NUR306 COMPLETE PREP U BASED
QUESTIONS AND ANSWERS
When explaining how the nurse would test graphesthesia, which of the following would the nurse
include? - ANS-✅Client will close the eyes and identify what number the nurse writes in the palm of the
client's hand with a blunt-ended object
Which of the following would lead the nurse to suspect meningeal irritation? - ANS-✅Pain and flexion
of the hips and knees with neck flexion
Which of the following is usually the first sign of neurological deterioration? - ANS-✅Altered mentation
and decreasing level of consciousness
A patient is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would
be most appropriate to test? - ANS-✅patellar
After testing deep tendon reflexes, the nurse documents 2+. The nurse should evaluate further. - ANS-
✅False
A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. What would
the nurse do? - ANS-✅Ask a client to identify scents.
The nurse is performing the Romberg test as part of a client's focused neurological assessment. What
finding would constitute a positive Romberg test? - ANS-✅The client moves her feet apart to prevent
herself from falling
During assessment, the nurse notes the client has limited movement of his lower extremities and sways
when standing with feet together. The nurse identifies that the client is at risk for what? - ANS-✅Falls
The Glasgow Coma Scale measures the level of consciousness in clients who are at high risk for rapid
deterioration of the nervous system. A score of 13 indicates - ANS-✅some impairment.
The nurse is planning to test position sensation in an adult female client. To perform this procedure, the
nurse should ask the client to close her eyes while the nurse moves the client's - ANS-✅toes up or
down.
When reviewing the neural pathways, a group of students identify which of the following as sensations
that travel via the spinothalamic tract. Select all that apply.
A) Pain
B) Temperature
C) Position
D) Vibration
E) Light touch - ANS-✅Light touch
Temperature
Pain
The nurse walks into a client's room and finds that the client is disoriented to time and place but is
awake and responsive. What term best describes this patient? - ANS-✅Confused
When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as
being at highest risk? - ANS-✅68-year-old African American male with hypertension
The nurse plans to test which cranial nerve when testing an elderly patient's hearing status? - ANS-✅VIII
What is the level of the spinal cord associated with the knee (patellar) deep tendon reflex? - ANS-✅L2
to L4
Which tests are appropriate for a nurse to perform to test cranial nerve VIII? - ANS-✅Whisper, Rinne,
and Weber tests
Examination of a client's gait reveals that the client is stooped over when walking and that he slowly
shuffles. As well, the client maintains a stiff posture when walking. The nurse should document what
type of gait? - ANS-✅Parkinsonian gait
, The nurse performs a neurological assessment and determines the Glasgow Coma Scale (GCS) score is
15. What is the nurse's best action? - ANS-✅Document the findings.
The nurse is assessing the neurological status of an unconscious client. The nurse should use which
assessment scale? - ANS-✅Glasgow
When assessing deep tendon reflexes in an elderly client what finding would the nurse anticipate? - ANS-
✅Decreased reaction time
Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, sleep, the
anterior and posterior pituitary, the autonomic nervous system, and emotions and maintains overall
autonomic control? - ANS-✅Hypothalamus
The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on
possibly omitting from the exam? - ANS-✅Hop on one foot
What task should a nurse ask a client to perform to assess the function of cranial nerve XI? - ANS-
✅shrug shoulders against resistance
A 48-year-old grocery store manager comes to the clinic complaining of her head being "stuck" to one
side. She says that today she was doing her normal routine when it suddenly felt like her head was being
moved to her left and then it just stuck that way. She says it is somewhat painful because she cannot
move it back to a normal position. She denies any recent neck trauma. Her past medical history consists
of type 2 diabetes and gastroparesis (slow-moving peristalsis in the digestive tract, seen in diabetes). She
is taking oral medication for each. She is married with three children. She denies tobacco, alcohol, or
drug use. Her father has diabetes and her mother passed away from breast cancer. Her children are
healthy. Examination reveals a slightly overweight Hispanic woman appearing her stated age. Her head is
twisted grotesquely to her left; otherwise, her examination is normal. What form of involuntary
movemen - ANS-✅Dystonia
A 21-year-old engineering student comes to your office complaining of leg and back pain and of tripping
when he walks. He states this started 3 months ago with back and buttock pain but has since progressed
to feeling weak in his left leg. He denies any bowel or bladder symptoms. He can think of no specific
traumatic incidences, but he was a defensive lineman in high school and junior college. His past medical
history is unremarkable. He denies tobacco use or alcohol or drug abuse. His parents are both healthy.
On examination he is tender over the lumbar spine and he has a positive straight leg raise on the left. His
Achilles tendon deep reflex is decreased on the left. While watching his gait the nurse notices that the
client has to pick his left foot up high in order not to trip. What abnormality of gait does he most likely
have? - ANS-✅Steppage gait
A client who was injured by a fall at a construction site has been admitted to the hospital. He has
suffered nerve damage such that his gag reflex is no longer intact, requiring him to receive intravenous
total parenteral nutrition. Which nerve should the nurse suspect to be involved in this client's injury? -
ANS-✅Glossopharyngeal (IX)
The nurse is planning to assess a client for graphesthesia. How will the nurse perform this phase of
assessment? - ANS-✅The client will close the eyes and identify what number the nurse writes in the
palm of the client's hand with a blunt-ended object.
The nurse is caring for a client in the hospital and identifies the client to be experiencing acute confusion
after cardiac surgery. The nurse recognizes this as what? - ANS-✅Delirium
The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the - ANS-
✅glossopharyngeal.
