NR-304 Health Assessment II - Set 4 - Part 2

Correct Answer: In the left cerebellar hemisphere

The cerebellum is the exception to crossed representation, so each hemisphere controls the same side of the body. Left sided ataxia and dysmetria with preserved strength therefore localise to the left cerebellar hemisphere. Option a is incorrect because applying the crossed rule to the cerebellum reverses the answer. Cerebellar signs never cross, so a right hemisphere lesion would throw the client toward the right instead. Option c is incorrect because a motor cortex lesion causes contralateral weakness with increased tone and brisk reflexes. This client moves with full power, which rules the primary motor strip out. Option d is incorrect because internal capsule damage produces a dense hemiparesis on the opposite side, often with sensory loss. Clumsiness without weakness or numbness does not fit that location at all.

Correct Answer: The hypothalamus below the thalamus

The hypothalamus is the master homeostatic controller, holding the body's thermostat along with appetite, thirst, the sleep wake cycle, autonomic outflow and pituitary regulation. Temperature control is its most directly tested function. Option a is incorrect because the medulla houses the vital autonomic centres for respiration, cardiac rate and vasomotor tone, plus cough and swallow reflexes. Thermoregulation is not among the medullary functions. Option b is incorrect because the thalamus relays sensory pathways to the cortex and forms synapses for every modality except smell. Relaying temperature sensation is not the same as setting the body's set point. Option d is incorrect because the pons bridges the cerebrum to the cerebellum and carries two respiratory centres that coordinate with the medulla. It has no role in setting body temperature.

Correct Answer: T10, which maps to the umbilicus

The umbilicus is the key sensory landmark for T10. Identifying the level matters because everything below a cord lesion is affected, and a rising level signals worsening injury that must be reported. Option a is incorrect because the nipple line marks T4, several segments higher than the umbilicus. Charting that level would overstate the extent of the injury and misdirect monitoring of respiratory and sensory status. Option b is incorrect because the lateral heel belongs to S1, far below the abdomen. A sacral landmark cannot describe a band crossing the trunk, and using it would understate how much of the body is involved. Option c is incorrect because L4 is tested at the medial malleolus of the ankle. Lumbar landmarks lie on the leg, so this choice confuses a lower limb dermatome with an abdominal one.

Correct Answer: The oculomotor nerve on the right

The oculomotor nerve lifts the lid, constricts the pupil and moves four of the six eye muscles. With it out, the intact lateral rectus and superior oblique pull the eye down and out beneath a drooping lid. Option a is incorrect because the optic nerve carries the incoming half of the light reflex and nothing else listed here. It never moves a lid, never positions the globe and never constricts a pupil. Option c is incorrect because trochlear damage affects a single muscle and shows itself as vertical double vision with a head tilt. Lid height and pupil size stay entirely normal in that palsy. Option d is incorrect because an abducens lesion leaves the eye turned inward, not outward, and spares both the eyelid and the pupil. Only horizontal diplopia results from loss of the lateral rectus.

Correct Answer: Score eye opening, verbal reply and motor response

The Glasgow Coma Scale has exactly three components, and nothing else contributes to the total. Pupils and vital signs belong to the wider neurologic recheck, not to this scored instrument. Option a is incorrect because pupil reaction feels neurologic and is therefore the distractor students choose most often. It is monitored alongside the scale during a recheck but adds no points to it. Option b is incorrect because the verbal score grades orientation, confusion, inappropriate words, incomprehensible sounds or silence. Blood pressure measures perfusion and changes only late, long after consciousness has already declined. Option d is incorrect because motor scoring asks whether the client obeys a command, localises, withdraws, postures or lies still. Grip strength is a separate muscle test and carries no place on the scale.

Correct Answer: Five, for localising to pain

Reaching toward the stimulus to push the examiner's hand away is purposeful, which defines localising and scores five. Withdrawal, worth four, is a reflexive pull away that never crosses toward the source. Option b is incorrect because withdrawal means the limb simply retracts from the painful spot without any aim. Crossing the midline to remove the examiner's hand is purposeful and belongs one step higher. Option c is incorrect because abnormal flexion describes decorticate rigidity, with arms drawn tightly onto the chest and legs extended. That posture is stereotyped and cannot be directed at a stimulus. Option d is incorrect because a score of six requires the client to follow a spoken instruction such as wiggling the fingers. Here a painful stimulus was needed before any movement occurred.

Correct Answer: The trigeminal nerve on the right

The corneal reflex runs in on the trigeminal nerve and out on the facial nerve. Because the right eye can blink when the left cornea is touched, the motor limb works and the right sensory limb is lost. Option a is incorrect because a right facial lesion would keep the right eye from blinking on every trial. That eye closed normally when the opposite cornea was stimulated, so its motor supply is intact. Option b is incorrect because the left eye blinked during both trials and therefore has a working outgoing pathway. Nothing in the findings implicates movement on that side of the face. Option c is incorrect because stimulation of the left cornea produced a full bilateral blink, proving that sensation entered normally from that side. The failure appeared only after the right cornea was contacted.

