NR-304 Health Assessment II - Set 4 - Part 1

Correct Answer: Pupils equal, round, reactive to light and accommodation

PERRLA stands for pupils equal, round, reactive to light and accommodation. It summarizes results rather than naming a procedure, and it says nothing about the consensual response, visual acuity or visual fields. Option a is incorrect because acuity is not part of the abbreviation at all. Sharpness of vision is measured with a Snellen chart, and a client with dense field loss can still have briskly reactive pupils. Option b is incorrect because no letter stands for level. Reordering the terms this way also drops roundness from its proper place and turns the near response into something the wording cannot actually describe. Option d is incorrect because lens adjustment describes only half of the near response, leaving out the pupillary reaction to light. Regular is an accepted reading of the second letter but cannot replace round and reactive together.

Correct Answer: Chart the infant response and report the adult

An extensor plantar response is expected until the corticospinal tract myelinates, roughly to two years of age. In the infant it is a normal finding to chart; in an adult it is a positive Babinski sign requiring report. Option a is incorrect because fanning toes in a four-week-old is one of the normal infantile automatisms and disappears by about two years. Treating it as abnormal alarms the family and wastes follow-up on an expected developmental finding. Option b is incorrect because plantar reflex present describes downward curling of the toes, the normal adult response. Applying that phrase to an upgoing toe hides a corticospinal lesion behind normal-sounding documentation. Option c is incorrect because it reverses the two situations. The immature nervous system explains the infant's upgoing toe, while an adult with the same response has lost the descending inhibition that normally suppresses it.

Correct Answer: A peripheral facial nerve lesion, Bell palsy

Forehead weakness with failure of eye closure marks a lower motor neuron lesion of the facial nerve itself. The palsy is on the same side as the lesion and comes without limb or speech findings. Option a is incorrect because a lesion above the facial nucleus spares the forehead. The upper face keeps a second cortical input from the opposite hemisphere, so brow lifting and eye closure would remain strong. Option b is incorrect because a right-sided brain lesion produces drooping on the left, not the right. Central weakness is contralateral, and it is rarely isolated to the face alone. Option d is incorrect because the trigeminal nerve carries facial sensation and drives chewing rather than expression. Loss there brings numbness and a deviating jaw, not a sagging cheek or an open eye.

Correct Answer: The finding points to a proprioceptive deficit

A positive Romberg means vision was compensating for a deficit elsewhere. Removing it unmasks loss of proprioception in the posterior columns or of vestibular function, and diabetic sensory neuropathy is a classic cause. Option a is incorrect because the Romberg is not designed to assess the cerebellum, and in cerebellar disease it is usually negative. Those clients are already unsteady with the eyes open, so closing them unmasks nothing. Option b is incorrect because unilateral corticospinal weakness is uncovered by pronator drift or by testing strength against resistance. Standing balance depends on sensory input, and this client's legs were strong enough to hold him with vision. Option c is incorrect because only slight swaying is expected once the eyes close. Marked sway, widening of the base or an actual fall is the definition of a positive sign and must be investigated.

Correct Answer: Rising intracranial pressure stretching the abducens nerve

The abducens nerve has a long intradural course and bends sharply over the petrous ridge, so downward displacement of the brainstem stretches it. An isolated sixth nerve palsy is a false localizing sign of raised pressure. Option b is incorrect because a sixth nerve palsy does not point to the site of the lesion. That is precisely why the finding is called false localizing, and the frontal lobe controls neither eye muscle. Option c is incorrect because swelling of the lids does not prevent the globe from turning outward. Worsening headache and vomiting alongside the new deficit point to pressure inside the skull, not to soft tissue. Option d is incorrect because trochlear injury creates vertical, not horizontal, image separation and troubles descending stairs. The described failure is a loss of outward gaze, which belongs to the lateral rectus.

Correct Answer: Assist with ambulation using a gait belt

Assisting a client to walk safely with a gait belt is within the assistive personnel's scope. Testing and grading cerebellar function are assessments that require the nurse's judgment and cannot be delegated. Option a is incorrect because tandem walking is a sensitive cerebellar test and deliberately narrows the base of support. Asking unlicensed staff to perform it both delegates an assessment and exposes an already unsteady client to falling. Option b is incorrect because grading performance requires interpretation of neurologic findings against expected norms. Assistive personnel may report what they observe, but assigning a grade to coordination is a professional nursing judgment. Option d is incorrect because finger-to-nose testing screens fine motor coordination and belongs to the nurse's neurologic examination. Adding it to a bath routine does not change the fact that interpreting the result requires licensed assessment.

