NSG 3160 / NSG3160 Exam 2 – Health
Assessment (2026/2027 Update) |
Verified Questions & Answers with
Rationale - Galen College of Nursing
SECTION 1: NEUROLOGICAL ASSESSMENT
Question 1
The nurse just received report on the neurological unit. Which of the following findings
would be of MOST concern?
A. Patient with chronic dementia, A&Ox1
B. Patient with a head injury who does not remember what was happening before or
during the injury
C. Patient reporting headache, denies any injury, no external abnormalities noted
D. Patient reporting generalized weakness
Answer: B
Rationale: A patient with a head injury who does not remember events before or during
the injury is exhibiting retrograde amnesia, which indicates a more significant
neurological event requiring immediate attention. While dementia with A&Ox1 represents
an altered baseline, it is a chronic condition. Generalized weakness and headache require
monitoring but do not represent the same level of acute concern as post-traumatic
amnesia .
,Question 2
A patient reports having a head injury while out with friends and reports ETOH intake.
Which of the following statements would concern you the MOST?
A. "I was being goofy and tripped."
B. "My legs feel unsteady."
C. "I am having trouble focusing."
D. "It is hard to swallow when taking a drink."
Answer: D
Rationale: Dysphagia (difficulty swallowing) indicates potential brainstem involvement
and represents a compromise to airway protection (ABCs). This is the most concerning
finding as it poses an immediate risk to patient safety. Unsteady gait, trouble focusing,
and the mechanism of injury, while noteworthy, do not represent the same level of threat
to airway, breathing, or circulation .
Question 3
Which of the following statements made by the student nurse requires further
education?
A. "One method to assess cranial nerve V would be to have the person puff their cheeks.
Then press on their cheeks to ensure the air escapes equally bilaterally."
B. "To assess the acoustic, or vestibulocochlear, nerve would be to administer the
whisper test. An expected finding is for the patient to correctly repeat at least four of the
six phrases."
C. "When assessing the pupil, if the patient has an increased ICP there will be a sudden,
unilateral, dilated, and nonreactive change in the pupils."
D. "To assess cranial nerve XII, ask the patient to protrude their tongue, ensuring no
tremors or wasting are present, and that the tongue is midline."
,Answer: C
Rationale: The statement about increased ICP requires further education because a
sudden, unilateral, dilated, and nonreactive pupil (blown pupil) is actually indicative of
uncal herniation, not simply increased ICP. While increased ICP can cause changes in
pupil reactivity, the classic sign of a blown pupil is an emergent finding indicating
brainstem compression. The other statements correctly describe assessment techniques for
CN V (trigeminal), CN VIII (vestibulocochlear), and CN XII (hypoglossal) .
Question 4
While practicing the Romberg Test, which of the following statements, if made by the
student nurse, would show understanding of this test?
A. "An expected finding for this test is negative. If negative, the patient will not sway, or
become unbalanced and fall."
B. "An expected finding for this test is positive. If positive, the patient will not sway, or
become unbalanced and fall."
C. "An unexpected finding for this test is negative. If negative, the patient will not sway,
or become unbalanced and fall."
D. "An unexpected finding for this test is positive. If positive, the patient will not sway, or
become unbalanced and fall."
Answer: A
Rationale: A negative Romberg test is the expected (normal) finding, indicating that the
patient can maintain balance with eyes closed without significant swaying. A positive
Romberg test is abnormal and indicates impaired proprioception or vestibular dysfunction.
The test assesses the integrity of the dorsal columns of the spinal cord and the vestibular
system .
, Question 5
Which of the following patients would be the LEAST alert?
A. GCS of 10
B. A patient opening eyes to speech, withdrawing to pain, and incomprehensible speech
C. GCS of 7
D. A patient opening eyes upon approach, obeys command, and oriented x3
Answer: C
Rationale: A GCS of 7 indicates a comatose state requiring immediate intervention. This is
the least alert state among the options. The patient described in option B has a GCS of 10
(E3 + V2 + M5 = 10), which indicates moderate impairment. Option D describes an alert
patient (GCS 15). A GCS of 7 represents severe impairment and the lowest level of
consciousness .
Question 6
Obtunded means:
A. Drifts off to sleep when not stimulated
B. Responds only to persistent shaking or pain
C. Will wake with loud shouting or vigorous shake
D. No response to pain or any external stimuli
Answer: C
Rationale: Obtunded describes a patient who can be awakened with loud shouting or
vigorous shaking but then drifts back to sleep. This is a state of reduced alertness that falls
Assessment (2026/2027 Update) |
Verified Questions & Answers with
Rationale - Galen College of Nursing
SECTION 1: NEUROLOGICAL ASSESSMENT
Question 1
The nurse just received report on the neurological unit. Which of the following findings
would be of MOST concern?
