NCLEX-RN EXAMINATION- HEALTH ASSESSMENT-QUESTIONS WITH
100% CORRECT ANSWERS 2025 UPDATE GRADED A+
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: 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: 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: 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: 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: 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
100% CORRECT ANSWERS 2025 UPDATE GRADED A+
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: 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: 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: 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: 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: 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