Correct Answer: Increased tone, brisk reflexes and upgoing toes

Cutting the upper motor neuron removes descending inhibition, so the unsupervised reflex arc becomes overactive. Tone rises into spasticity, deep tendon reflexes become brisk, and the plantar response turns extensor as a positive Babinski. Option a is incorrect because flaccidity, areflexia and fasciculations are the lower motor neuron picture, seen when the muscle loses its only nerve supply. A stroke damages fibers that never leave the central nervous system. Option b is incorrect because it pairs absent reflexes with early wasting, and both belong to denervation. Reflexes cannot be absent when descending restraint has been lost, and marked early atrophy does not follow stroke. Option c is incorrect because flaccid tone contradicts brisk reflexes in a settled lesion, and clonus is expected rather than absent once spasticity develops. The two halves of this option cancel each other.

Correct Answer: Treat the score as severe injury

The standard bands are mild thirteen to fifteen, moderate nine to twelve and severe three to eight, so a total of eight is severe. That number is also the threshold attached to airway protection. Option a is incorrect because mild injury covers totals of thirteen through fifteen only. A client scoring eight sits at the bottom of the scale and is nowhere near the mild band. Option b is incorrect because thresholds are not averaged, and inventing a number falsifies the record. When a course sentence is quoted verbatim answer it as written, and otherwise apply the standard bands. Option d is incorrect because a low score demands action now rather than later. Waiting for a second measurement in a head injured client wastes the interval during which deterioration can be caught.

Correct Answer: A total score of fifteen

A fully alert normal person scores fifteen, the maximum: four for spontaneous eye opening, five for oriented speech and six for obeying commands. The minimum possible total is three, never zero. Option a is incorrect because ten falls in the moderate band and describes someone with confused speech or an impaired motor reply. A client who is oriented and obeying commands scores far higher. Option c is incorrect because no combination of the three components can exceed fifteen. Eye opening tops out at four, verbal response at five and motor response at six, which is the ceiling. Option d is incorrect because each of the three areas has a floor of one point, so even a completely unresponsive client totals three. Writing a zero on this scale is always an error.

Correct Answer: The medulla oblongata of the brainstem

Respiration is controlled by the medulla, with pontine centres modulating it. The hypothalamus governs temperature, appetite, thirst, sleep, autonomic activity and the pituitary, and no source credits it with a respiratory centre. Option b is incorrect because the study guide statement the student read is simply an error that the same guide contradicts two lines later. Hypothalamic functions are homeostatic and endocrine, not respiratory. Option c is incorrect because the cerebellum coordinates voluntary movement, equilibrium and muscle tone below the level of awareness. Breathing rhythm is generated well below it in the lower brainstem. Option d is incorrect because the midbrain conducts tracts and serves visual and auditory reflexes along with pupil and eye movement control through cranial nerves three and four. Respiratory drive arises lower.

Correct Answer: Summon help and prepare to support ventilation

These findings describe myasthenic crisis, respiratory muscle failure that needs immediate help and ventilatory support. Falling oxygen saturation comes late in neuromuscular failure, so a normal reading must never delay action. Option a is incorrect because rest improves ordinary myasthenic fatigue but cannot reverse a crisis; the client is losing the muscles of breathing, and waiting for a meal time squanders the chance to intervene. Option c is incorrect because saturation measures oxygenation, not the strength of the respiratory pump; vital capacity, cough force and the ability to speak a full sentence fall long before the number drops. Option d is incorrect because a client with bulbar weakness and a weak cough is at high risk of aspiration, so nothing should be given by mouth until swallowing has been assessed as safe.

Correct Answer: Dysdiadochokinesia, a loss of rhythmic alternation

Rapid alternating movements test the cerebellum's ability to switch one muscle group off and the antagonist on in time. Slow, clumsy, arrhythmic performance is dysdiadochokinesia and occurs with cerebellar disease. Option a is incorrect because dysmetria names the inability to control the distance, power and speed of a movement, seen when a client overshoots the examiner's finger. It belongs to finger-to-nose testing, not to hand flipping. Option b is incorrect because astereognosis is the failure to identify a familiar object placed in the hand with the eyes closed. That is a cortical sensory deficit and has nothing to do with movement rhythm. Option c is incorrect because past-pointing is a steady deviation of the reaching finger toward one side, suggesting a unilateral cerebellar or vestibular lesion. Nothing in this task involves reaching toward a target.

Correct Answer: Early peripheral neuropathy affecting large sensory fibers

Vibration and position travel on the largest, most heavily myelinated fibers, which fail first in diabetic neuropathy, so vibration is often the earliest sensation lost while pain on small fibers persists. Option b is incorrect because a parietal lesion leaves the primary modalities intact and shows itself through failed stereognosis, graphesthesia or extinction. Vibration is a primary posterior column modality rather than a cortical interpretive one. Option c is incorrect because the spinothalamic tract carries pain and temperature, and this client identified the sharp point without difficulty. Loss confined to vibration points instead toward the posterior columns and the peripheral nerves feeding them. Option d is incorrect because absent vibration at the toe in a person with diabetes signals neuropathy and a foot at risk for unnoticed injury. Referral and protective foot teaching are needed, not reassurance.

