CPA 4 Quizizz
What is the Glasco Coma Scale: Spontaneous eye-opening, verbal confusion, flexion withdrawal to pain. • 12 • 15 • 8 • 10
• 12
The nurse assesses the patient's deep tendon reflexes to be very brisk and hyperactive, with clonus. Which grade would the nurse enter in the patient's medical record? • 1+ • 2+ • 3+ • 4+
• 4+
What is the Glasco Coma Scale: No eye-opening, incomprehensible speech, extension abnormal posturing. • 5 • 8 • 10 • 3
• 5
The nurse is assessing the neurologic status of a client. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the client's toes fan out, and the big toe shows dorsiflexion. The nurse recognizes this as which of the following? Select all that apply. • Abnormal reflex for adults • Normal reflex for adults • Positive Achilles reflex • Positive Babinski sign
• Abnormal reflex for adults • Positive Babinski sign
Which of the following is an appropriate location for eliciting deep tendon reflexes? • Achilles • Posterior tibial • Popliteal • Dorsalis pedis
• Achilles
Which reflex is the nurse assessing? (hitting the back on the ankle) • Biceps • Patellar • Plantar • Achilles
• Achilles
To test for gross motor skill and coordination of a 6-year-old, which of the following techniques would be appropriate? • Ask child to hop on one foot. • Have the child stand on his head. • Have child touch finger to his nose. • Have the child make "funny" faces at the nurse.
• Ask child to hop on one foot.
During the history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." In doing the assessment of his sensory system, the nurse would do which of the following? • The nurse would not do this part of the examination because results would not be valid. • The nurse would perform the tests, knowing that mental status does not effect sensory ability. • The nurse would proceed with the explanations of each test, making sure the wife understands. • Before testing, the nurse would assess the client's mental status and ability to follow directions at this time
• Before testing, the nurse would assess the client's mental status and ability to follow directions at this time
A patient tells the nurse, "I'd like to go to my room, broom, tomb, loom, doom. I'd like to have dinner now, cow, how, wow." Which thought process abnormality would the patient's speech indicate? • Clanging • Echolalia • Perseveration • Circumstantiality
• Clanging
Which expression is NOT mediated by the Facial nerve? • Smiling • Frowning • Clenching teeth • Grimacing
• Clenching teeth
A 50-year-old woman is in the clinic for "weakness in my left arm and leg for the past week." The nurse will perform which type of neurologic examination? • Glasgow Coma Scale • Neurologic recheck examination • Screening neurologic examination • Complete neurologic examination
• Complete neurologic examination
A client has a seizure & their LOC includes disoriented & impaired thinking. What is this LOC? • Confused • Somnolent • Lethargic • Delirious
• Confused
How would an adult patient normally respond to the plantar reflex? • Flexing the toes • Flexing the elbow • Extending the great toe • Extending the lower leg
• Flexing the toes
Which response to the brachioradialis reflex test is documented as normal? • Extension of the lower leg • Extension of the forearm • Dorsiflexion of the toes • Flexion and supination of the forearm
• Flexion and supination of the forearm
You watch your client's uvula move & elicit a gag reflex to test which 2 cranial nerves? • Glossopharyngeal and Vagus • Vestibulocochlear and Glossopharyngeal • Vagus and Accessory • Hypoglossal and Glossopharyngeal
• Glossopharyngeal and Vagus
Your client closes their eyes & you trace the number "6" in their hand. What is this called? • Kinesthesia • Stereognosis • Graphesthesia • Tardive Dyskinesia
• Graphesthesia
The nurse documents the client has absent light reflex due to glaucoma. Which cranial nerve has this affected? • IV • VII • II • III
• II
The patient tells the nurse, "I want a hamburger on Wednesdays, and went swimming in Paris, love to walk and I can't sing songs. When will I get to sleep?" Which thought process abnormality would the nurse report that the patient is exhibiting? • Flight of ideas • Confabulation • Circumstantiality • Loosening associations
• Loosening associations
During an assessment of the cranial nerves, the nurse finds the following: lack of or inability to stick their tongue out at their computer software that is having problems. This would indicate dysfunction of which of the following cranial nerves? • Motor component of IV • Motor component of XII • Motor and sensory components of XI • Motor component of X and sensory component of VII
• Motor component of XII
Which of the following describes the assessment of the cranial nerve XI? • Uvula and soft palate rise in the midline • Sticks tongue out midline without tremors or deviation • Follows an object with eyes without nystagmus or strabismus • Moves the head against resistance with equal strength
• Moves the head against resistance with equal strength
A 15 year old male comes to the health care provider for a pre-school physical. Based on a past medical history of numerous sports related joint and skeletal injuries, what part of the physical assessment would be more focused? • Neurological assessment • Musculoskeletal assessment • Abdominal assessment • Auditory assessment
• Musculoskeletal assessment
Use the corneal light reflex, cover test & 6 fields of gaze to test which 3 cranial nerves? • Optic, Oculomotor, Abducens • Oculomotor, Trochlear, Abducens • Optic, Oculomotor, Trochlear • Optic, Trochlear, Abducens
• Oculomotor, Trochlear, Abducens
Which cranial nerve would you test by using the Snellen chart? • Optic • Oculomotor • Trochlear • Abducens
• Optic
What signs and symptoms will the nurse observe on a patient who has festinating gait? Select all that apply. • Patient will have difficulty coming to a complete stop. • Patient will have a delayed walk with short, quick, shuffling steps. • Patient will have a staggering wide-based gait. • Patients hips and knees are flex while the body is rigid.
