Question 1

The nurse asks the patient to identify a distinct odor. Which cranial nerve (CN) is being assessed?

Accepted Answer

A)  CN I 
B)  CN V 
C)  CN VII 
D)  CN VIII 
A)  CN I 
B)  CN V 
C)  CN VII 
D)  CN VIII A

Question 2

To assess vibratory sensation, where should the nurse place the vibrating tuning fork?

Accepted Answer

A)  On a tendon 
B)  On a bony prominence 
C)  On a muscle 
D)  On a dermatome 
A)  On a tendon 
B)  On a bony prominence 
C)  On a muscle 
D)  On a dermatome B

Question 3

Of the following patients, who is most likely to need a neurologic assessment?

Accepted Answer

A)  A 2-year-old, in for a well-child visit, sitting quietly the on mother's lap 
B)  An 8-year-old with rhinitis, coloring in a book 
C)  An 18-year-old car accident victim who appears sleepy 
D)  A 56-year-old patient with complaints of difficulty breathing 
A)  A 2-year-old, in for a well-child visit, sitting quietly the on mother's lap 
B)  An 8-year-old with rhinitis, coloring in a book 
C)  An 18-year-old car accident victim who appears sleepy 
D)  A 56-year-old patient with complaints of difficulty breathing C

Question 4

An adult patient is involved in an automobile accident and brought to the emergency department (ED) with head trauma. Which question would best assess cerebral function?

Accepted Answer

A)  "How would you describe your eyesight?" 
B)  "Can you tell me your address?" 
C)  "Have you noticed a change in your muscle strength?" 
D)  "Have you noticed a change in your coordination?" 
A)  "How would you describe your eyesight?" 
B)  "Can you tell me your address?" 
C)  "Have you noticed a change in your muscle strength?" 
D)  "Have you noticed a change in your coordination?"

Question 5

To assess stereognosis, which action by the nurse is appropriate?

Accepted Answer

A)  Touching two points simultaneously and have patient identify touch 
B)  Having patient identify familiar object by touch 
C)  Having patient identify number written in palm of hand 
D)  Moving finger and having patient identify direction of movement 
A)  Touching two points simultaneously and have patient identify touch 
B)  Having patient identify familiar object by touch 
C)  Having patient identify number written in palm of hand 
D)  Moving finger and having patient identify direction of movement

Question 6

The nurse is providing care to an adult patient who is diagnosed with a degenerative cerebellar disorder. Which test would best assess the patient's balance?

Accepted Answer

A)  Tandem gait walking 
B)  Point-to-point localization 
C)  Rapid alternating movements (RAM) 
D)  Leg coordination 
A)  Tandem gait walking 
B)  Point-to-point localization 
C)  Rapid alternating movements (RAM) 
D)  Leg coordination

Question 7

When assessing the deep tendon reflexes (DTRs), what is the normal response of the biceps reflex?

Accepted Answer

A)  Elbow flexion 
B)  Elbow extension 
C)  Forearm supination 
D)  Hand pronation 
A)  Elbow flexion 
B)  Elbow extension 
C)  Forearm supination 
D)  Hand pronation

Question 8

What is the best score a patient can make on the Glasgow Coma Scale?

Accepted Answer

A)  1 
B)  10 
C)  15 
D)  25 
A)  1 
B)  10 
C)  15 
D)  25

Question 9

What is the normal response for the Achilles reflex?

Accepted Answer

A)  Inversion of foot 
B)  Dorsiflexion of foot 
C)  Plantarflexion of foot 
D)  Eversion of foot 
A)  Inversion of foot 
B)  Dorsiflexion of foot 
C)  Plantarflexion of foot 
D)  Eversion of foot

Question 10

Which nutrient is recommended during pregnancy to prevent neural tube defects in the fetus?

