NSG 55-Assessment Exam Study UPDATED
ACTUAL Exam Questions and CORECT
Answers
Each patient has had consistent BP readings during the last three clinic visits. Which patient has
a BP consistent with expected findings?
1. Ms. J, whose BP has been 140/90.
2. Mr. Q, whose BP has been 130/76.
3. Ms. Y, whose BP has been 120/80
4. Mr. P, whose BP has been 110/78. - CORRECT ANSWER - 4. Mr. P, whose BP has
been 110/78.
During a health history, a patient reports having difficulty swallowing. Based on this report,
which assessment technique does the nurse use to collect more date about the patient's ability to
swallow?
1. Ask the patient to puff out her cheeks, purse her lips, and blow out.
2. observe the soft palate when the patient says "ahh."
3. Observe the patient while she swallows water from a paper cup.
4.Wearing gloves, grasp the patient's tongue and palpate all sides. - CORRECT
ANSWER - 2. Observe the soft palate when the patient says "ahh'
As a patient is walking into the exam room, the nurse notices his unsteady gait. What findings
does the nurse anticipate during the neurologic exam?
1. When the patient stands with his feet together and eyes closed, his upright posture is
maintained.
2. The nurse notices no patient responses after striking the right patellar tendon with a reflex
hammer.
3. The patient is able to move the heel of one foot down the shin of the other leg while lying
supine.
,4. A tremor is observed in his hands while he touches his finger to his thumb on the same hand. -
CORRECT ANSWER - 4. A tremor is observed in his hands while he touches his finger to
his thumb on the same hand
During a symptom analysis the patient reports a pain that radiates from the right lateral thigh,
over the knee, and around to the right medial ankle. The nurse refers to the dermatome map to
determine that the patient's description of pain is consistent with dysfunction of which spinal
nerve?
1. Second lumbar (L2)
2. Third lumbar (L3)
3. Fourth lumbar (L4)
4. Fifth lumbar (L5) - CORRECT ANSWER - 3. Fourth lumbar (L4)
Which question gives the nurse additional information about a patient's report of his hands
shaking for the last 2 months?
1. "Does the shaking occur when your hands are at rest or when you are picking up an item"
2. "Do you experience any abnormal sensations, such as tingling or coldness, at the same time?"
3. "What actions do you take to relieve the shaking when it occurs?"
4. "Have you ever experienced this shaking before?" - CORRECT ANSWER - 1. "Does
the shaking occur when your hands are at rest or when you are picking up an item"
Which technique does the nurse use to assess the triceps reflex?
1. Holds the patient's relaxed arm with the elbow extended while striking the appropriate tendon
with a reflex hammer
2. Holds the patient's relaxed forearm with the hand slightly pronated while striking the
appropriate tendon with a reflex hammer
3. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle, places a thumb over
the appropriate tendon, and strikes the thumb with the reflex hammer.
4. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle in one hand and strikes
the appropriate tendon just above the elbow with a reflex hammer - CORRECT
ANSWER - 4. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle in
one hand and strikes the appropriate tendon just above the elbow with a reflex hammer
,Which patient behavior indicates to the nurse that the patient's facial cranial nerve (CN VII) is
intact?
1. The patient's eyes move to the left, right, up, down, and obliquely.
2. The patient moistens the lips with the tongue.
3. The sides of the mouth are symmetric when the patient smiles.
4. The patient's eyelids blink periodically. - CORRECT ANSWER - 3. The sides of the
mouth are symmetric when the patient smiles.
The nurse asks a patient to stand with her feet together, her arms placed at her sides, and her eyes
closed. The nurse then observes the patient moving her foot to maintain balance and opening her
eyes, Based on the finding, which additional assessment does the nurse perform to confirm an
abnormality with balance?
1. Ask the patient to walk in tandem, putting the heel of one foot directly against the toes of the
other foot.
