NSG 3160 – Health Assessment | Exam 4
Practice Questions with answers
alongside Rationales
⭐⭐⭐⭐⭐
Topics covered: Neurological Assessment • Musculoskeletal Assessment •
Peripheral Vascular & Lymphatic Assessment • Functional/Older Adult
Assessment
1. A nurse asks a patient to close their eyes and identifies a coin placed in the
patient's hand. This tests which sensory function? A. Graphesthesia B.
Stereognosis C. Two-point discrimination D. Proprioception
Rationale: Stereognosis is the ability to identify an object by touch alone.
Graphesthesia involves identifying numbers/letters traced on the skin.
2. Which cranial nerve is tested by asking a patient to shrug their shoulders
against resistance? A. CN IX B. CN X C. CN XI D. CN XII
Rationale: CN XI (spinal accessory nerve) controls the trapezius and
sternocleidomastoid muscles, tested via shoulder shrug and head turn against
resistance.
3. A patient exhibits a positive Romberg test. This indicates a problem with:
A. Cerebellar function only B. Proprioception and/or vestibular function C.
Motor strength D. Cranial nerve VII
Rationale: A positive Romberg (swaying or falling with eyes closed) suggests
impaired proprioceptive or vestibular input, since vision was compensating for the
deficit.
,4. When assessing deep tendon reflexes, a grade of 2+ indicates: A. Absent
reflex B. Hyperactive reflex C. Normal, average reflex D. Diminished, low-
normal reflex
Rationale: On the standard 0–4+ scale, 2+ is normal/average. 0 is absent, 1+ is
diminished, 3+ is brisker than average, 4+ is hyperactive with clonus.
5. The nurse notes unequal pupil size in a patient after a head injury. This
finding is called: A. Nystagmus B. Anisocoria C. Miosis D. Ptosis
Rationale: Anisocoria is unequal pupil size and can be a sign of increased
intracranial pressure or neurological injury, warranting immediate follow-up.
6. Which test assesses cerebellar function related to rapid alternating
movements? A. Romberg test B. Rapid alternating movements
(RAM)/dysdiadochokinesia test C. Babinski reflex D. Finger-to-nose test only
Rationale: The RAM test (e.g., rapidly pronating/supinating hands on thighs)
evaluates cerebellar coordination; inability to perform smoothly is termed
dysdiadochokinesia.
7. A newborn's plantar reflex causing toes to fan and the big toe to dorsiflex
is: A. An abnormal finding requiring referral B. A normal Babinski response in
infants C. Indicative of cerebral palsy D. A sign of spinal cord injury
Rationale: The Babinski reflex is normal up to about 2 years of age due to
incomplete corticospinal tract myelination; it is abnormal in adults.
8. Which of the following best describes decorticate posturing? A. Arms
extended, wrists pronated, legs extended B. Arms flexed toward the core, legs
extended C. Flaccid paralysis of all extremities D. Arms and legs both flexed
, Rationale: Decorticate posturing ("decorticate = core") involves flexion of the
arms toward the body with leg extension, indicating a lesion above the brainstem.
9. Decerebrate posturing indicates damage at what level? A. Cerebral cortex B.
Brainstem C. Spinal cord only D. Peripheral nerves
Rationale: Decerebrate posturing (rigid extension of arms and legs) reflects
brainstem dysfunction and is a more ominous sign than decorticate posturing.
10. Glasgow Coma Scale scoring: a patient who opens eyes to pain (2), makes
incomprehensible sounds (2), and exhibits abnormal extension (2) has a total
score of: A. 4 B. 6 C. 8 D. 10
Rationale: Adding Eye (2) + Verbal (2) + Motor (2) = 6, indicating severe
impairment; a fully alert patient scores 15.
11. To test CN II (optic nerve), the nurse would assess: A. Extraocular
movements B. Visual acuity and visual fields C. Pupillary constriction only D.
Corneal reflex
Rationale: CN II is purely sensory and is assessed through visual acuity (Snellen
chart) and visual field testing.
12. Which combination of cranial nerves is responsible for extraocular
movements? A. CN II, III, IV B. CN III, IV, VI C. CN V, VI, VII D. CN III, V,
VII
Rationale: CN III (oculomotor), IV (trochlear), and VI (abducens) control the
extraocular muscles, tested via the six cardinal fields of gaze.
