NR-302 – Health Assessment II, maintaining the same advanced/hard difficulty level,
head-to-toe focus, and clinical documentation emphasis. Each question includes a correct
answer and rationale.
Title: Advanced Clinical Judgment in Systematic Health Assessment: Differentiating Subtle
Abnormalities, Recognizing Geriatric & Cultural Variations, and Prioritizing
Documentation for Safe Nursing Practice
Section 1: Neurological & Cranial Nerve Assessment (Questions 1–20)
1. A 74-year-old patient has a new onset of unilateral neglect, where they ignore the left side of their body and
environment. They deny any problem. This is most consistent with a lesion in the:
A) Right parietal lobe
B) Left frontal lobe
C) Brainstem reticular formation
D) Cerebellar vermis
Correct Answer: A) Right parietal lobe
Rationale: Unilateral neglect (usually left-sided) occurs with right parietal (non-dominant hemisphere) lesions, often
after stroke. Anosognosia = denial of deficit.
2. During assessment of cranial nerve XI (spinal accessory), you ask the patient to shrug their shoulders against
resistance. Weakness on the right side with leftward head turning suggests:
A) Right CN XI lesion
B) Left CN XI lesion
C) Cervical myelopathy
D) Myasthenia gravis
Correct Answer: A) Right CN XI lesion
Rationale: CN XI innervates trapezius (shoulder shrug) and sternocleidomastoid (head turn to opposite side). Right
CN XI lesion → weak right shoulder shrug + weak left head turn.
3. A patient has ptosis, miosis, anhidrosis, and apparent enophthalmos on the right eye. This constellation is called:
A) Horner’s syndrome
B) Third nerve palsy
C) Myasthenia gravis
D) Miller Fisher syndrome
Correct Answer: A) Horner’s syndrome
Rationale: Horner’s = sympathetic chain disruption (ptosis, miosis, anhidrosis). Enophthalmos is often apparent due
to ptosis.
4. When testing plantar reflex, the great toe extends and the other toes fan. The nurse should document:
A) Normal plantar reflex
B) Babinski sign present (positive)
,C) Withdrawal response
D) Hoffman’s sign
Correct Answer: B) Babinski sign present (positive)
Rationale: Extensor plantar response (Babinski) = upper motor neuron lesion. Normal = flexor (toes curl down).
5. A patient with multiple sclerosis has a tremor that occurs during goal-directed movement (e.g., finger-to-nose). This
is best described as:
A) Resting tremor
B) Postural tremor
C) Intention tremor
D) Flapping tremor (asterixis)
Correct Answer: C) Intention tremor
Rationale: Cerebellar lesion (MS) → intention tremor (worsens as target approached). Resting = Parkinson’s.
Asterixis = metabolic encephalopathy.
6. On Glasgow Coma Scale, the patient opens eyes to speech, uses inappropriate words, and withdraws to pain. The
score is:
A) 10 (E3, V3, M4)
B) 11 (E3, V3, M5)
C) 12 (E4, V3, M5)
D) 9 (E2, V3, M4)
Correct Answer: B) 11 (E3, V3, M5)
Rationale: Eye to speech = 3; Inappropriate words = 3; Withdraws to pain = 4? Wait – correction: Withdrawal = 4,
Localizes = 5. The scenario says withdraws = M4. Total = 3+3+4 = 10. Actually recalc: Eye to speech = 3; Inappropriate = 3;
Withdrawal = 4 → total 10. Answer would be A) 10. Corrected answer: A) 10 (E3 V3 M4).
7. A patient has loss of vibration sense at the great toe, but pain and temperature are intact. This suggests a lesion in
the:
A) Spinothalamic tract
B) Dorsal column (medial lemniscus)
C) Anterior horn cell
D) Corticospinal tract
Correct Answer: B) Dorsal column (medial lemniscus)
Rationale: Dorsal columns = fine touch, vibration, proprioception. Spinothalamic = pain/temp. Dissociated sensory
loss = cord lesion.
8. Which finding differentiates a psychogenic tremor from an organic tremor?
A) Tremor worsens with distraction
B) Tremor improves with concentration
C) Tremor stops when the patient is distracted and restarts when asked to perform a task
D) Tremor is present at rest and during sleep
Correct Answer: C) Tremor stops when distracted and restarts when asked to perform a task
,Rationale: Psychogenic tremor = entrainment, variability, improvement with distraction. Organic tremor is present
regardless.
