NUR 3270/NUR3270 Exam 3 V2 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing the cranial nerves, which nerve is the nurse evaluating by asking the
patient to identify a familiar scent such as coffee?
A. Cranial Nerve I (Olfactory)
B. Cranial Nerve II (Optic)
C. Cranial Nerve V (Trigeminal)
D. Cranial Nerve VIII (Acoustic)
Answer: A
Rationale: Cranial Nerve I is the olfactory nerve responsible for the sense of smell. Testing
involves occluding one nostril at a time and presenting a non-irritating odor to the patient.
This assessment is particularly important for patients reporting a loss of taste or smell.
2. Which assessment finding would the nurse document as ‘Lordosis’?
A. An exaggerated thoracic curvature
B. An exaggerated lumbar curvature
C. A lateral curvature of the spine
D. A stiffness in the joints of the spine
,Answer: B
Rationale: Lordosis is characterized by an exaggerated inward curvature of the lumbar
spine. This condition is commonly seen in pregnant women or individuals with significant
abdominal obesity. It helps compensate for the shift in the center of gravity caused by extra
weight in the front.
3. During a breast examination, in which quadrant is the ‘Tail of Spence’ located?
A. Lower Inner Quadrant
B. Upper Inner Quadrant
C. Lower Outer Quadrant
D. Upper Outer Quadrant
Answer: D
Rationale: The Tail of Spence is an extension of the tissue of the breast into the axilla. It is
located in the upper outer quadrant, which is the most common site for breast tumors.
Nurses must ensure they palpate this area thoroughly during every clinical breast exam.
4. What is the primary purpose of the Romberg test?
A. To evaluate cerebellar function and balance
B. To assess visual acuity
C. To check for deep tendon reflexes
D. To measure muscle strength in the lower extremities
, Answer: A
Rationale: The Romberg test evaluates the patient’s ability to maintain balance with their
eyes closed. A positive result occurs if the patient loses balance or sways significantly. This
indicates a potential problem with the vestibular system or proprioception in the brain.
5. How should a nurse grade a reflex that is very brisk and hyperactive with clonus?
A. 1+
B. 2+
C. 4+
D. 3+
Answer: C
Rationale: Reflexes are graded on a scale from 0 to 4+, where 2+ is considered normal. A
grade of 4+ signifies a hyperactive reflex that often indicates upper motor neuron disease.
Grade 1+ is diminished, while 3+ is brisker than average but not necessarily indicative of
disease.
6. Which cranial nerve is responsible for the movement of the tongue?
A. Cranial Nerve IX (Glossopharyngeal)
B. Cranial Nerve XII (Hypoglossal)
C. Cranial Nerve X (Vagus)
D. Cranial Nerve VII (Facial)
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing the cranial nerves, which nerve is the nurse evaluating by asking the
patient to identify a familiar scent such as coffee?
A. Cranial Nerve I (Olfactory)
B. Cranial Nerve II (Optic)
C. Cranial Nerve V (Trigeminal)
D. Cranial Nerve VIII (Acoustic)
Answer: A
Rationale: Cranial Nerve I is the olfactory nerve responsible for the sense of smell. Testing
involves occluding one nostril at a time and presenting a non-irritating odor to the patient.
This assessment is particularly important for patients reporting a loss of taste or smell.
2. Which assessment finding would the nurse document as ‘Lordosis’?
A. An exaggerated thoracic curvature
B. An exaggerated lumbar curvature
C. A lateral curvature of the spine
D. A stiffness in the joints of the spine
,Answer: B
Rationale: Lordosis is characterized by an exaggerated inward curvature of the lumbar
spine. This condition is commonly seen in pregnant women or individuals with significant
abdominal obesity. It helps compensate for the shift in the center of gravity caused by extra
weight in the front.
3. During a breast examination, in which quadrant is the ‘Tail of Spence’ located?
A. Lower Inner Quadrant
B. Upper Inner Quadrant
C. Lower Outer Quadrant
D. Upper Outer Quadrant
Answer: D
Rationale: The Tail of Spence is an extension of the tissue of the breast into the axilla. It is
located in the upper outer quadrant, which is the most common site for breast tumors.
Nurses must ensure they palpate this area thoroughly during every clinical breast exam.
4. What is the primary purpose of the Romberg test?
A. To evaluate cerebellar function and balance
B. To assess visual acuity
C. To check for deep tendon reflexes
D. To measure muscle strength in the lower extremities
, Answer: A
Rationale: The Romberg test evaluates the patient’s ability to maintain balance with their
eyes closed. A positive result occurs if the patient loses balance or sways significantly. This
indicates a potential problem with the vestibular system or proprioception in the brain.
5. How should a nurse grade a reflex that is very brisk and hyperactive with clonus?
A. 1+
B. 2+
C. 4+
D. 3+
Answer: C
Rationale: Reflexes are graded on a scale from 0 to 4+, where 2+ is considered normal. A
grade of 4+ signifies a hyperactive reflex that often indicates upper motor neuron disease.
Grade 1+ is diminished, while 3+ is brisker than average but not necessarily indicative of
disease.
6. Which cranial nerve is responsible for the movement of the tongue?
A. Cranial Nerve IX (Glossopharyngeal)
B. Cranial Nerve XII (Hypoglossal)
C. Cranial Nerve X (Vagus)
D. Cranial Nerve VII (Facial)
