Assess Q&A | Physical Assessment
**1. A nurse is performing a neurological assessment and asks the patient to
identify different scents, such as coffee or peppermint. Which cranial nerve is
being evaluated by this action?**
A) Cranial nerve I (Olfactory)
B) Cranial nerve II (Optic)
C) Cranial nerve V (Trigeminal)
D) Cranial nerve VIII (Acoustic)
Correct Answer: A) Cranial nerve I (Olfactory)
Rationale: Cranial nerve I (Olfactory) is the sensory nerve responsible for the
sense of smell. Asking the patient to identify scents is the standard method
to test its function. Cranial nerve II is tested for visual acuity, Cranial nerve V
for facial sensation, and Cranial nerve VIII for hearing.
**2. When testing the six cardinal directions of gaze, which cranial nerves
are being assessed together?**
A) Cranial nerves I, II, and III
B) Cranial nerves III, IV, and VI
C) Cranial nerves IV, V, and VI
D) Cranial nerves II, IV, and V
Correct Answer: B) Cranial nerves III, IV, and VI
Rationale: The six cardinal directions of gaze assess the extraocular muscles,
which are innervated by cranial nerves III (Oculomotor), IV (Trochlear), and VI
(Abducens). Testing these movements is a critical component of the
neurological assessment.
,**3. While assessing a patient's pupillary light reflex, the nurse notes that
both pupils constrict when a light is shone into the right eye. How should the
nurse document this response?**
A) Direct light reflex present, consensual light reflex absent
B) Direct light reflex absent, consensual light reflex present
C) Both direct and consensual light reflexes are present
D) Neither direct nor consensual light reflex is present
Correct Answer: C) Both direct and consensual light reflexes are present
Rationale: The right pupil constricting when light is shone in the right eye is
the direct reflex. The left pupil also constricting is the consensual reflex. This
indicates that the afferent and efferent pathways for both eyes are intact.
**4. A nurse is assessing a patient's hearing acuity. After performing the
whisper test, the patient is unable to repeat the whispered words. To further
evaluate the hearing deficit, the nurse would then perform which test?**
A) Weber test
B) Rinne test
C) Romberg test
D) Snellen test
Correct Answer: B) Rinne test
Rationale: The Rinne test compares air and bone conduction to differentiate
between conductive and sensorineural hearing loss. The Weber test is a
screening test for lateralization, and the Romberg test assesses balance,
which is part of the vestibular system.
,**5. A nurse observes that a patient's tongue deviates to the left when the
patient is asked to stick it out. Which cranial nerve is likely affected?**
A) Cranial nerve IX (Glossopharyngeal)
B) Cranial nerve X (Vagus)
C) Cranial nerve XI (Accessory)
D) Cranial nerve XII (Hypoglossal)
Correct Answer: D) Cranial nerve XII (Hypoglossal)
Rationale: Cranial nerve XII (Hypoglossal) controls the muscles of the tongue.
Damage to this nerve causes the tongue to deviate toward the affected side
upon protrusion. Cranial nerves IX and X control swallowing and the gag
reflex, and XI controls shoulder shrug and head turn.
**6. The nurse asks the patient to swallow. Which two cranial nerves are
being assessed by this action?**
A) Cranial nerves III and IV
B) Cranial nerves V and VII
C) Cranial nerves IX and X
D) Cranial nerves XI and XII
Correct Answer: C) Cranial nerves IX and X
Rationale: The glossopharyngeal nerve (IX) and the vagus nerve (X) work
together to control the muscles of the pharynx and larynx, which are
responsible for swallowing and the gag reflex. Testing the ability to swallow is
a key part of the neurological assessment.
**7. The nurse is testing the strength of a patient's trapezius and
sternocleidomastoid muscles. Which cranial nerve is being assessed?**
, A) Cranial nerve IX (Glossopharyngeal)
B) Cranial nerve X (Vagus)
C) Cranial nerve XI (Accessory)
D) Cranial nerve XII (Hypoglossal)
Correct Answer: C) Cranial nerve XI (Accessory)
Rationale: The spinal accessory nerve (XI) innervates the trapezius and
sternocleidomastoid muscles. Its function is assessed by asking the patient
to shrug their shoulders and turn their head against resistance.
**8. In assessing a patient's facial nerve (CN VII), what action would the
nurse ask the patient to perform?**
A) Clench their teeth
B) Identify a scent
C) Smile and puff out their cheeks
D) Follow a finger with their eyes
Correct Answer: C) Smile and puff out their cheeks
Rationale: Cranial nerve VII (Facial) controls the muscles of facial expression.
Asking the patient to smile, puff out their cheeks, or wrinkle their forehead
assesses the motor function of this nerve.
**9. The nurse is assessing a patient's level of consciousness. Which of the
following questions is the most appropriate to assess orientation?**
A) "Who is the president of the United States?"
B) "What month is it, and where are you right now?"
C) "Can you repeat this sentence back to me?"