NUR612/NUR 612 Exam 4 V2 | Advanced
Nursing II Q&A with Rationale | William
Paterson University
1. When assessing the Cranial Nerve III, which clinical finding is the nurse primarily checking?
A. Facial symmetry during a smile
B. The ability to smell cinnamon
C. Extraocular movements and pupillary constriction
D. Hearing acuity using a tuning fork
Answer: C
Rationale: Cranial Nerve III is the Oculomotor nerve responsible for pupil constriction and
most eye movements. The nurse assesses this by checking the pupillary light reflex and the
cardinal positions of gaze. Dysfunction in this nerve may manifest as ptosis or an inability
to move the eye in specific directions.
2. Which test is most appropriate to evaluate a patient’s cerebellar function for balance and
coordination?
A. The Romberg test
B. Phalen’s test
C. Graphesthesia
D. The Weber test
,Answer: A
Rationale: The Romberg test assesses cerebellar function and proprioception by having
the patient stand with eyes closed. A positive Romberg sign occurs when the patient loses
balance, indicating a potential vestibular or cerebellar issue. This assessment is vital for
determining a patient’s risk for falls and neurological stability.
3. A patient exhibits a positive Babinski sign. How does this present in an adult?
A. Plantar flexion of all toes
B. Dorsiflexion of the big toe and fanning of other toes
C. Rapid, rhythmic contractions of the calf muscle
D. Involuntary flexion of the hips when the neck is flexed
Answer: B
Rationale: A positive Babinski sign in an adult is characterized by the dorsiflexion of the
great toe. While this is a normal finding in infants, it indicates upper motor neuron disease
in adults. This reflex assessment is a standard component of a comprehensive neurological
examination.
4. Which cranial nerve is being tested when the nurse asks the patient to shrug their
shoulders against resistance?
A. CN XI (Spinal Accessory)
B. CN X (Vagus)
, C. CN IX (Glossopharyngeal)
D. CN XII (Hypoglossal)
Answer: A
Rationale: Cranial Nerve XI, the Spinal Accessory nerve, controls the sternocleidomastoid
and trapezius muscles. Shrugging the shoulders and turning the head against resistance are
the primary methods for testing its strength. Weakness or asymmetry in these movements
could indicate nerve damage or muscle pathology.
5. During a musculoskeletal exam, the nurse performs the McMurray test. What is the nurse
assessing for?
A. Anterior cruciate ligament (ACL) tear
B. Carpal tunnel syndrome
C. A torn meniscus in the knee
D. Hip dysplasia
Answer: C
Rationale: The McMurray test is specifically designed to detect a meniscus tear within the
knee joint. The nurse rotates the leg while extending the knee to check for a palpable click
or pain. Positive results are significant indicators for orthopedic follow-up and further
imaging like an MRI.
Nursing II Q&A with Rationale | William
Paterson University
1. When assessing the Cranial Nerve III, which clinical finding is the nurse primarily checking?
A. Facial symmetry during a smile
B. The ability to smell cinnamon
C. Extraocular movements and pupillary constriction
D. Hearing acuity using a tuning fork
Answer: C
Rationale: Cranial Nerve III is the Oculomotor nerve responsible for pupil constriction and
most eye movements. The nurse assesses this by checking the pupillary light reflex and the
cardinal positions of gaze. Dysfunction in this nerve may manifest as ptosis or an inability
to move the eye in specific directions.
2. Which test is most appropriate to evaluate a patient’s cerebellar function for balance and
coordination?
A. The Romberg test
B. Phalen’s test
C. Graphesthesia
D. The Weber test
,Answer: A
Rationale: The Romberg test assesses cerebellar function and proprioception by having
the patient stand with eyes closed. A positive Romberg sign occurs when the patient loses
balance, indicating a potential vestibular or cerebellar issue. This assessment is vital for
determining a patient’s risk for falls and neurological stability.
3. A patient exhibits a positive Babinski sign. How does this present in an adult?
A. Plantar flexion of all toes
B. Dorsiflexion of the big toe and fanning of other toes
C. Rapid, rhythmic contractions of the calf muscle
D. Involuntary flexion of the hips when the neck is flexed
Answer: B
Rationale: A positive Babinski sign in an adult is characterized by the dorsiflexion of the
great toe. While this is a normal finding in infants, it indicates upper motor neuron disease
in adults. This reflex assessment is a standard component of a comprehensive neurological
examination.
4. Which cranial nerve is being tested when the nurse asks the patient to shrug their
shoulders against resistance?
A. CN XI (Spinal Accessory)
B. CN X (Vagus)
, C. CN IX (Glossopharyngeal)
D. CN XII (Hypoglossal)
Answer: A
Rationale: Cranial Nerve XI, the Spinal Accessory nerve, controls the sternocleidomastoid
and trapezius muscles. Shrugging the shoulders and turning the head against resistance are
the primary methods for testing its strength. Weakness or asymmetry in these movements
could indicate nerve damage or muscle pathology.
5. During a musculoskeletal exam, the nurse performs the McMurray test. What is the nurse
assessing for?
A. Anterior cruciate ligament (ACL) tear
B. Carpal tunnel syndrome
C. A torn meniscus in the knee
D. Hip dysplasia
Answer: C
Rationale: The McMurray test is specifically designed to detect a meniscus tear within the
knee joint. The nurse rotates the leg while extending the knee to check for a palpable click
or pain. Positive results are significant indicators for orthopedic follow-up and further
imaging like an MRI.