2. Ask the patient to sit down and alternatively tap the thighs with your hands using rapid
supination and pronation movements
3. Place a vibrating tuning fork in the patient's ankle and ask when she no longer detects the
vibration.
4. With the patient in a seated position, support one lower leg while sharply dorsiflexing the foot
and maintain it in flexion. - CORRECT ANSWER - 1. Ask the patient to walk in tandem,
putting the heel of one foot directly against the toes of the other foot.
What is the earliest and most sensitive indication of altered cerebral function?
1. Memory impairment
2. Loss of deep tendon reflexes
3. Inability to communicate
4. Change in level of consciousness - CORRECT ANSWER - 4. Change in level of
consciousness
What is the expected patient response when assessing the function of CN XI (spinal accessory)?
1. Demonstrates full, active range of motion of the neck
, 2. Moves shoulders against resistance equally
3. Follows an object with eyes without nystagmus
4. Sticks out tongue without tremor or deviation - CORRECT ANSWER - 2. Moves
shoulders against resistance equally
You had to yell his name to get him to open his eyes; he could not tell you his name or location,
and he could raise his hands when asked. Using the Glasgow Coma Scale, What score would you
give to this patient?
1. (12)
2. (13)
3. (14)
4. (15) - CORRECT ANSWER - 2. (13)
Average adult Temperature - CORRECT ANSWER - 37 degrees Celsius
How long should you wait to take a oral temperature after a patient has had a hot or cold
beverage? - CORRECT ANSWER - 10 minutes
How do you take the temperature of a child 12 and under - CORRECT ANSWER - ◦Peds
12 & under- pull earl Down and back and insert tempanic thermometer
What color is the probe used to take a rectal temperature - CORRECT ANSWER - Red-
insert only a few cm
A patient suffered a head injury, and the neurologist notes a deficit in cerebellar function. As the
nurse performs the neurologic assessment, which finding indicates a deficit in cerebellar
function?
A. The patient is unable to count by serial sevens in reverse order.
B. When doing the heel-shin exercise while the patient is supine, the patient's heel overshoots
shin and oscillates.
ACTUAL Exam Questions and CORECT
Answers
Each patient has had consistent BP readings during the last three clinic visits. Which patient has
a BP consistent with expected findings?
1. Ms. J, whose BP has been 140/90.
2. Mr. Q, whose BP has been 130/76.
3. Ms. Y, whose BP has been 120/80
4. Mr. P, whose BP has been 110/78. - CORRECT ANSWER - 4. Mr. P, whose BP has
been 110/78.
During a health history, a patient reports having difficulty swallowing. Based on this report,
which assessment technique does the nurse use to collect more date about the patient's ability to
swallow?
1. Ask the patient to puff out her cheeks, purse her lips, and blow out.
2. observe the soft palate when the patient says "ahh."
3. Observe the patient while she swallows water from a paper cup.
4.Wearing gloves, grasp the patient's tongue and palpate all sides. - CORRECT
ANSWER - 2. Observe the soft palate when the patient says "ahh'
As a patient is walking into the exam room, the nurse notices his unsteady gait. What findings
does the nurse anticipate during the neurologic exam?
1. When the patient stands with his feet together and eyes closed, his upright posture is
maintained.
2. The nurse notices no patient responses after striking the right patellar tendon with a reflex
hammer.
3. The patient is able to move the heel of one foot down the shin of the other leg while lying
supine.
,4. A tremor is observed in his hands while he touches his finger to his thumb on the same hand. -
CORRECT ANSWER - 4. A tremor is observed in his hands while he touches his finger to
his thumb on the same hand
During a symptom analysis the patient reports a pain that radiates from the right lateral thigh,
over the knee, and around to the right medial ankle. The nurse refers to the dermatome map to
determine that the patient's description of pain is consistent with dysfunction of which spinal
nerve?
1. Second lumbar (L2)
2. Third lumbar (L3)
3. Fourth lumbar (L4)
4. Fifth lumbar (L5) - CORRECT ANSWER - 3. Fourth lumbar (L4)
Which question gives the nurse additional information about a patient's report of his hands
shaking for the last 2 months?