Correct Answer: Notify the provider of the change immediately

A new unilateral fully dilated nonreactive pupil after head injury suggests uncal herniation compressing the oculomotor nerve. This is an emergency, so the nurse alerts the provider or activates rapid response without delay. Option a is incorrect because waiting an hour allows herniation to progress while the client still has a chance of intervention. This finding changes what happens in the next few minutes, not the next check. Option b is incorrect because room lighting does not explain a one-sided failure to react. Both pupils see the same illumination, so dimming the lights only delays the call that this client needs. Option d is incorrect because nothing about a new, one-sided, fixed and widely dilated pupil is ever normal after trauma. Bilateral sluggishness may follow drugs or hypoxia, but a single blown pupil signals compression.

Correct Answer: The left abducens nerve

The lateral rectus is the only muscle the abducens nerve supplies, and abduction is the only movement it produces. An eye that cannot turn outward past midline localizes the deficit to that nerve. Option a is incorrect because the trochlear nerve moves the eye down and inward through the superior oblique. Its failure appears on the down-and-in position of gaze, never on straight lateral movement. Option c is incorrect because oculomotor loss turns the eye outward rather than preventing it, and adds a drooping lid with a widened pupil. This client shows no lid or pupil change. Option d is incorrect because the optic nerve serves sight rather than movement. Drawing the H examines the three eye movers, while acuity and visual fields test the optic nerve instead.

Correct Answer: The occipital lobe of both hemispheres

The occipital lobe is the primary visual receptor centre, so bilateral damage causes cortical blindness. Pupils still react because the pupillary light reflex arc never passes through the visual cortex. Option a is incorrect because frontal damage alters personality, judgment and voluntary motor output, and may take out Broca area. Sight is not processed anywhere in front of the central sulcus. Option b is incorrect because the parietal lobe is the primary centre for sensation and spatial awareness. Bilateral parietal injury would blunt touch, position sense and object recognition rather than abolish sight. Option c is incorrect because the temporal lobe handles primary auditory reception, smell and new memory formation, and it houses Wernicke area. Loss of vision points behind it to the calcarine cortex.

Correct Answer: Retest with the opposite ear occluded

Masking the untested ear prevents the better ear from answering for the weaker one. Without that step the result is invalid, so the nurse repeats the screen with the opposite ear occluded or massaged. Option b is incorrect because charting a conclusion the maneuver could not support repeats the error the technique introduced. A single good ear may have carried both responses, leaving the weaker side untested. Option c is incorrect because referral follows a properly performed screen that actually fails. Sending a client for formal audiometry on the strength of an invalid bedside test wastes time and resources. Option d is incorrect because raising the volume defeats the purpose of a whisper. The examiner should exhale fully first so the whisper stays at the softest reproducible level, and remain out of the line of sight.

Correct Answer: Receptive aphasia from a superior temporal lesion

Fluent output paired with failed comprehension defines receptive or Wernicke aphasia, which arises in the posterior superior temporal gyrus of the dominant hemisphere. Preserved strength fits, because that area lies far from the motor strip. Option a is incorrect because Broca aphasia sounds effortful, halting and telegraphic, and the client understands what is said. This client produces words easily and fails the command, which is the opposite pattern. Option b is incorrect because global aphasia is non fluent as well as uncomprehending, and it almost always brings a dense right hemiplegia. Strong movement in every limb argues against so large a lesion. Option d is incorrect because dysarthria slurs the sounds while word choice and grammar stay correct. Here articulation is clean and the words themselves are wrong, which points to language rather than muscle.

Correct Answer: The thalamus, the sensory relay station

The thalamus is the brain's main relay station, where essentially all sensory pathways form synapses before being forwarded to the appropriate cortical area. A small thalamic lesion therefore removes every modality contralaterally. Option b is incorrect because the hypothalamus governs temperature, appetite, thirst, sleep, autonomic activity and pituitary hormone release. It handles homeostasis rather than passing sensory traffic upward to the cerebral cortex. Option c is incorrect because the cerebellum smooths voluntary movement, equilibrium and muscle tone without initiating any contraction. Its failure produces ataxia, dysmetria and intention tremor on the same side, not sensory loss. Option d is incorrect because the basal ganglia start and modulate movement and control automatic associated movements such as arm swing. Damage there yields Parkinson features or chorea, leaving sensation intact.

Correct Answer: We will come back if one pupil looks larger.

One pupil larger than the other is a danger sign of an expanding bleed and rising intracranial pressure, and it requires emergency evaluation at once. Repeated vomiting, worsening headache and inability to wake are the others. Option a is incorrect because headache is expected after concussion; what signals danger is a headache that steadily worsens and will not go away, not mild soreness on the first evening. Option b is incorrect because return to sport is graded and proceeds only while the teenager stays free of symptoms at each stage; a second injury before recovery carries a far worse outcome. Option c is incorrect because sleeping more than usual is a common concussion symptom; the emergency finding is a teenager who cannot be woken or cannot stay awake once roused.