Correct Answer: Balance loss and eye changes

The expanded mnemonic adds B for balance, meaning sudden loss of balance, coordination or walking, and E for eyes, meaning sudden blurred or double vision or vision loss. Both point to posterior circulation stroke. Option a is incorrect because face drooping and arm weakness are the original F and A letters, and neither describes the unsteady gait or the bilateral visual blurring this client actually reported. Option b is incorrect because S stands for speech difficulty and T for time to call for help; the client described no slurred or confused speech, and T names an action rather than a symptom. Option d is incorrect because arm weakness and speech difficulty belong to the older four-letter version, which misses roughly one stroke in five arising in the posterior circulation of the brain.

Correct Answer: The right parietal postcentral region

Astereognosis and agraphesthesia are cortical sensory failures localising to the parietal lobe. Because representation is crossed, a left hand deficit points to the right parietal cortex behind the central sulcus. Option a is incorrect because the precentral gyrus is the primary motor cortex and drives voluntary movement of the opposite side. A lesion there weakens the limb instead of blunting object recognition. Option c is incorrect because occipital cortex receives vision relayed from the thalamus, so damage there costs visual fields. This client had the eyes closed throughout, which removes vision from the explanation. Option d is incorrect because the temporal lobe serves primary auditory reception, smell and memory formation. Nothing about hearing or recall was tested here, and touch based recognition is not a temporal function.

Correct Answer: I check the bath water temperature with my foot before stepping in.

Insensate feet cannot judge temperature, so testing bath water with the foot risks a scald that goes unnoticed and becomes an ulcer. Water should be tested with the hand or elbow instead. Option b is incorrect because daily inspection of the soles, using a mirror when the client cannot see them, is exactly the practice that finds blisters and cracks before they become infected wounds. Option c is incorrect because a pebble or a wrinkled seam inside a shoe cannot be felt by a numb foot, so checking inside footwear each time prevents a pressure injury the client would never notice. Option d is incorrect because walking barefoot exposes the feet to cuts and burns that will not be felt, and keeping them covered indoors is correct protective behaviour for a client with lost sensation.

Correct Answer: Cogwheel rigidity of the wrist joint

Cogwheeling is a ratchety, stop-start resistance superimposed on passive motion and is felt most easily at the wrist. It is the rigidity characteristic of Parkinson disease and arises from extrapyramidal basal ganglia dysfunction. Option a is incorrect because spasticity only appears when the limb is moved quickly and often ends in a sudden clasp-knife release. The resistance here is present at slow speed and repeats rhythmically instead. Option b is incorrect because paratonia is an apparent voluntary opposition to the examiner seen in diffuse cerebral disease such as advanced dementia. Nothing suggests the client is resisting on purpose, and the catch is mechanical and repetitive. Option d is incorrect because flaccid hypotonia means the limb feels limp and offers less resistance than normal, falling when released. This client offers increased resistance, which places the problem in a central rather than peripheral pathway.

Correct Answer: The two numbers belong to different instruments

Neither convention is wrong. The Glasgow Coma Scale is a fixed validated tool whose verbal five means person, place and time, while this course's general documentation adds situation as a fourth sphere. Option b is incorrect because the four sphere entry is exactly what this course models in its general survey and neurologic rows. Calling correct charting an error would teach the student to drop a sphere. Option c is incorrect because the scale's verbal criteria have not been rewritten to include situation. Adding a sphere to a scored instrument would change what its published totals mean and break comparison. Option d is incorrect because age has nothing to do with the difference. Adults are routinely charted to person, place, time and situation, and the fourth sphere asks why they are here.

Correct Answer: The facial nerve on the left is impaired

Sensation enters normally from both corneas because each touch produces a blink somewhere. The left eye never closes regardless of which side is stimulated, which places the fault in the outgoing facial nerve on the left. Option a is incorrect because touching the left cornea did generate a response, proving the sensory limb on that side conducts. A trigeminal failure would produce no blink in either eye from that stimulus. Option c is incorrect because stimulating the right cornea also produced a blink, so sensation reached the brainstem from the right side too. Neither trial showed the total absence that marks a sensory block. Option d is incorrect because the right eye closed on every trial and therefore carries a working motor command. Blinking on both stimulations rules out any weakness of facial movement on that side.