Accepted Answer

A)  Iron 
B)  Vitamin A 
C)  Vitamin C 
D)  Folic acid 
A)  Iron 
B)  Vitamin A 
C)  Vitamin C 
D)  Folic acid

Question 11

The nurse has difficulty eliciting an Achilles reflex response. What reinforcement technique may be used to enhance this response?

Accepted Answer

A)  Smile 
B)  Dorsiflex foot 
C)  Plantarflex foot 
D)  Interlock hands 
A)  Smile 
B)  Dorsiflex foot 
C)  Plantarflex foot 
D)  Interlock hands

Question 12

After an injury to the back of the head, the nurse anticipates an individual might have difficulty with which item?

Accepted Answer

A)  Speech 
B)  Spatial relationships 
C)  Sexual arousal 
D)  Memory 
A)  Speech 
B)  Spatial relationships 
C)  Sexual arousal 
D)  Memory

Question 13

The nurse is assessing a preschool-age patient who is exhibiting symptoms of hyperactivity. Which question is most appropriate for the nurse to ask the patient's mother during the health history interview?

Accepted Answer

A)  "Does your child consume a lot of sugar?" 
B)  "Did you use drugs while you were pregnant?" 
C)  "Did you consume enough folic acid during pregnancy?" 
D)  "Does your child eat a lot of vegetables?" 
A)  "Does your child consume a lot of sugar?" 
B)  "Did you use drugs while you were pregnant?" 
C)  "Did you consume enough folic acid during pregnancy?" 
D)  "Does your child eat a lot of vegetables?"

Question 14

Which statement regarding superficial sensation is accurate?

Accepted Answer

A)  If superficial sensations are intact distally, they are intact proximally. 
B)  If superficial sensations are intact proximally, they are intact distally. 
C)  Dermatomes sense superficial sensations. 
D)  Neurons sense superficial sensations. 
A)  If superficial sensations are intact distally, they are intact proximally. 
B)  If superficial sensations are intact proximally, they are intact distally. 
C)  Dermatomes sense superficial sensations. 
D)  Neurons sense superficial sensations.

Question 15

To perform the Romberg test, the nurse should instruct the patient to do which task?

Accepted Answer

A)  Stand with feet together and arms at side with eyes open, then closed 
B)  Walk on the heels, then on the toes 
C)  Touch thumb of one hand to each finger 
D)  Run heel of foot down shin of opposite leg 
A)  Stand with feet together and arms at side with eyes open, then closed 
B)  Walk on the heels, then on the toes 
C)  Touch thumb of one hand to each finger 
D)  Run heel of foot down shin of opposite leg

Question 16

An older adult patient is admitted to the medical unit with speech disturbance and right-sided weakness. Sensory assessment is included in the neurologic evaluation. If pain sensation is intact, which other area is intact and need not be tested?

Accepted Answer

A)  Two-point discrimination 
B)  Vibratory sensation 
C)  Temperature sensation 
D)  Kinesthetic sensation 
A)  Two-point discrimination 
B)  Vibratory sensation 
C)  Temperature sensation 
D)  Kinesthetic sensation

Question 17

The nurse is assessing the trigeminal nerve, which is responsible for which task?

Accepted Answer

A)  Moving eyes diagonally 
B)  Moving eyes laterally 
C)  Chewing and conveying sensory data from the eyes, nose, and mouth 
D)  Articulating with the tongue, movement of the tongue, and swallowing 
A)  Moving eyes diagonally 
B)  Moving eyes laterally 
C)  Chewing and conveying sensory data from the eyes, nose, and mouth 
D)  Articulating with the tongue, movement of the tongue, and swallowing

Question 18

The nurse is assessing a preschool-age patient during a scheduled health maintenance visit. Which question is appropriate to determine whether the patient is at risk for lead poisoning?

Accepted Answer

A)  "Does your child eat a balanced diet?" 
B)  "Does your child attend day care?" 
C)  "What year was your house built?" 
D)  "What type of child safety seat do you use?" 
A)  "Does your child eat a balanced diet?" 
B)  "Does your child attend day care?" 
C)  "What year was your house built?" 
D)  "What type of child safety seat do you use?"

