NR 304/ NR304 (Latest 2025/ 2026 Update) Health Assessment II Review | Questions & Answers

NR 304/ NR304 (Latest 2025/ 2026 Update) Health Assessment II Review | Questions & Answers /.2 point discrimination - Answer-fingertips: 0.3-0.6 cm hands and feet: 1.5-2. cm lower leg: 4 cm /.A client has a flattened nasolabial fold and drooping of the mouth on the left side. Which of the following cranial nerves is most likely to be involved? 1. Cranial nerve V (Trigeminal) 2. Cranial nerve VII (Facial) 3. Cranial nerve XII (Hypoglossal) 4. Cranial nerve XI (Accessory) - Answer-2. Cranial nerve VII (Facial) -Cranial nerve VII (Facial) is responsible for symmetry of facial expressions such as smiling, frowning, and puffing of the cheeks. Cranial nerve V (Trigeminal) is responsible for facial sensation and temporal and masseter muscle strength. Cranial nerve XII (Hypoglossal) is responsible for movements of the tongue and protrusion of the tongue in the midline. Cranial nerve XI (Accessory) is responsible for sternocleidomastoid and trapezius muscle strength. /.A client has a history of anosmia over the past three months. The nurse knows that this condition is: 1. Related to swallowing difficulty 2. Associated with ataxia 3. Difficulty with tongue movements 4. Loss of ability to smell or detect odors - Answer-4. Loss of ability to smell or detect odors -Anosmia, the absence of the sense of smell, may be due to cranial nerve dysfunction, colds, rhinitis, or zinc deficiency, or it may be genetic. Difficulty in swallowing is called dysphagia. Ataxia is an unsteady gait. Difficulty with tongue movements may cause problems with swallowing or speech. /.A client with a head injury is demonstrating dysphagia and dysphasia. Which cranial nerve(s) might be involved with this symptom? Select all that apply. 1. Glossopharyngeal (CN IX) 2. Vagus (CN X) 3. Accessory (CN XI) 4. Facial (CN VII) 5. Trigeminal (CN V) - Answer-1. and 2. -Glossopharyngeal (CN IX) - Produces the gag and swallowing reflexes and taste on the posterior third of the tongue. -Vagus (CN X) - Innervates the muscles of the throat and mouth for swallowing and talking. -Accessory (CN XI) - Is responsible for movement of the trapezius and sternocleidomastoid muscles. -Facial (CN VII) - Is responsible for facial movements such as smiling, closing of the eyes, frowning; production of tears and salivary stimulation, as well as taste on the anterior two thirds of the tongue. -Trigeminal (CN V) - Is responsible for facial sensation and muscle strength of the mandible. /.A client, seen previously for herpes zoster, comes into the clinic with ongoing neurologic changes, pain, and sensory/motor function changes. The nurse realizes that this client might be experiencing: 1. Myasthenia gravis 2. Lyme disease 3. Meningitis 4. Myelitis - Answer-4. Myelitis -Myelitis is an inflammation of the spinal cord. Herpes zoster infection is a common cause. Myasthenia gravis is a chronic neuromuscular disorder involving increasing weakness of voluntary muscles with activity, and some abatement of symptoms with rest. Lyme disease is an infection caused by a bite from an infected deer tick. Major symptoms include arthritis, a flulike syndrome and a rash. Meningitis is caused by a virus or bacteria that infects the meninges of the brain or spinal cord. Headache, fever, and altered levels of consciousness can occur. /.Agnosia - Answer-inability to recognize the forming nature of an object (personal, smell, taste) /.Amyotrophic Lateral Sclerosis ALS - Answer--chronic degenerative disease involving the cerebral cortex and motor neurons in the spinal cord -progressive wasting of skeletal muscles -cause unknown, viral infection? /.An elderly client is experiencing an alteration in his equilibrium and coordinated muscle movements. The nurse realizes that these functions are controlled by which area of the nervous system? 