NCLEX-RN Health Assessment Review: Key Topics,
Practice Questions, Verified Answers & Clinical
Rotation Insights
The nurse is performing a neurological assessment on a client and notes a positive
Romberg's test. The nurse makes this determination based on which observation?
1.An involuntary rhythmic, rapid, twitching of the eyeballs
2.A dorsiflexion of the great toe with fanning of the other toes
3.A significant sway when the client stands erect with feet together, arms at the side,
and the eyes closed
4.A lack of normal sense of position when the client is unable to return extended fingers
to a point of reference - correct answersCorrect: 3
Rationale: In Romberg's test, the client is asked to stand with the feet together and the
arms at the sides, and to close the eyes and hold the position; normally the client can
maintain posture and balance. A positive Romberg's sign is a vestibular neurological
sign that is found when a client exhibits a loss of balance when closing the eyes. This
may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function.
A lack of normal sense of position coupled with an inability to return extended fingers to
a point of reference is a finding that indicates a problem with coordination. A positive
gaze nystagmus evaluation results in an involuntary rhythmic, rapid twitching of the
eyeballs. A positive Babinski's test results in dorsiflexion of the great toe with fanning of
the other toes; if this occurs in anyone older than 2 years it indicates the presence of
central nervous system disease.
The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations.
On assessment of the client, the nurse should expect to note which finding?
1.Rhythmic respirations with periods of apnea
2.Regular rapid and deep, sustained respirations
3.Totally irregular respiration in rhythm and depth
4.Irregular respirations with pauses at the end of inspiration and expiration - correct
answersCorrect: 1
,Rationale: Cheyne-Stokes respirations are rhythmic respirations with periods of apnea
and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia.
Neurogenic hyperventilation is a regular, rapid and deep, sustained respiration that can
indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are
totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic
respirations are irregular respirations with pauses at the end of inspiration and
expiration and can indicate a dysfunction in the middle or caudal pons.
A client diagnosed with conductive hearing loss asks the nurse to explain the cause of
the hearing problem. The nurse plans to explain to the client that this condition is
caused by which problem?
1.A defect in the cochlea
2.A defect in cranial nerve VIII
3.A physical obstruction to the transmission of sound waves
4.A defect in the sensory fibers that lead to the cerebral cortex - correct
answersCorrect: 3
Rationale: A conductive hearing loss occurs as a result of a physical obstruction to the
transmission of sound waves. A sensorineural hearing loss occurs as a result of a
pathological process in the inner ear, a defect in cranial nerve VIII, or a defect of the
sensory fibers that lead to the cerebral cortex.
While performing a cardiac assessment on a client with an incompetent heart valve, the
nurse auscultates a murmur. The nurse documents the finding and describes the sound
as which?
1.Lub-dub sounds
2.Scratchy, leathery heart noise
3.A blowing or swooshing noise
4.Abrupt, high-pitched snapping noise - correct answersCorrect: 3
Rationale: A heart murmur is an abnormal heart sound and is described as a faint or
loud blowing, swooshing sound with a high, medium, or low pitch. Lub-dub sounds are
normal and represent the S1 (first) heart sound and S2 (second) heart sound,
respectively. A pericardial friction rub is described as a scratchy, leathery heart sound.
A click is described as an abrupt, high-pitched snapping sound
,The nurse is testing the extraocular movements in a client to assess for muscle
weakness in the eyes. The nurse should implement which assessment technique to
assess for muscle weakness in the eye?
1.Test the corneal reflexes.
2.Test the 6 cardinal positions of gaze.
3.Test visual acuity, using a Snellen eye chart.
4.Test sensory function by asking the client to close the eyes and then lightly touching
the forehead, cheeks, and chin. - correct answersCorrect: 2
Rationale: Testing the 6 cardinal positions of gaze (diagnostic positions test) is done to
assess for muscle weakness in the eyes. The client is asked to hold the head steady,
and then to follow movement of an object through the positions of gaze. The client
should follow the object in a parallel manner with the 2 eyes. A Snellen eye chart
assesses visual acuity and cranial nerve II (optic). Testing sensory function by having
the client close his or her eyes and then lightly touching areas of the face and testing
the corneal reflexes assess cranial nerve V (trigeminal).
The nurse is instructing a client how to perform a testicular self-examination (TSE). The
nurse should explain that which is the best time to perform this exam?