9. A patient cannot perform rapid alternating hand movements (dysdiadochokinesia). This localizes to the:
A) Basal ganglia
B) Cerebellum
C) Frontal lobe
D) Parietal lobe
Correct Answer: B) Cerebellum
Rationale: Dysdiadochokinesia = cerebellar dysfunction. Rapid alternating movements test cerebellar coordination.
10. On examination of the pupils, the left pupil is 4 mm and the right is 2 mm in room light. Both constrict briskly to
light. This is:
A) Horner’s syndrome (right)
B) Physiologic anisocoria
C) Third nerve palsy (left)
D) Adie’s tonic pupil
Correct Answer: B) Physiologic anisocoria
Rationale: Physiologic anisocoria (up to 1 mm difference) → equal and brisk reaction. Horner’s = smaller pupil with
dilation lag. Adie’s = tonic reaction.
11. A patient has a wide-based, unsteady gait that does not improve with visual input. This is most consistent with:
A) Sensory ataxia (dorsal column)
B) Cerebellar ataxia
C) Vestibular ataxia
D) Frontal gait disorder
Correct Answer: B) Cerebellar ataxia
Rationale: Cerebellar ataxia = wide-based, irregular, does NOT improve with vision. Sensory ataxia improves with
visual input (Romberg positive).
12. On muscle strength testing, you grade a patient’s right arm as 3/5. This means:
A) No movement
B) Movement against gravity but not against resistance
C) Full strength
D) Movement only with gravity eliminated
Correct Answer: B) Movement against gravity but not against resistance
Rationale: 5/5 = normal; 4/5 = against some resistance; 3/5 = against gravity only; 2/5 = gravity eliminated; 1/5 =
flicker; 0 = none.
13. A patient has a unilateral, painless, fixed, dilated pupil. The most likely cause is:
A) Pharmacologic dilation (anticholinergic)
B) Third nerve compression (aneurysm)
C) Traumatic mydriasis
D) Adie’s pupil
, Correct Answer: A) Pharmacologic dilation (anticholinergic)
Rationale: Fixed, dilated pupil without ptosis or diplopia = topical anticholinergic (e.g., scopolamine patch) until
proven otherwise. CN III palsy = ptosis, “down and out.”
14. Which reflex is mediated by the S1 spinal nerve root?
A) Biceps (C5-C6)
B) Patellar (L2-L4)
C) Achilles (S1-S2)
D) Brachioradialis (C5-C6)
Correct Answer: C) Achilles (S1-S2)
Rationale: Achilles reflex tests S1 (and S2). Loss of ankle jerk is early sign of peripheral neuropathy (diabetes).
15. A patient has a positive Hoffman’s sign. This indicates:
A) Lower motor neuron disease
B) Upper motor neuron lesion above C6
C) Peripheral neuropathy
D) Myopathy
Correct Answer: B) Upper motor neuron lesion above C6
Rationale: Hoffman’s = hyperreflexia variant (flicking middle finger causes thumb/index flexion) → UMN lesion
(cervical myelopathy).
16. On assessment of extraocular movements, the left eye cannot move laterally. Which cranial nerve is involved?
A) CN III (oculomotor)
B) CN IV (trochlear)
C) CN VI (abducens)
D) CN II (optic)
Correct Answer: C) CN VI (abducens)
Rationale: CN VI → lateral rectus → abduction. CN IV = superior oblique (down and in). CN III = all other EOMs.
17. A patient with a history of heavy alcohol use has ataxia, ophthalmoplegia, and confusion. This triad is classic for:
A) Wernicke’s encephalopathy
B) Korsakoff syndrome
C) Cerebellar degeneration
D) Hepatic encephalopathy
Correct Answer: A) Wernicke’s encephalopathy
Rationale: Wernicke’s = confusion + ataxia + ophthalmoplegia (thiamine deficiency). Korsakoff = memory loss.
18. Which finding is most suggestive of normal pressure hydrocephalus (NPH)?
A) Tremor, rigidity, bradykinesia
B) Cognitive decline, urinary incontinence, magnetic gait
C) Asymmetric weakness, hyperreflexia, Babinski
D) Monocular vision loss
Correct Answer: B) Cognitive decline, urinary incontinence, magnetic gait
head-to-toe focus, and clinical documentation emphasis. Each question includes a correct
answer and rationale.