Question 19

Which is an appropriate method to administer central painful stimuli to assess arousal level?

Accepted Answer

A)  Nipple twist 
B)  Sternal rub 
C)  Nail pressure 
D)  Achilles tendon squeeze 
A)  Nipple twist 
B)  Sternal rub 
C)  Nail pressure 
D)  Achilles tendon squeeze

Question 20

Which three assessments make the Cushing triad?

Accepted Answer

A)  Widening pulse pressure, bradycardia, and irregular respiratory pattern 
B)  Decreased pulse pressure, tachycardia, and irregular respiratory pattern 
C)  Confusion, aphasia, and tachycardia 
D)  Elevated blood pressure, bradycardia, and aphasia 
A)  Widening pulse pressure, bradycardia, and irregular respiratory pattern 
B)  Decreased pulse pressure, tachycardia, and irregular respiratory pattern 
C)  Confusion, aphasia, and tachycardia 
D)  Elevated blood pressure, bradycardia, and aphasia

Exam 13: Assessing the Sensory-Neurologic System

The nurse asks the patient to identify a distinct odor. Which cranial nerve (CN) is being assessed?

To assess vibratory sensation, where should the nurse place the vibrating tuning fork?

Of the following patients, who is most likely to need a neurologic assessment?

An adult patient is involved in an automobile accident and brought to the emergency department (ED) with head trauma. Which question would best assess cerebral function?

To assess stereognosis, which action by the nurse is appropriate?

The nurse is providing care to an adult patient who is diagnosed with a degenerative cerebellar disorder. Which test would best assess the patient's balance?

When assessing the deep tendon reflexes (DTRs), what is the normal response of the biceps reflex?

What is the best score a patient can make on the Glasgow Coma Scale?

What is the normal response for the Achilles reflex?

Which nutrient is recommended during pregnancy to prevent neural tube defects in the fetus?

The nurse has difficulty eliciting an Achilles reflex response. What reinforcement technique may be used to enhance this response?

After an injury to the back of the head, the nurse anticipates an individual might have difficulty with which item?

The nurse is assessing a preschool-age patient who is exhibiting symptoms of hyperactivity. Which question is most appropriate for the nurse to ask the patient's mother during the health history interview?

Which statement regarding superficial sensation is accurate?

To perform the Romberg test, the nurse should instruct the patient to do which task?

An older adult patient is admitted to the medical unit with speech disturbance and right-sided weakness. Sensory assessment is included in the neurologic evaluation. If pain sensation is intact, which other area is intact and need not be tested?

The nurse is assessing the trigeminal nerve, which is responsible for which task?

The nurse is assessing a preschool-age patient during a scheduled health maintenance visit. Which question is appropriate to determine whether the patient is at risk for lead poisoning?

Which is an appropriate method to administer central painful stimuli to assess arousal level?

Which three assessments make the Cushing triad?

The Complete Health Assessment

Assessing the Integumentary System

Assessing the Head, Face, and Neck

Assessing the Eye and the Ear

Assessing the Respiratory System

Assessing the Cardiovascular System

Assessing the Peripheral-Vascular and Lymphatic System

Assessing the Breasts

Assessing the Abdomen

Assessing the Female Genitourinary System

Assessing the Male Genitourinary System

Assessing the Motor-Musculoskeletal System

Assessing the Mother-To-Be

Assessing the Newborn and Infant

Assessing the Toddler and Preschooler

Assessing the School-Age Child and Adolescent

Assessing the Older Adult

Assessing the Homeless Person

Assessing Pain

Approach to the Mental Health Assessment

Assessing Nutrition

Assessing Spirituality

Assessing Culture

Assessing the Patients Environment

Assessing Abuse

Assessing the Dying Patient

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