1. Cerebrum 2. Hypothalamus 3. Cerebellum 4. Brainstem - Answer-3. Cerebellum -The cerebellum is located below the cerebrum and behind the brain stem. It coordinates stimuli from the cerebral cortex to provide precise timing for skeletal muscle coordination and smooth movements. The cerebellum also assists with maintaining equilibrium and muscle tone. The cerebrum is responsible for all conscious behavior and consists of the frontal, parietal, occipital, and temporal lobes. The hypothalamus is the autonomic control center and influences blood pressure, heart rate, digestive motility, respirations, regulation of body temperature, water balance, and sleep cycles. The brainstem controls blood pressure, respiratory rate, swallowing, and coughing. /.Analgesia - Answer-absence of pain sensation /.Anethesia - Answer-inability to perceive the sense of touch /.Ansomia - Answer-absence of sense of smell - cranial nerve dysfunction, colds, rhinitis, zinc deficiency unilateral change - sign of brain tumor /.Apraxia - Answer-inability to carry out simple tasks /.Ataxic gait - Answer--wide base, uneven steps, feet slapping, tendency to sway -associated w/ posterior column disease, MS, drug or alcohol intoxication /.Athetoid movement - Answer--continuous, involuntary, repetitive, slow, "wormlike" arrythmic muscular movement -muscles are in state of hypotoxicity producing distortion to the limb -seen in cerebral palsy /.Babinski response - Answer--fanning of the toes with big toe pointing towards dorsum of the foot (dorsiflexion of the toe) -ABNORMAL in adults, normal in children up to age of 2 /.Brain stem - Answer--midbrain, pons, medulla oblongata -between cerebrum and spinal cord -connects pathways between higher and lower structures -10 of 12 cranial nerves originate in brain stem -influences BP by controlling vasoconstriction -regulates RR depth, rhythm, vomiting, hiccuping, swallowing, coughing, sneezing /.Broca - Answer--Aphagia- frontal lobe speech trouble -Expressive aphagia- they can't talk, but they understand /.Brudzinski's sign - Answer--neck flexion causes flexion of legs and thighs -test for meningitis /.Central nervous system CNS - Answer--brain -spinal cord /.Cerebellum - Answer--located below the cerebrum, behind brain stem -coordinates stimuli from cerebral cortex to provide precise timing for skeletal muscle coordination and smooth movements -assists w/ maintaining equilibrium and muscle tone -receives info from inner ear - sends impulse to the muscles - contraction maintains or restores balance /.Cerebral cortex - Answer--outermost portion of brain -gray matter -responsible for conscious behavior -enables person to perceive, remember, communicate and initiation of voluntary movement /.Cerebrum: - Answer-largest portion of brain /.Chronic disease - Answer-hypertension or diabetes can predispose clients to neurological problems /.Clonus - Answer-rhythmically alternating flexion and extension - upper motor neuron disease /.Cortical disease - Answer--inability to identify a familiar object on the skin -inability to perceive a number on the skin -inability to perceive 2 separate points w/in normal distances -inability to identify a touched area /.Cranial nerves - Answer-originate in the brain and serve various parts of head and neck /.Dermatome - Answer-area of skin innervated by the cutaneous branch of one spinal nerve /.Dicenphalon - Answer-composed of: thalmus, hypothalmus, epithalmus /.During an assessment of an adult client's plantar reflex, the nurse notes a normal response. Which of the following would be considered normal for this client? 1. Babinski response 2. Dorsiflexion of the foot 3. Plantar flexion of the foot 4. Fanning of the toes - Answer-3. Plantar flexion of the foot -When assessing the plantar reflex, observe for plantar flexion where the toes curl toward the sole of the foot. The Babinski response is dorsiflexion of the great toe and fanning of the other toes when eliciting the plantar reflex. The Babinski response is considered abnormal in an adult and may indicate upper motor neuron disease. A positive Babinski response is considered a normal response in a child until about 2 years of age. Dorsiflexion of the foot is not a normal plantar reflex response. Fanning of the toes occurs with a positive Babinski.