• Patient will have difficulty coming to a complete stop. • Patient will have a delayed walk with short, quick, shuffling steps. • Patients hips and knees are flex while the body is rigid.
Which of the following are abnormal gait patterns? Select all that apply. • Scissors • Festinating • Tandem walking • Cerebellar ataxia
• Scissors • Festinating • Cerebellar ataxia
The nurse is assessing a patient who had a stroke and is unconscious. What will the nurse be able to observe when assessing the pupillary assessment. Select all that apply. • Convergence • Size • Accommodation • Shape
• Size • Shape
The nurse describes the clients gait as short steps, along with dragging of the foot and jerky, uncoordinated, cross-knee movement. What type of gait pattern is this? • Steppage gait • Spastic gait • Festinating gait • Short-leg gait
• Spastic gait
What cranial nerve are the sternomastoid & trapezius controlled by? • Spinal accessory • Hypoglossal • Facial • Vagus
• Spinal accessory
The extension of the client's head against the examiner's hand is a test of: • Cervical spine alignment • Passive range of motion • Sternocleidomastoid muscle strength • Scapular muscle strength.
• Sternocleidomastoid muscle strength
Client is in a sleep-like state, only responding to vigorous stimuli. What is this LOC called? • Lethargic • Comatose • Obtunded • Stuporous
• Stuporous
Which cranial nerve test?: The client clenches their teeth, then you push down on the jaw. • Trigeminal • Facial • Glossopharyngeal • Hypoglossal
• Trigeminal
Which of the following signs and symptoms are associated with a stroke? • Unrelieved bounding headache • Decrease attention span • Cluttered mind • Increased thirst
• Unrelieved bounding headache
The nurse suspects damage to which cranial nerve in a patient who has an asymmetric smile and is unable to wrinkle the forehead? • II (optic nerve) • III (oculomotor nerve) • VII (facial nerve) • VIII (auditory nerve)
• VII (facial nerve)
The nurse documents tinnitus related to drug toxicity. What cranial nerve has this affected? • II • VIII • X • V
• VIII
Which cranial nerve would you test with the whisper test and normal conversation? • Vestibulocochlear/Acoustic • Glossopharyngeal • Trochlear • Trigeminal
• Vestibulocochlear/Acoustic
A young swimmer comes to the sports clinic complaining of a very sore shoulder. He was running at the pool, slipped on some wet concrete, and tried to catch himself with his outstretched hand. He landed on his outstretched hand and has not been able to move his shoulder since. The nurse suspects: • joint effusion. • tear of meniscus. • adhesive capsulitis. • dislocated shoulder.
• dislocated shoulder.
Which areas of consciousness would a nurse rate while assessing a patient with the Glasgow Coma Scale? Select all that apply. • eye opening • blood pressure • verbal response • motor response
• eye opening • verbal response • motor response
Which test will the nurse ask the client to perform to test cerebellar function? Select all that apply. • finger to nose test • rapid alternating movements • heel to shin test • four unrelated word test
• finger to nose test • rapid alternating movements • heel to shin test
A client tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for the client to move her hand to her mouth, she must perform the following movement: • flexion. • abduction. • adduction. • extension.
• flexion.
The nurse is explaining to a client that there are "shock absorbers" in his back to cushion the spine and to help it move. The nurse is referring to the: • costal facets. • nucleus pulposus. • vertebral foramen. • intervertebral discs.
• intervertebral discs.
The knee joint is the articulation of the femur, the tibia, and the: • fibula. • radius. • patella. • humerus.
• patella.
What position will the nurse document the baby is sleeping on? (sleeping on stomach) • supination • inversion • prone • supine
• prone
When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be: • proximal to distal. • distal to proximal. • posterior to anterior. • anterior to posterior.
• proximal to distal.
A man who has had gout for several years comes to the clinic with a "problem with my toe." On examination, the nurse notes the presence of hard, painless nodules over the great toe; one had burst open with a chalky discharge. This finding is known as: • a callus. • a plantar wart. • tenosynovitis. • tophi.
• tophi.
