A. 1+
B. 2+
C. 4+
D. 3+
Answer: C