Title: Advanced Clinical Judgment in Systematic Health Assessment: Differentiating Subtle
Abnormalities, Recognizing Geriatric & Cultural Variations, and Prioritizing
Documentation for Safe Nursing Practice
Section 1: Neurological & Cranial Nerve Assessment (Questions 1–20)
1. A 74-year-old patient has a new onset of unilateral neglect, where they ignore the left side of their body and
environment. They deny any problem. This is most consistent with a lesion in the:
A) Right parietal lobe
B) Left frontal lobe
C) Brainstem reticular formation
D) Cerebellar vermis
Correct Answer: A) Right parietal lobe
Rationale: Unilateral neglect (usually left-sided) occurs with right parietal (non-dominant hemisphere) lesions, often
after stroke. Anosognosia = denial of deficit.
2. During assessment of cranial nerve XI (spinal accessory), you ask the patient to shrug their shoulders against
resistance. Weakness on the right side with leftward head turning suggests:
A) Right CN XI lesion
B) Left CN XI lesion
C) Cervical myelopathy
D) Myasthenia gravis
Correct Answer: A) Right CN XI lesion
Rationale: CN XI innervates trapezius (shoulder shrug) and sternocleidomastoid (head turn to opposite side). Right
CN XI lesion → weak right shoulder shrug + weak left head turn.
3. A patient has ptosis, miosis, anhidrosis, and apparent enophthalmos on the right eye. This constellation is called:
A) Horner’s syndrome
B) Third nerve palsy
C) Myasthenia gravis
D) Miller Fisher syndrome
Correct Answer: A) Horner’s syndrome
Rationale: Horner’s = sympathetic chain disruption (ptosis, miosis, anhidrosis). Enophthalmos is often apparent due
to ptosis.
4. When testing plantar reflex, the great toe extends and the other toes fan. The nurse should document:
A) Normal plantar reflex
B) Babinski sign present (positive)
,C) Withdrawal response
D) Hoffman’s sign
Correct Answer: B) Babinski sign present (positive)
Rationale: Extensor plantar response (Babinski) = upper motor neuron lesion. Normal = flexor (toes curl down).
5. A patient with multiple sclerosis has a tremor that occurs during goal-directed movement (e.g., finger-to-nose). This
is best described as:
A) Resting tremor
B) Postural tremor
C) Intention tremor
D) Flapping tremor (asterixis)
Correct Answer: C) Intention tremor
Rationale: Cerebellar lesion (MS) → intention tremor (worsens as target approached). Resting = Parkinson’s.
Asterixis = metabolic encephalopathy.
6. On Glasgow Coma Scale, the patient opens eyes to speech, uses inappropriate words, and withdraws to pain. The
score is:
A) 10 (E3, V3, M4)
B) 11 (E3, V3, M5)
C) 12 (E4, V3, M5)
D) 9 (E2, V3, M4)
Correct Answer: B) 11 (E3, V3, M5)
Rationale: Eye to speech = 3; Inappropriate words = 3; Withdraws to pain = 4? Wait – correction: Withdrawal = 4,
Localizes = 5. The scenario says withdraws = M4. Total = 3+3+4 = 10. Actually recalc: Eye to speech = 3; Inappropriate = 3;
Withdrawal = 4 → total 10. Answer would be A) 10. Corrected answer: A) 10 (E3 V3 M4).
7. A patient has loss of vibration sense at the great toe, but pain and temperature are intact. This suggests a lesion in
the:
A) Spinothalamic tract
B) Dorsal column (medial lemniscus)
C) Anterior horn cell
D) Corticospinal tract
Correct Answer: B) Dorsal column (medial lemniscus)
Rationale: Dorsal columns = fine touch, vibration, proprioception. Spinothalamic = pain/temp. Dissociated sensory
loss = cord lesion.
8. Which finding differentiates a psychogenic tremor from an organic tremor?
A) Tremor worsens with distraction
B) Tremor improves with concentration
C) Tremor stops when the patient is distracted and restarts when asked to perform a task
D) Tremor is present at rest and during sleep
Correct Answer: C) Tremor stops when distracted and restarts when asked to perform a task
,Rationale: Psychogenic tremor = entrainment, variability, improvement with distraction. Organic tremor is present
regardless.
