CRITICAL CARE NURSING QUESTIONS AND ANSWERS EXAM WITH
QUESTIONS AND CORRECT DETAILED ANSWERS/EXPERT VERIFIED
FOR GUARANTEED PASS!/LATEST UPDATE
Mental Status Q's - CORRECT ANSWERS-What's your name? *person*
What's your mother's name? *other ppl*
What year is it? *time*
Where are you now? *place*
How old are you? *memory*
Where were you born? *remote memory*
What did you have for breakfast? *recent memory*
Who's Pres of the U.S. now? *general knowledge*
Can you count backward from 20 to 1? *Attn span &*
*calculation skills*
Steps to arousal - CORRECT ANSWERS-1. auditory
2. tactile
3. painful
Assess for dysarthria - CORRECT ANSWERS-(=diff forming words)
Ask pt to repeat "no ifs, ands, or buts"
CN I Assess - CORRECT ANSWERS-Check the patency of each nostril. Then instruct the patient
to close his eyes. Occlude one nostril, and hold a familiar, pungent-smelling substance under the
patient's nose and ask him to identify it.
Repeat this with the other nostril.
CN II Assess - CORRECT ANSWERS-Do this by asking the patient to read a newspaper,
starting with large headlines and moving to small print.
,CN III, IV, VI Assess - CORRECT ANSWERS-Check pupil size, pupil shape, and pupillary response
to light. When assessing pupil size, look for trends, such as a gradual increase in the size of one pupil or
appearance of unequal pupils.
Ask the patient to follow your finger through six cardinal positions of gaze. (assess the patient for
nystagmus, or involuntary eye movement,
and the ability to hold gaze in that particular position.)
CN V Assess - CORRECT ANSWERS-Gently touch the right and left sides of the
patient's forehead with a cotton ball while his eyes are closed. Instruct him to tell you the moment the
cotton touches each area. Compare the patient's responses on both sides. Repeat the technique on the
right and left cheek and on the right and left jaw.
Next, repeat the entire procedure using a sharp object, such as the tip of a safety pin. Ask the patient to
describe and compare both sensations.
To assess the motor function, ask the patient to clench his teeth while you palpate his temporal and
masseter muscles.
Corneal reflex.
CN VII Assess - CORRECT ANSWERS-Ask pt to:
• wrinkle his forehead
• raise and lower his eyebrows
• smile to show his teeth
• puff out his cheeks.
Also, with the patient's eyes tightly closed, attempt to open his eyelids. As you conduct each part of this
test, look for symmetry.
,CN VIII Assess - CORRECT ANSWERS-Ask the patient to cover one ear. Then stand on the
opposite side and whisper a few words. Find out whether the patient can repeat what you said. Test the
other ear in the same way.
To test the vestibular portion of the acoustic nerve, observe the patient for nystagmus and disturbed
balance. Note reports of the room spinning or dizzines.
CN IX & X Assess - CORRECT ANSWERS-• The glossopharyngeal nerve is responsible for
swallowing, salivating, and taste perception on the
posterior one-third of the tongue.
• The vagus nerve controls swallowing and is
responsible for voice quality.
Assess these nerves, first, by listening to
the patient's voice.
Then check the gag reflex by touching the tip of a tongue blade against the posterior pharynx and asking
the patient to open wide and say "ah." Watch for the symmetrical upward movement of the soft palate
and uvula and for the midline position of the uvula.
CN XI Assess - CORRECT ANSWERS-Press down on the patient's shoulders while he
attempts to shrug against this resistance. Note shoulder strength and symmetry while inspecting and
palpating the trapezius muscles.
Apply resistance from one side while the patient tries to return his head to midline position.
Look for neck strength. Repeat on the other side.
CN XII Assess - CORRECT ANSWERS-Ask the patient to stick out his tongue. Look for any
deviation from the midline, atrophy, or fasciculations.
Test tongue strength by asking the patient to push his tongue against his cheek as you apply resistance.
Observe the tongue for symmetry.
, Test the patient's speech by asking him to repeat the sentence, "Round the rugged rock that ragged
rascal ran."
Stereognosis - CORRECT ANSWERS-the ability to discriminate the shape, size, weight,
texture, and form of an object by touching and manipulating it
Graphesthesia - CORRECT ANSWERS-ability to identify something by tactile sense (ID drawn
number on pt's hand)
Extinction - CORRECT ANSWERS-the failure to perceive touch on one side
Point localization - CORRECT ANSWERS-have the patient close his eyes, touch one of
his limbs, and then ask where you touched him
2-Point localization - CORRECT ANSWERS-touch the patient simultaneously in two
contralateral areas and note whether he can identify touch on both sides.
Pronator Drift Test - CORRECT ANSWERS-ask the patient to extend both arms, palms up. Have
him close his eyes and maintain this position
for 20 to 30 seconds. Observe the arm for downward drifting and pronation.
Romberg Test - CORRECT ANSWERS-Have the patient stand with his feet
together, arms at his sides, and without support. Note his ability to maintain balance with both eyes
open and then closed. (Stand nearby in case the patient loses his balance.)
A small amount of swaying *normally* occurs when the eyes are closed. If the patient has trouble
maintaining a steady position with eyes open or closed, *cerebellar ataxia* may be present.