A client has sustained an injury to the cerebellum. Which area would be the primary area for
assessment? - ANS-✅Coordination
Which of the following would the nurse most likely expect to find when assessing a client diagnosed with
a frontal lobe contusion following a motor vehicle accident? - ANS-✅Difficulty speaking
QUESTIONS AND ANSWERS
When explaining how the nurse would test graphesthesia, which of the following would the nurse
include? - ANS-✅Client will close the eyes and identify what number the nurse writes in the palm of the
client's hand with a blunt-ended object
Which of the following would lead the nurse to suspect meningeal irritation? - ANS-✅Pain and flexion
of the hips and knees with neck flexion
Which of the following is usually the first sign of neurological deterioration? - ANS-✅Altered mentation
and decreasing level of consciousness
A patient is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would
be most appropriate to test? - ANS-✅patellar
After testing deep tendon reflexes, the nurse documents 2+. The nurse should evaluate further. - ANS-
✅False
A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. What would
the nurse do? - ANS-✅Ask a client to identify scents.
The nurse is performing the Romberg test as part of a client's focused neurological assessment. What
finding would constitute a positive Romberg test? - ANS-✅The client moves her feet apart to prevent
herself from falling
During assessment, the nurse notes the client has limited movement of his lower extremities and sways
when standing with feet together. The nurse identifies that the client is at risk for what? - ANS-✅Falls
The Glasgow Coma Scale measures the level of consciousness in clients who are at high risk for rapid
deterioration of the nervous system. A score of 13 indicates - ANS-✅some impairment.
The nurse is planning to test position sensation in an adult female client. To perform this procedure, the
nurse should ask the client to close her eyes while the nurse moves the client's - ANS-✅toes up or
down.
When reviewing the neural pathways, a group of students identify which of the following as sensations
that travel via the spinothalamic tract. Select all that apply.
A) Pain
B) Temperature
C) Position
D) Vibration
E) Light touch - ANS-✅Light touch
Temperature
Pain
The nurse walks into a client's room and finds that the client is disoriented to time and place but is
awake and responsive. What term best describes this patient? - ANS-✅Confused
When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as
being at highest risk? - ANS-✅68-year-old African American male with hypertension
The nurse plans to test which cranial nerve when testing an elderly patient's hearing status? - ANS-✅VIII
What is the level of the spinal cord associated with the knee (patellar) deep tendon reflex? - ANS-✅L2
to L4
Which tests are appropriate for a nurse to perform to test cranial nerve VIII? - ANS-✅Whisper, Rinne,
and Weber tests
Examination of a client's gait reveals that the client is stooped over when walking and that he slowly
shuffles. As well, the client maintains a stiff posture when walking. The nurse should document what
type of gait? - ANS-✅Parkinsonian gait
, The nurse performs a neurological assessment and determines the Glasgow Coma Scale (GCS) score is
15. What is the nurse's best action? - ANS-✅Document the findings.
The nurse is assessing the neurological status of an unconscious client. The nurse should use which
assessment scale? - ANS-✅Glasgow
When assessing deep tendon reflexes in an elderly client what finding would the nurse anticipate? - ANS-
✅Decreased reaction time
Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, sleep, the
anterior and posterior pituitary, the autonomic nervous system, and emotions and maintains overall
autonomic control? - ANS-✅Hypothalamus
The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on
possibly omitting from the exam? - ANS-✅Hop on one foot
What task should a nurse ask a client to perform to assess the function of cranial nerve XI? - ANS-
✅shrug shoulders against resistance
A 48-year-old grocery store manager comes to the clinic complaining of her head being "stuck" to one
side. She says that today she was doing her normal routine when it suddenly felt like her head was being
moved to her left and then it just stuck that way. She says it is somewhat painful because she cannot
move it back to a normal position. She denies any recent neck trauma. Her past medical history consists
of type 2 diabetes and gastroparesis (slow-moving peristalsis in the digestive tract, seen in diabetes). She
is taking oral medication for each. She is married with three children. She denies tobacco, alcohol, or
drug use. Her father has diabetes and her mother passed away from breast cancer. Her children are
healthy. Examination reveals a slightly overweight Hispanic woman appearing her stated age. Her head is
twisted grotesquely to her left; otherwise, her examination is normal. What form of involuntary
movemen - ANS-✅Dystonia
A 21-year-old engineering student comes to your office complaining of leg and back pain and of tripping
when he walks. He states this started 3 months ago with back and buttock pain but has since progressed
to feeling weak in his left leg. He denies any bowel or bladder symptoms. He can think of no specific
traumatic incidences, but he was a defensive lineman in high school and junior college. His past medical
history is unremarkable. He denies tobacco use or alcohol or drug abuse. His parents are both healthy.
On examination he is tender over the lumbar spine and he has a positive straight leg raise on the left. His
Achilles tendon deep reflex is decreased on the left. While watching his gait the nurse notices that the
client has to pick his left foot up high in order not to trip. What abnormality of gait does he most likely
have? - ANS-✅Steppage gait
A client who was injured by a fall at a construction site has been admitted to the hospital. He has
suffered nerve damage such that his gag reflex is no longer intact, requiring him to receive intravenous
total parenteral nutrition. Which nerve should the nurse suspect to be involved in this client's injury? -
ANS-✅Glossopharyngeal (IX)
The nurse is planning to assess a client for graphesthesia. How will the nurse perform this phase of
assessment? - ANS-✅The client will close the eyes and identify what number the nurse writes in the
palm of the client's hand with a blunt-ended object.
The nurse is caring for a client in the hospital and identifies the client to be experiencing acute confusion
after cardiac surgery. The nurse recognizes this as what? - ANS-✅Delirium
The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the - ANS-
✅glossopharyngeal.
A client has sustained an injury to the cerebellum. Which area would be the primary area for
assessment? - ANS-✅Coordination
Which of the following would the nurse most likely expect to find when assessing a client diagnosed with
a frontal lobe contusion following a motor vehicle accident? - ANS-✅Difficulty speaking