A. Patient with chronic dementia, A&Ox1
B. Patient with a head injury who does not remember what was happening before or
during the injury
C. Patient reporting headache, denies any injury, no external abnormalities noted
D. Patient reporting generalized weakness
Answer: B
Rationale: A patient with a head injury who does not remember events before or during
the injury is exhibiting retrograde amnesia, which indicates a more significant
neurological event requiring immediate attention. While dementia with A&Ox1 represents
an altered baseline, it is a chronic condition. Generalized weakness and headache require
monitoring but do not represent the same level of acute concern as post-traumatic
amnesia .
,Question 2
A patient reports having a head injury while out with friends and reports ETOH intake.
Which of the following statements would concern you the MOST?
A. "I was being goofy and tripped."
B. "My legs feel unsteady."
C. "I am having trouble focusing."
D. "It is hard to swallow when taking a drink."
Answer: D
Rationale: Dysphagia (difficulty swallowing) indicates potential brainstem involvement
and represents a compromise to airway protection (ABCs). This is the most concerning
finding as it poses an immediate risk to patient safety. Unsteady gait, trouble focusing,
and the mechanism of injury, while noteworthy, do not represent the same level of threat
to airway, breathing, or circulation .
Question 3
Which of the following statements made by the student nurse requires further
education?
A. "One method to assess cranial nerve V would be to have the person puff their cheeks.
Then press on their cheeks to ensure the air escapes equally bilaterally."
B. "To assess the acoustic, or vestibulocochlear, nerve would be to administer the
whisper test. An expected finding is for the patient to correctly repeat at least four of the
six phrases."
C. "When assessing the pupil, if the patient has an increased ICP there will be a sudden,
unilateral, dilated, and nonreactive change in the pupils."
D. "To assess cranial nerve XII, ask the patient to protrude their tongue, ensuring no
tremors or wasting are present, and that the tongue is midline."
,Answer: C
Rationale: The statement about increased ICP requires further education because a
sudden, unilateral, dilated, and nonreactive pupil (blown pupil) is actually indicative of
uncal herniation, not simply increased ICP. While increased ICP can cause changes in
pupil reactivity, the classic sign of a blown pupil is an emergent finding indicating
brainstem compression. The other statements correctly describe assessment techniques for
CN V (trigeminal), CN VIII (vestibulocochlear), and CN XII (hypoglossal) .
Question 4
While practicing the Romberg Test, which of the following statements, if made by the
student nurse, would show understanding of this test?
A. "An expected finding for this test is negative. If negative, the patient will not sway, or
become unbalanced and fall."
B. "An expected finding for this test is positive. If positive, the patient will not sway, or
become unbalanced and fall."
C. "An unexpected finding for this test is negative. If negative, the patient will not sway,
or become unbalanced and fall."
D. "An unexpected finding for this test is positive. If positive, the patient will not sway, or
become unbalanced and fall."
Answer: A
Rationale: A negative Romberg test is the expected (normal) finding, indicating that the
patient can maintain balance with eyes closed without significant swaying. A positive
Romberg test is abnormal and indicates impaired proprioception or vestibular dysfunction.
The test assesses the integrity of the dorsal columns of the spinal cord and the vestibular
system .
, Question 5
Which of the following patients would be the LEAST alert?
A. GCS of 10
B. A patient opening eyes to speech, withdrawing to pain, and incomprehensible speech
C. GCS of 7
D. A patient opening eyes upon approach, obeys command, and oriented x3
Answer: C
Rationale: A GCS of 7 indicates a comatose state requiring immediate intervention. This is
the least alert state among the options. The patient described in option B has a GCS of 10
(E3 + V2 + M5 = 10), which indicates moderate impairment. Option D describes an alert
patient (GCS 15). A GCS of 7 represents severe impairment and the lowest level of
consciousness .
Question 6
Obtunded means:
A. Drifts off to sleep when not stimulated
B. Responds only to persistent shaking or pain
C. Will wake with loud shouting or vigorous shake
D. No response to pain or any external stimuli
Answer: C
Rationale: Obtunded describes a patient who can be awakened with loud shouting or
vigorous shaking but then drifts back to sleep. This is a state of reduced alertness that falls