1. "Does the shaking occur when your hands are at rest or when you are picking up an item"
2. "Do you experience any abnormal sensations, such as tingling or coldness, at the same time?"
3. "What actions do you take to relieve the shaking when it occurs?"
4. "Have you ever experienced this shaking before?" - CORRECT ANSWER - 1. "Does
the shaking occur when your hands are at rest or when you are picking up an item"
Which technique does the nurse use to assess the triceps reflex?
1. Holds the patient's relaxed arm with the elbow extended while striking the appropriate tendon
with a reflex hammer
2. Holds the patient's relaxed forearm with the hand slightly pronated while striking the
appropriate tendon with a reflex hammer
3. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle, places a thumb over
the appropriate tendon, and strikes the thumb with the reflex hammer.
4. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle in one hand and strikes
the appropriate tendon just above the elbow with a reflex hammer - CORRECT
ANSWER - 4. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle in
one hand and strikes the appropriate tendon just above the elbow with a reflex hammer
,Which patient behavior indicates to the nurse that the patient's facial cranial nerve (CN VII) is
intact?
1. The patient's eyes move to the left, right, up, down, and obliquely.
2. The patient moistens the lips with the tongue.
3. The sides of the mouth are symmetric when the patient smiles.
4. The patient's eyelids blink periodically. - CORRECT ANSWER - 3. The sides of the
mouth are symmetric when the patient smiles.
The nurse asks a patient to stand with her feet together, her arms placed at her sides, and her eyes
closed. The nurse then observes the patient moving her foot to maintain balance and opening her
eyes, Based on the finding, which additional assessment does the nurse perform to confirm an
abnormality with balance?
1. Ask the patient to walk in tandem, putting the heel of one foot directly against the toes of the
other foot.
2. Ask the patient to sit down and alternatively tap the thighs with your hands using rapid
supination and pronation movements
3. Place a vibrating tuning fork in the patient's ankle and ask when she no longer detects the
vibration.
4. With the patient in a seated position, support one lower leg while sharply dorsiflexing the foot
and maintain it in flexion. - CORRECT ANSWER - 1. Ask the patient to walk in tandem,
putting the heel of one foot directly against the toes of the other foot.
What is the earliest and most sensitive indication of altered cerebral function?
1. Memory impairment
2. Loss of deep tendon reflexes
3. Inability to communicate
4. Change in level of consciousness - CORRECT ANSWER - 4. Change in level of
consciousness
What is the expected patient response when assessing the function of CN XI (spinal accessory)?
1. Demonstrates full, active range of motion of the neck
, 2. Moves shoulders against resistance equally
3. Follows an object with eyes without nystagmus
4. Sticks out tongue without tremor or deviation - CORRECT ANSWER - 2. Moves
shoulders against resistance equally
You had to yell his name to get him to open his eyes; he could not tell you his name or location,
and he could raise his hands when asked. Using the Glasgow Coma Scale, What score would you
give to this patient?
1. (12)
2. (13)
3. (14)
4. (15) - CORRECT ANSWER - 2. (13)
Average adult Temperature - CORRECT ANSWER - 37 degrees Celsius
How long should you wait to take a oral temperature after a patient has had a hot or cold
beverage? - CORRECT ANSWER - 10 minutes
How do you take the temperature of a child 12 and under - CORRECT ANSWER - ◦Peds
12 & under- pull earl Down and back and insert tempanic thermometer
What color is the probe used to take a rectal temperature - CORRECT ANSWER - Red-
insert only a few cm
A patient suffered a head injury, and the neurologist notes a deficit in cerebellar function. As the
nurse performs the neurologic assessment, which finding indicates a deficit in cerebellar
function?
A. The patient is unable to count by serial sevens in reverse order.
B. When doing the heel-shin exercise while the patient is supine, the patient's heel overshoots
shin and oscillates.