Correct Answer: The response is normal at this age

The corticospinal tract is not yet myelinated in infancy, so dorsiflexion of the great toe with fanning is the expected plantar response until about twenty-four months of age. After that it is abnormal. Option a is incorrect because a cord injury in a newborn would show flaccid limbs, absent movement and abnormal tone, not an isolated toe response that every healthy infant of this age produces. Option b is incorrect because referral is warranted when a primitive response persists past its expected age or when responses are asymmetric, and neither applies to a four-week-old infant with this finding. Option c is incorrect because toes that curl downward are the mature pattern charted as a present plantar reflex in adults and older children; expecting it in a newborn reverses the developmental sequence.

Correct Answer: That rooting response normally fades at three to four months.

Rooting is elicited by brushing the cheek near the mouth and normally disappears at three to four months as the maturing cortex inhibits the primitive circuits. Persistence beyond the expected age suggests a central nervous system problem. Option a is incorrect because rooting is present from birth and remains normal through the first months; telling this parent it should already be gone would create alarm about a perfectly ordinary finding. Option b is incorrect because ten to twelve months is the timetable for sucking, which outlasts rooting; giving that figure for the cheek response would leave the parent expecting it far too long. Option d is incorrect because the second year belongs to the infant plantar response, which stays extensor until about twenty-four months; a rooting reflex still active then would signal a neurologic concern.

Correct Answer: The slowed response compared with the earlier check

Consciousness samples the whole brain at once, so a slower response is the earliest sign of rising pressure. Headache and projectile vomiting are early too, but the change in responsiveness outranks them and demands reporting. Option a is incorrect because a headache that is worse in the morning or with straining is a genuine early feature, yet it is subjective and does not measure how much brain function has been lost. Option c is incorrect because vomiting without preceding nausea does reflect medullary stimulation and should be charted, but a single episode carries less weight than a documented decline in the client's responsiveness. Option d is incorrect because vital signs stay normal during the compensated phase, so numbers in the usual range are falsely reassuring; the Cushing triad appears only after compensation has already failed.

Correct Answer: Parkinson disease with its cardinal signs

The four cardinal signs of Parkinson disease are a resting pill-rolling tremor, cogwheel rigidity, bradykinesia producing masked facies and shuffling steps, and postural instability with a high fall risk. This client shows them. Option b is incorrect because cerebellar disease produces a wide based unsteady gait, an intention tremor that worsens near a target, and scanning speech, none of which matches a tremor present at rest. Option c is incorrect because essential tremor appears with action or sustained posture, often involves the head and voice, and carries no rigidity, masked face or shuffling gait alongside it. Option d is incorrect because multiple sclerosis usually begins between twenty and forty years of age and presents with scattered findings such as optic neuritis, numbness and fatigue rather than this movement pattern.

Correct Answer: Conductive loss in the left ear

Weber lateralizing to the poorer ear together with bone conduction exceeding air conduction in that ear defines a conductive loss. The blocked air route is bypassed by bone, and room noise no longer masks the ear. Option a is incorrect because a sensorineural loss sends the Weber tone toward the better ear. It also leaves air conduction louder than bone conduction, which is the opposite of what this client shows. Option b is incorrect because the whispered voice screen failed on the left, so the right ear is the healthier one. Nothing in the tuning fork results places any deficit on the right side. Option c is incorrect because both tuning fork findings point at the left ear rather than the right. Lateralization toward a blocked ear and a reversed Rinne occur on the same side as the problem.

Correct Answer: Guillain-Barre syndrome following infection

Ascending weakness that starts in the feet days to weeks after a respiratory or gastrointestinal infection, with diminished or absent reflexes, is the signature of Guillain-Barre syndrome. Respiratory failure is the principal threat. Option a is incorrect because myasthenia gravis descends, beginning with ptosis and double vision before bulbar and limb muscles, and it leaves reflexes and sensation entirely normal because the fault lies at the neuromuscular junction. Option b is incorrect because multiple sclerosis attacks central myelin and produces scattered deficits separated in time and place, often with brisk reflexes, instead of a symmetric climb from the feet over a few days. Option d is incorrect because motor neuron disease combines wasting and fasciculations with spasticity and brisk reflexes, spares sensation completely, and advances over months rather than following an infection within days.

Correct Answer: I will move him somewhere quiet and ask again

The mental status examination assumes the person can hear, see and attend. Before labelling anyone confused the nurse removes background noise, faces the client, speaks in a lower pitch and repeats the questions. Option a is incorrect because charting a client as confused when the barrier was hearing records a finding that does not exist. That error follows him through the record and shapes later care decisions. Option c is incorrect because having a family member answer replaces the assessment rather than completing it. The nurse still has no information about what this client knows or how well he attends. Option d is incorrect because declaring mental status unreliable abandons the examination instead of fixing a correctable obstacle. Sensory barriers are removed first, and only then does an abnormal result mean anything.