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Exam 2 - Health Assessment Q&A (Nursing Program)

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Exam 2 - Health Assessment Q&A (Nursing Program)Exam 2 - Health Assessment Q&A (Nursing Program)

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Maritsa Aguilar
Exam 2 Health Assessment Q&A’s
This exam pulls from information provided in the sources and is based on material found on or
around a nursing student's second exam in a nursing program. Topics covered include neuro, HEENT,
and the integumentary system.
Neuro
1.A nurse is performing a neurological assessment on a patient. What is the
correct sequence for the examination?
a. Cranial nerves, mental status, motor system, sensory system, reflexes
b. Mental status, cranial nerves, motor system, sensory system, reflexes
c. Motor system, sensory system, cranial nerves, mental status, reflexes
d. Reflexes, sensory system, motor system, cranial nerves, mental status
Answer: B - The correct sequence for a complete neurologic examination is mental
status, cranial nerves, motor system, sensory system, and reflexes.
2.A patient presents with a complaint of a severe headache that they have
never had before. What should the nurse's priority action be?
a. Administer an analgesic medication as ordered.
b. Assess the patient’s neurological status.
c. Ask the patient about the characteristics of their headache.
d. Immediately refer the patient to the emergency department.
Answer: D - A sudden onset of a severe headache, especially if the patient has never had
one before, can be a sign of a serious medical condition such as a stroke or aneurysm.
The patient should be referred to the emergency department immediately for further
evaluation and treatment.
3.What is the most important factor in a neuro recheck?
a. Vital signs
b. Pupillary response
c. Level of consciousness (LOC)
d. Glasgow Coma Scale
Answer: C - A change in LOC is the single most important factor in this
examination.
4.Which cranial nerve is responsible for smell?
a. CN I
b. CN II
c. CN V
d. CN VII
Answer: A - Cranial Nerve I, the olfactory nerve, is responsible for the sense of
smell.
5.A nurse is testing a patient’s biceps reflex. What is the expected response?
a. Extension of the forearm
b. Flexion of the forearm
c. Dorsiflexion of the foot
d. Plantar flexion of the foot


Page 1 of 9

, Maritsa Aguilar
Exam 2 Health Assessment Q&A’s
Answer: B - Striking the biceps tendon should cause contraction of the biceps muscle and
flexion of the forearm.
6.Which of the following is not a component of the mental status
examination?
a. Appearance
b. Temperature
c. Behavior
d. Cognition
Answer: B - Temperature is a vital sign and not a component of the mental status exam. The
components are health history, appearance, behavior, cognition, and thought process.
7.The nurse is assessing a patient who has experienced a stroke. The patient is
unable to speak clearly but seems to understand what the nurse is saying.
What type of aphasia is this patient experiencing?
a. Global aphasia
b. Receptive aphasia
c. Expressive aphasia
d. Anomic aphasia
Answer: C - Expressive aphasia is a neurological condition that affects a person's ability to
speak fluently and to find the right words, despite having intact comprehension. This is
also known as Broca's Aphasia.
8.A patient who is experiencing a stroke may have difÏculty swallowing. What is
the medical term for difÏculty swallowing?
a. Aphasia
b. Dysarthria
c. Dysphagia
d. Aphagia
Answer: C - Dysphagia is the medical term for difÏculty swallowing.
9.A patient scores a 3 on the Glasgow Coma Scale. How would the nurse
interpret this score?
a. Mild head injury
b. Moderate head injury
c. Severe head injury
d. Comatose
Answer: C - A score of 3-8 on the Glasgow Coma Scale indicates a severe head injury.


10. The Mini-Mental State Exam (MMSE) is used to screen for what condition?
a. Depression
b. Delirium
c. Dementia
d. Anxiety
Answer: C - The Mini-Mental State Exam (MMSE) is a valid detector of organic disease such
as dementia, but lacks sensitivity to detect mild cognitive impairment. It is used to screen
for cognitive impairment, most commonly associated with dementia.


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