1.After a shower or bath
2.While standing to void
3.After having a bowel movement
4.While lying in bed before arising - correct answersCorrect: 1
Rationale: The nurse needs to teach the client how to perform a TSE. The nurse should
instruct the client to perform the exam on the same day each month. The nurse should
also instruct the client that the best time to perform a TSE is after a shower or bath
when the hands are warm and soapy and the scrotum is warm. Palpation is easier and
the client will be better able to identify any abnormalities. The client would stand to
perform the exam, but it would be difficult to perform the exam while voiding. Having a
bowel movement is unrelated to performing a TSE.
The nurse is assessing a client suspected of having meningitis for meningeal irritation
and elicits a positive Brudzinski's sign. Which finding did the nurse observe?
1.The client rigidly extends the arms with pronated forearms and plantar flexion of the
feet.
, 2.The client flexes a leg at the hip and knee and reports pain in the vertebral column
when the leg is extended.
3.The client passively flexes the hip and knee in response to neck flexion and reports
pain in the vertebral column.
4.The client's upper arms are flexed and held tightly to the sides of the body and the
legs are extended and internally rotated. - correct answersCorrect: 3
Rationale: Brudzinski's sign is tested with the client in the supine position. The nurse
flexes the client's head (gently moves the head to the chest), and there should be no
reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed
if the client passively flexes the hip and knee in response to neck flexion and reports
pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is
positive when the client flexes the legs at the hip and knee and complains of pain along
the vertebral column when the leg is extended. Decorticate posturing is abnormal
flexion and is noted when the client's upper arms are flexed and held tightly to the sides
of the body and the legs are extended and internally rotated. Decerebrate posturing is
abnormal extension and occurs when the arms are fully extended, forearms pronated,
wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed.
A client with a diagnosis of asthma is admitted to the hospital with respiratory distress.
Which type of adventitious lung sounds should the nurse expect to hear when
performing a respiratory assessment on this client?
1.Stridor
2.Crackles
3.Wheezes
4.Diminished - correct answersCorrect: 3
Rationale: Asthma is a respiratory disorder characterized by recurring episodes of
dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-
pitched musical sounds heard when air passes through an obstructed or narrowed
lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway
obstruction and often signals a life-threatening emergency. Crackles are produced by
air passing over retained airway secretions or fluid, or the sudden opening of collapsed
airways. Diminished lung sounds are heard over lung tissue where poor oxygen
exchange is occurring.
The clinic nurse prepares to perform a focused assessment on a client who is
complaining of symptoms of a cold, a cough, and lung congestion. Which should the
nurse include for this type of assessment? Select all that apply
Practice Questions, Verified Answers & Clinical
Rotation Insights
The nurse is performing a neurological assessment on a client and notes a positive
Romberg's test. The nurse makes this determination based on which observation?
1.An involuntary rhythmic, rapid, twitching of the eyeballs
2.A dorsiflexion of the great toe with fanning of the other toes
3.A significant sway when the client stands erect with feet together, arms at the side,
and the eyes closed
4.A lack of normal sense of position when the client is unable to return extended fingers
to a point of reference - correct answersCorrect: 3
Rationale: In Romberg's test, the client is asked to stand with the feet together and the
arms at the sides, and to close the eyes and hold the position; normally the client can
maintain posture and balance. A positive Romberg's sign is a vestibular neurological
sign that is found when a client exhibits a loss of balance when closing the eyes. This
may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function.
A lack of normal sense of position coupled with an inability to return extended fingers to
a point of reference is a finding that indicates a problem with coordination. A positive
gaze nystagmus evaluation results in an involuntary rhythmic, rapid twitching of the
eyeballs. A positive Babinski's test results in dorsiflexion of the great toe with fanning of
the other toes; if this occurs in anyone older than 2 years it indicates the presence of
central nervous system disease.
The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations.
On assessment of the client, the nurse should expect to note which finding?
1.Rhythmic respirations with periods of apnea
2.Regular rapid and deep, sustained respirations
3.Totally irregular respiration in rhythm and depth
4.Irregular respirations with pauses at the end of inspiration and expiration - correct
answersCorrect: 1
,Rationale: Cheyne-Stokes respirations are rhythmic respirations with periods of apnea
and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia.
Neurogenic hyperventilation is a regular, rapid and deep, sustained respiration that can
indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are
totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic
respirations are irregular respirations with pauses at the end of inspiration and
expiration and can indicate a dysfunction in the middle or caudal pons.
A client diagnosed with conductive hearing loss asks the nurse to explain the cause of
the hearing problem. The nurse plans to explain to the client that this condition is
caused by which problem?
1.A defect in the cochlea
2.A defect in cranial nerve VIII
3.A physical obstruction to the transmission of sound waves
4.A defect in the sensory fibers that lead to the cerebral cortex - correct
answersCorrect: 3
Rationale: A conductive hearing loss occurs as a result of a physical obstruction to the
transmission of sound waves. A sensorineural hearing loss occurs as a result of a
pathological process in the inner ear, a defect in cranial nerve VIII, or a defect of the
sensory fibers that lead to the cerebral cortex.