9. A patient cannot perform rapid alternating hand movements (dysdiadochokinesia). This localizes to the:
A) Basal ganglia
B) Cerebellum
C) Frontal lobe
D) Parietal lobe
Correct Answer: B) Cerebellum
Rationale: Dysdiadochokinesia = cerebellar dysfunction. Rapid alternating movements test cerebellar coordination.
10. On examination of the pupils, the left pupil is 4 mm and the right is 2 mm in room light. Both constrict briskly to
light. This is:
A) Horner’s syndrome (right)
B) Physiologic anisocoria
C) Third nerve palsy (left)
D) Adie’s tonic pupil
Correct Answer: B) Physiologic anisocoria
Rationale: Physiologic anisocoria (up to 1 mm difference) → equal and brisk reaction. Horner’s = smaller pupil with
dilation lag. Adie’s = tonic reaction.
11. A patient has a wide-based, unsteady gait that does not improve with visual input. This is most consistent with:
A) Sensory ataxia (dorsal column)
B) Cerebellar ataxia
C) Vestibular ataxia
D) Frontal gait disorder
Correct Answer: B) Cerebellar ataxia
Rationale: Cerebellar ataxia = wide-based, irregular, does NOT improve with vision. Sensory ataxia improves with
visual input (Romberg positive).
12. On muscle strength testing, you grade a patient’s right arm as 3/5. This means:
A) No movement
B) Movement against gravity but not against resistance
C) Full strength
D) Movement only with gravity eliminated
Correct Answer: B) Movement against gravity but not against resistance
Rationale: 5/5 = normal; 4/5 = against some resistance; 3/5 = against gravity only; 2/5 = gravity eliminated; 1/5 =
flicker; 0 = none.
13. A patient has a unilateral, painless, fixed, dilated pupil. The most likely cause is:
A) Pharmacologic dilation (anticholinergic)
B) Third nerve compression (aneurysm)
C) Traumatic mydriasis
D) Adie’s pupil
, Correct Answer: A) Pharmacologic dilation (anticholinergic)
Rationale: Fixed, dilated pupil without ptosis or diplopia = topical anticholinergic (e.g., scopolamine patch) until
proven otherwise. CN III palsy = ptosis, “down and out.”
14. Which reflex is mediated by the S1 spinal nerve root?
A) Biceps (C5-C6)
B) Patellar (L2-L4)
C) Achilles (S1-S2)
D) Brachioradialis (C5-C6)
Correct Answer: C) Achilles (S1-S2)
Rationale: Achilles reflex tests S1 (and S2). Loss of ankle jerk is early sign of peripheral neuropathy (diabetes).
15. A patient has a positive Hoffman’s sign. This indicates:
A) Lower motor neuron disease
B) Upper motor neuron lesion above C6
C) Peripheral neuropathy
D) Myopathy
Correct Answer: B) Upper motor neuron lesion above C6
Rationale: Hoffman’s = hyperreflexia variant (flicking middle finger causes thumb/index flexion) → UMN lesion
(cervical myelopathy).
16. On assessment of extraocular movements, the left eye cannot move laterally. Which cranial nerve is involved?
A) CN III (oculomotor)
B) CN IV (trochlear)
C) CN VI (abducens)
D) CN II (optic)
Correct Answer: C) CN VI (abducens)
Rationale: CN VI → lateral rectus → abduction. CN IV = superior oblique (down and in). CN III = all other EOMs.
17. A patient with a history of heavy alcohol use has ataxia, ophthalmoplegia, and confusion. This triad is classic for:
A) Wernicke’s encephalopathy
B) Korsakoff syndrome
C) Cerebellar degeneration
D) Hepatic encephalopathy
Correct Answer: A) Wernicke’s encephalopathy
Rationale: Wernicke’s = confusion + ataxia + ophthalmoplegia (thiamine deficiency). Korsakoff = memory loss.
18. Which finding is most suggestive of normal pressure hydrocephalus (NPH)?
A) Tremor, rigidity, bradykinesia
B) Cognitive decline, urinary incontinence, magnetic gait
C) Asymmetric weakness, hyperreflexia, Babinski
D) Monocular vision loss
Correct Answer: B) Cognitive decline, urinary incontinence, magnetic gait
