Ati health assessment exam 2 – questions with 100% correct
answers | complete nursing practice test material
SECTION I — HEAD, FACE, EYES, EARS, NOSE & THROAT
1. A nurse is assessing a client's cranial nerve II function. Which
assessment should the nurse perform?
A. Ask the client to smile
B. Test visual acuity
C. Ask the client to shrug the shoulders
D. Assess the gag reflex
ANSWER: B
RATIONALE: Cranial nerve II, the optic nerve, is responsible for vision
and is assessed through visual acuity and visual-field testing.
2. A client has an impairment of cranial nerve II. Which intervention is
most appropriate for promoting safety?
A. Encourage the client to ambulate independently
B. Provide an obstacle-free environment
C. Keep the room dark at all times
D. Limit oral fluid intake
ANSWER: B
RATIONALE: Impaired vision increases the risk of falls, so removing
environmental obstacles promotes safe mobility.
,3. Which cranial nerve is assessed when the nurse asks a client to
smile and show their teeth?
A. CN V
B. CN VII
C. CN IX
D. CN XII
ANSWER: B
RATIONALE: The facial nerve (CN VII) controls muscles of facial
expression.
4. Which finding indicates an abnormal pupillary response?
A. Pupils equal in size
B. Pupils constrict in response to light
C. Pupils react briskly and equally
D. One pupil remains dilated when exposed to light
ANSWER: D
RATIONALE: Unequal or nonreactive pupils can indicate neurologic or
ocular pathology and require further evaluation.
5. The nurse shines a light into the client's right eye. Which response
is expected?
A. Both pupils constrict
B. Only the left pupil constricts
C. Both pupils dilate
D. Neither pupil changes
ANSWER: A
,RATIONALE: The direct and consensual pupillary light reflex causes
both pupils to constrict when one eye is illuminated.
6. Which finding is most concerning when assessing the client's eyes?
A. Symmetric eyebrows
B. Clear conjunctiva
C. Sudden loss of vision
D. PERRLA
ANSWER: C
RATIONALE: Sudden vision loss may indicate a serious vascular,
neurologic, or ophthalmic emergency.
7. A nurse observes a drooping upper eyelid covering part of the pupil.
How should this finding be documented?
A. Strabismus
B. Ptosis
C. Nystagmus
D. Diplopia
ANSWER: B
RATIONALE: Ptosis is drooping of the upper eyelid and may occur with
neurologic or muscular disorders.
8. Which finding is characteristic of nystagmus?
A. Inability to hear high-frequency sounds
B. Involuntary rhythmic eye movement
, C. Drooping eyelids
D. Unequal pupils
ANSWER: B
RATIONALE: Nystagmus consists of involuntary, repetitive oscillations
of the eyes.
9. Which cranial nerve is primarily responsible for facial sensation?
A. CN II
B. CN V
C. CN VII
D. CN XII
ANSWER: B
RATIONALE: The trigeminal nerve (CN V) provides facial sensation and
controls muscles involved in mastication.
10. Which action assesses cranial nerve V motor function?
A. Ask the client to clench their teeth
B. Ask the client to identify a smell
C. Ask the client to shrug their shoulders
D. Ask the client to protrude the tongue
ANSWER: A
RATIONALE: CN V controls the muscles of mastication, which can be
assessed by asking the client to clench the teeth.
answers | complete nursing practice test material
SECTION I — HEAD, FACE, EYES, EARS, NOSE & THROAT
1. A nurse is assessing a client's cranial nerve II function. Which
assessment should the nurse perform?
A. Ask the client to smile
B. Test visual acuity
C. Ask the client to shrug the shoulders
D. Assess the gag reflex
ANSWER: B
RATIONALE: Cranial nerve II, the optic nerve, is responsible for vision
and is assessed through visual acuity and visual-field testing.
2. A client has an impairment of cranial nerve II. Which intervention is
most appropriate for promoting safety?
A. Encourage the client to ambulate independently
B. Provide an obstacle-free environment
C. Keep the room dark at all times
D. Limit oral fluid intake
ANSWER: B
RATIONALE: Impaired vision increases the risk of falls, so removing
environmental obstacles promotes safe mobility.
,3. Which cranial nerve is assessed when the nurse asks a client to
smile and show their teeth?
A. CN V
B. CN VII
C. CN IX
D. CN XII
ANSWER: B
RATIONALE: The facial nerve (CN VII) controls muscles of facial
expression.
4. Which finding indicates an abnormal pupillary response?
A. Pupils equal in size
B. Pupils constrict in response to light
C. Pupils react briskly and equally
D. One pupil remains dilated when exposed to light
ANSWER: D
RATIONALE: Unequal or nonreactive pupils can indicate neurologic or
ocular pathology and require further evaluation.
5. The nurse shines a light into the client's right eye. Which response
is expected?
A. Both pupils constrict
B. Only the left pupil constricts
C. Both pupils dilate
D. Neither pupil changes
ANSWER: A
,RATIONALE: The direct and consensual pupillary light reflex causes
both pupils to constrict when one eye is illuminated.
6. Which finding is most concerning when assessing the client's eyes?
A. Symmetric eyebrows
B. Clear conjunctiva
C. Sudden loss of vision
D. PERRLA
ANSWER: C
RATIONALE: Sudden vision loss may indicate a serious vascular,
neurologic, or ophthalmic emergency.
7. A nurse observes a drooping upper eyelid covering part of the pupil.
How should this finding be documented?
A. Strabismus
B. Ptosis
C. Nystagmus
D. Diplopia
ANSWER: B
RATIONALE: Ptosis is drooping of the upper eyelid and may occur with
neurologic or muscular disorders.
8. Which finding is characteristic of nystagmus?
A. Inability to hear high-frequency sounds
B. Involuntary rhythmic eye movement
, C. Drooping eyelids
D. Unequal pupils
ANSWER: B
RATIONALE: Nystagmus consists of involuntary, repetitive oscillations
of the eyes.
9. Which cranial nerve is primarily responsible for facial sensation?
A. CN II
B. CN V
C. CN VII
D. CN XII
ANSWER: B
RATIONALE: The trigeminal nerve (CN V) provides facial sensation and
controls muscles involved in mastication.
10. Which action assesses cranial nerve V motor function?
A. Ask the client to clench their teeth
B. Ask the client to identify a smell
C. Ask the client to shrug their shoulders
D. Ask the client to protrude the tongue
ANSWER: A
RATIONALE: CN V controls the muscles of mastication, which can be
assessed by asking the client to clench the teeth.
