NSG 3160 – Health Assessment Exam With
Correct Questions And Answers
Exam
**1. Q: A patient is alert and oriented x4. What does the "x4" refer
to?**
**A:** Person, Place, Time, and Situation (or Purpose).
**Rationale:** Orientation is a reliable indicator of cerebral function.
X4 is the gold standard, indicating the patient knows who they are
(Person), where they are (Place), the current date/time (Time), and
why they are here/what is happening (Situation).
**2. Q: During a neurological assessment, the nurse asks the patient
to identify a familiar object placed in their hand with their eyes
closed. What is the nurse assessing?**
**A:** Stereognosis.
**Rationale:** Stereognosis is the ability to recognize objects by
touch. It tests the sensory cortex's ability to interpret tactile
information. The inability to do this (astereognosis) suggests a
parietal lobe lesion.
**3. Q: How do you test Cranial Nerve XI (Spinal Accessory)?**
**A:** Ask the patient to shrug their shoulders against resistance
and turn their head against resistance.
,**Rationale:** CN XI innervates the trapezius and
sternocleidomastoid muscles. Strength testing in these motions
evaluates motor function of this nerve.
**4. Q: A patient has difficulty swallowing and a hoarse voice. Which
cranial nerve is likely affected?**
**A:** Cranial Nerve X (Vagus).
**Rationale:** CN X provides motor innervation to the pharynx and
larynx. Damage results in dysphagia (difficulty swallowing) and
dysphonia (hoarseness).
**5. Q: A patient's pupils are dilated and non-reactive to light. This is
characteristic of which drug effect?**
**A:** Anticholinergic toxicity (e.g., atropine overdose) or severe
brain stem herniation.
**Rationale:** The parasympathetic nervous system constricts pupils
(CN III). Anticholinergics block this, causing mydriasis (dilation). In
brain stem herniation, CN III is compressed, leading to a "blown"
fixed and dilated pupil.
**6. Q: What is the expected normal finding for the Glascow Coma
Scale (GCS) score?**
**A:** 15 (Eye opening 4, Verbal response 5, Motor response 6).
**Rationale:** A GCS of 15 indicates a fully alert and oriented
patient. The minimum score is 3 (1+1+1). A score of 8 or less
generally indicates a coma.
, **7. Q: The nurse observes a rhythmic, rapid tremor in the patient's
hands that subsides when they reach for an object. What is this
called?**
**A:** Intention tremor.
**Rationale:** Intention tremors occur during purposeful movement
and are associated with cerebellar disease. Resting tremors
(Parkinsonian) are present at rest and decrease with movement.
**8. Q: While assessing a patient's coordination, the nurse has them
rapidly touch their nose and then the nurse's finger. This is known as
the...?**
**A:** Finger-to-Nose Test.
**Rationale:** This tests cerebellar function and coordination.
Dysmetria (overshooting or undershooting the target) indicates a
cerebellar lesion.
**9. Q: A patient presents with unilateral facial drooping, but can still
wrinkle their forehead. What type of peripheral nerve injury is
this?**
**A:** Upper Motor Neuron (UMN) lesion.
**Rationale:** UMN lesions (e.g., stroke) cause weakness of the
lower face (sparing the forehead) because the forehead receives
bilateral UMN innervation. Lower Motor Neuron (LMN) lesions (e.g.,
Bell's Palsy) affect the entire half of the face, including the forehead.
**10. Q: What does a positive "Babinski sign" indicate in an adult?**
**A:** Upper Motor Neuron disease.
Correct Questions And Answers
Exam
**1. Q: A patient is alert and oriented x4. What does the "x4" refer
to?**
**A:** Person, Place, Time, and Situation (or Purpose).
**Rationale:** Orientation is a reliable indicator of cerebral function.
X4 is the gold standard, indicating the patient knows who they are
(Person), where they are (Place), the current date/time (Time), and
why they are here/what is happening (Situation).
**2. Q: During a neurological assessment, the nurse asks the patient
to identify a familiar object placed in their hand with their eyes
closed. What is the nurse assessing?**
**A:** Stereognosis.
**Rationale:** Stereognosis is the ability to recognize objects by
touch. It tests the sensory cortex's ability to interpret tactile
information. The inability to do this (astereognosis) suggests a
parietal lobe lesion.
**3. Q: How do you test Cranial Nerve XI (Spinal Accessory)?**
**A:** Ask the patient to shrug their shoulders against resistance
and turn their head against resistance.
,**Rationale:** CN XI innervates the trapezius and
sternocleidomastoid muscles. Strength testing in these motions
evaluates motor function of this nerve.
**4. Q: A patient has difficulty swallowing and a hoarse voice. Which
cranial nerve is likely affected?**
**A:** Cranial Nerve X (Vagus).
**Rationale:** CN X provides motor innervation to the pharynx and
larynx. Damage results in dysphagia (difficulty swallowing) and
dysphonia (hoarseness).
**5. Q: A patient's pupils are dilated and non-reactive to light. This is
characteristic of which drug effect?**
**A:** Anticholinergic toxicity (e.g., atropine overdose) or severe
brain stem herniation.
**Rationale:** The parasympathetic nervous system constricts pupils
(CN III). Anticholinergics block this, causing mydriasis (dilation). In
brain stem herniation, CN III is compressed, leading to a "blown"
fixed and dilated pupil.
**6. Q: What is the expected normal finding for the Glascow Coma
Scale (GCS) score?**
**A:** 15 (Eye opening 4, Verbal response 5, Motor response 6).
**Rationale:** A GCS of 15 indicates a fully alert and oriented
patient. The minimum score is 3 (1+1+1). A score of 8 or less
generally indicates a coma.
, **7. Q: The nurse observes a rhythmic, rapid tremor in the patient's
hands that subsides when they reach for an object. What is this
called?**
**A:** Intention tremor.
**Rationale:** Intention tremors occur during purposeful movement
and are associated with cerebellar disease. Resting tremors
(Parkinsonian) are present at rest and decrease with movement.
**8. Q: While assessing a patient's coordination, the nurse has them
rapidly touch their nose and then the nurse's finger. This is known as
the...?**
**A:** Finger-to-Nose Test.
**Rationale:** This tests cerebellar function and coordination.
Dysmetria (overshooting or undershooting the target) indicates a
cerebellar lesion.
**9. Q: A patient presents with unilateral facial drooping, but can still
wrinkle their forehead. What type of peripheral nerve injury is
this?**
**A:** Upper Motor Neuron (UMN) lesion.
**Rationale:** UMN lesions (e.g., stroke) cause weakness of the
lower face (sparing the forehead) because the forehead receives
bilateral UMN innervation. Lower Motor Neuron (LMN) lesions (e.g.,
Bell's Palsy) affect the entire half of the face, including the forehead.
**10. Q: What does a positive "Babinski sign" indicate in an adult?**
**A:** Upper Motor Neuron disease.