While performing a cardiac assessment on a client with an incompetent heart valve, the
nurse auscultates a murmur. The nurse documents the finding and describes the sound
as which?
1.Lub-dub sounds
2.Scratchy, leathery heart noise
3.A blowing or swooshing noise
4.Abrupt, high-pitched snapping noise - correct answersCorrect: 3
Rationale: A heart murmur is an abnormal heart sound and is described as a faint or
loud blowing, swooshing sound with a high, medium, or low pitch. Lub-dub sounds are
normal and represent the S1 (first) heart sound and S2 (second) heart sound,
respectively. A pericardial friction rub is described as a scratchy, leathery heart sound.
A click is described as an abrupt, high-pitched snapping sound
,The nurse is testing the extraocular movements in a client to assess for muscle
weakness in the eyes. The nurse should implement which assessment technique to
assess for muscle weakness in the eye?
1.Test the corneal reflexes.
2.Test the 6 cardinal positions of gaze.
3.Test visual acuity, using a Snellen eye chart.
4.Test sensory function by asking the client to close the eyes and then lightly touching
the forehead, cheeks, and chin. - correct answersCorrect: 2
Rationale: Testing the 6 cardinal positions of gaze (diagnostic positions test) is done to
assess for muscle weakness in the eyes. The client is asked to hold the head steady,
and then to follow movement of an object through the positions of gaze. The client
should follow the object in a parallel manner with the 2 eyes. A Snellen eye chart
assesses visual acuity and cranial nerve II (optic). Testing sensory function by having
the client close his or her eyes and then lightly touching areas of the face and testing
the corneal reflexes assess cranial nerve V (trigeminal).
The nurse is instructing a client how to perform a testicular self-examination (TSE). The
nurse should explain that which is the best time to perform this exam?
1.After a shower or bath
2.While standing to void
3.After having a bowel movement
4.While lying in bed before arising - correct answersCorrect: 1
Rationale: The nurse needs to teach the client how to perform a TSE. The nurse should
instruct the client to perform the exam on the same day each month. The nurse should
also instruct the client that the best time to perform a TSE is after a shower or bath
when the hands are warm and soapy and the scrotum is warm. Palpation is easier and
the client will be better able to identify any abnormalities. The client would stand to
perform the exam, but it would be difficult to perform the exam while voiding. Having a
bowel movement is unrelated to performing a TSE.
The nurse is assessing a client suspected of having meningitis for meningeal irritation
and elicits a positive Brudzinski's sign. Which finding did the nurse observe?
1.The client rigidly extends the arms with pronated forearms and plantar flexion of the
feet.
, 2.The client flexes a leg at the hip and knee and reports pain in the vertebral column
when the leg is extended.
3.The client passively flexes the hip and knee in response to neck flexion and reports
pain in the vertebral column.
4.The client's upper arms are flexed and held tightly to the sides of the body and the
legs are extended and internally rotated. - correct answersCorrect: 3
Rationale: Brudzinski's sign is tested with the client in the supine position. The nurse
flexes the client's head (gently moves the head to the chest), and there should be no
reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed
if the client passively flexes the hip and knee in response to neck flexion and reports
pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is
positive when the client flexes the legs at the hip and knee and complains of pain along
the vertebral column when the leg is extended. Decorticate posturing is abnormal
flexion and is noted when the client's upper arms are flexed and held tightly to the sides
of the body and the legs are extended and internally rotated. Decerebrate posturing is
abnormal extension and occurs when the arms are fully extended, forearms pronated,
wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed.
A client with a diagnosis of asthma is admitted to the hospital with respiratory distress.
Which type of adventitious lung sounds should the nurse expect to hear when
performing a respiratory assessment on this client?
1.Stridor
2.Crackles
3.Wheezes
4.Diminished - correct answersCorrect: 3
Rationale: Asthma is a respiratory disorder characterized by recurring episodes of
dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-
pitched musical sounds heard when air passes through an obstructed or narrowed
lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway
obstruction and often signals a life-threatening emergency. Crackles are produced by
air passing over retained airway secretions or fluid, or the sudden opening of collapsed
airways. Diminished lung sounds are heard over lung tissue where poor oxygen
exchange is occurring.
The clinic nurse prepares to perform a focused assessment on a client who is
complaining of symptoms of a cold, a cough, and lung congestion. Which should the
nurse include for this type of assessment? Select all that apply