Cerebellar Function Tests - CORRECT ANSWERS--Touch his nose and then your outstretched
finger
QUESTIONS AND CORRECT DETAILED ANSWERS/EXPERT VERIFIED
FOR GUARANTEED PASS!/LATEST UPDATE
Mental Status Q's - CORRECT ANSWERS-What's your name? *person*
What's your mother's name? *other ppl*
What year is it? *time*
Where are you now? *place*
How old are you? *memory*
Where were you born? *remote memory*
What did you have for breakfast? *recent memory*
Who's Pres of the U.S. now? *general knowledge*
Can you count backward from 20 to 1? *Attn span &*
*calculation skills*
Steps to arousal - CORRECT ANSWERS-1. auditory
2. tactile
3. painful
Assess for dysarthria - CORRECT ANSWERS-(=diff forming words)
Ask pt to repeat "no ifs, ands, or buts"
CN I Assess - CORRECT ANSWERS-Check the patency of each nostril. Then instruct the patient
to close his eyes. Occlude one nostril, and hold a familiar, pungent-smelling substance under the
patient's nose and ask him to identify it.
Repeat this with the other nostril.
CN II Assess - CORRECT ANSWERS-Do this by asking the patient to read a newspaper,
starting with large headlines and moving to small print.
,CN III, IV, VI Assess - CORRECT ANSWERS-Check pupil size, pupil shape, and pupillary response
to light. When assessing pupil size, look for trends, such as a gradual increase in the size of one pupil or
appearance of unequal pupils.
Ask the patient to follow your finger through six cardinal positions of gaze. (assess the patient for
nystagmus, or involuntary eye movement,
and the ability to hold gaze in that particular position.)
CN V Assess - CORRECT ANSWERS-Gently touch the right and left sides of the
patient's forehead with a cotton ball while his eyes are closed. Instruct him to tell you the moment the
cotton touches each area. Compare the patient's responses on both sides. Repeat the technique on the
right and left cheek and on the right and left jaw.
Next, repeat the entire procedure using a sharp object, such as the tip of a safety pin. Ask the patient to
describe and compare both sensations.
To assess the motor function, ask the patient to clench his teeth while you palpate his temporal and
masseter muscles.
Corneal reflex.
CN VII Assess - CORRECT ANSWERS-Ask pt to:
• wrinkle his forehead
• raise and lower his eyebrows
• smile to show his teeth
• puff out his cheeks.
Also, with the patient's eyes tightly closed, attempt to open his eyelids. As you conduct each part of this
test, look for symmetry.
,CN VIII Assess - CORRECT ANSWERS-Ask the patient to cover one ear. Then stand on the
opposite side and whisper a few words. Find out whether the patient can repeat what you said. Test the
other ear in the same way.
To test the vestibular portion of the acoustic nerve, observe the patient for nystagmus and disturbed
balance. Note reports of the room spinning or dizzines.
CN IX & X Assess - CORRECT ANSWERS-• The glossopharyngeal nerve is responsible for
swallowing, salivating, and taste perception on the
posterior one-third of the tongue.
• The vagus nerve controls swallowing and is
responsible for voice quality.
Assess these nerves, first, by listening to
the patient's voice.
Then check the gag reflex by touching the tip of a tongue blade against the posterior pharynx and asking
the patient to open wide and say "ah." Watch for the symmetrical upward movement of the soft palate
and uvula and for the midline position of the uvula.
CN XI Assess - CORRECT ANSWERS-Press down on the patient's shoulders while he
attempts to shrug against this resistance. Note shoulder strength and symmetry while inspecting and
palpating the trapezius muscles.
Apply resistance from one side while the patient tries to return his head to midline position.
Look for neck strength. Repeat on the other side.
CN XII Assess - CORRECT ANSWERS-Ask the patient to stick out his tongue. Look for any
deviation from the midline, atrophy, or fasciculations.
Test tongue strength by asking the patient to push his tongue against his cheek as you apply resistance.
Observe the tongue for symmetry.
, Test the patient's speech by asking him to repeat the sentence, "Round the rugged rock that ragged
rascal ran."
Stereognosis - CORRECT ANSWERS-the ability to discriminate the shape, size, weight,
texture, and form of an object by touching and manipulating it
Graphesthesia - CORRECT ANSWERS-ability to identify something by tactile sense (ID drawn
number on pt's hand)
Extinction - CORRECT ANSWERS-the failure to perceive touch on one side
Point localization - CORRECT ANSWERS-have the patient close his eyes, touch one of
his limbs, and then ask where you touched him
2-Point localization - CORRECT ANSWERS-touch the patient simultaneously in two
contralateral areas and note whether he can identify touch on both sides.
Pronator Drift Test - CORRECT ANSWERS-ask the patient to extend both arms, palms up. Have
him close his eyes and maintain this position
for 20 to 30 seconds. Observe the arm for downward drifting and pronation.
Romberg Test - CORRECT ANSWERS-Have the patient stand with his feet
together, arms at his sides, and without support. Note his ability to maintain balance with both eyes
open and then closed. (Stand nearby in case the patient loses his balance.)
A small amount of swaying *normally* occurs when the eyes are closed. If the patient has trouble
maintaining a steady position with eyes open or closed, *cerebellar ataxia* may be present.
Cerebellar Function Tests - CORRECT ANSWERS--Touch his nose and then your outstretched
finger