Practice Questions with answers
alongside Rationales
⭐⭐⭐⭐⭐
Topics covered: Neurological Assessment • Musculoskeletal Assessment •
Peripheral Vascular & Lymphatic Assessment • Functional/Older Adult
Assessment
1. A nurse asks a patient to close their eyes and identifies a coin placed in the
patient's hand. This tests which sensory function? A. Graphesthesia B.
Stereognosis C. Two-point discrimination D. Proprioception
Rationale: Stereognosis is the ability to identify an object by touch alone.
Graphesthesia involves identifying numbers/letters traced on the skin.
2. Which cranial nerve is tested by asking a patient to shrug their shoulders
against resistance? A. CN IX B. CN X C. CN XI D. CN XII
Rationale: CN XI (spinal accessory nerve) controls the trapezius and
sternocleidomastoid muscles, tested via shoulder shrug and head turn against
resistance.
3. A patient exhibits a positive Romberg test. This indicates a problem with:
A. Cerebellar function only B. Proprioception and/or vestibular function C.
Motor strength D. Cranial nerve VII
Rationale: A positive Romberg (swaying or falling with eyes closed) suggests
impaired proprioceptive or vestibular input, since vision was compensating for the
deficit.
,4. When assessing deep tendon reflexes, a grade of 2+ indicates: A. Absent
reflex B. Hyperactive reflex C. Normal, average reflex D. Diminished, low-
normal reflex
Rationale: On the standard 0–4+ scale, 2+ is normal/average. 0 is absent, 1+ is
diminished, 3+ is brisker than average, 4+ is hyperactive with clonus.
5. The nurse notes unequal pupil size in a patient after a head injury. This
finding is called: A. Nystagmus B. Anisocoria C. Miosis D. Ptosis
Rationale: Anisocoria is unequal pupil size and can be a sign of increased
intracranial pressure or neurological injury, warranting immediate follow-up.
6. Which test assesses cerebellar function related to rapid alternating
movements? A. Romberg test B. Rapid alternating movements
(RAM)/dysdiadochokinesia test C. Babinski reflex D. Finger-to-nose test only
Rationale: The RAM test (e.g., rapidly pronating/supinating hands on thighs)
evaluates cerebellar coordination; inability to perform smoothly is termed
dysdiadochokinesia.
7. A newborn's plantar reflex causing toes to fan and the big toe to dorsiflex
is: A. An abnormal finding requiring referral B. A normal Babinski response in
infants C. Indicative of cerebral palsy D. A sign of spinal cord injury
Rationale: The Babinski reflex is normal up to about 2 years of age due to
incomplete corticospinal tract myelination; it is abnormal in adults.
8. Which of the following best describes decorticate posturing? A. Arms
extended, wrists pronated, legs extended B. Arms flexed toward the core, legs
extended C. Flaccid paralysis of all extremities D. Arms and legs both flexed
, Rationale: Decorticate posturing ("decorticate = core") involves flexion of the
arms toward the body with leg extension, indicating a lesion above the brainstem.
9. Decerebrate posturing indicates damage at what level? A. Cerebral cortex B.
Brainstem C. Spinal cord only D. Peripheral nerves
Rationale: Decerebrate posturing (rigid extension of arms and legs) reflects
brainstem dysfunction and is a more ominous sign than decorticate posturing.
10. Glasgow Coma Scale scoring: a patient who opens eyes to pain (2), makes
incomprehensible sounds (2), and exhibits abnormal extension (2) has a total
score of: A. 4 B. 6 C. 8 D. 10
Rationale: Adding Eye (2) + Verbal (2) + Motor (2) = 6, indicating severe
impairment; a fully alert patient scores 15.
11. To test CN II (optic nerve), the nurse would assess: A. Extraocular
movements B. Visual acuity and visual fields C. Pupillary constriction only D.
Corneal reflex
Rationale: CN II is purely sensory and is assessed through visual acuity (Snellen
chart) and visual field testing.
12. Which combination of cranial nerves is responsible for extraocular
movements? A. CN II, III, IV B. CN III, IV, VI C. CN V, VI, VII D. CN III, V,
VII
Rationale: CN III (oculomotor), IV (trochlear), and VI (abducens) control the
extraocular muscles, tested via the six cardinal fields of gaze.
