NEUROLOGIC

Question 1

The nurse is assessing a client’s level of consciousness using the Glasgow Coma Scale (GCS). Which GCS score indicates a comatose state?
A. 15
B. 10
C. 8
D. 3

Answer 1

D. 3
Rationale: The lowest score on the GCS is 3, which indicates deep coma or unresponsiveness. A score of 8 or below usually signals coma and requires immediate attention.

Question 2

The nurse assesses a client’s pupils and finds them to be unequal in size. Which term best describes this finding?
A. Mydriasis
B. Miosis
C. Anisocoria
D. Nystagmus

Answer 2

C. Anisocoria
Rationale: Anisocoria refers to unequal pupil sizes, which can be a normal variant or a sign of neurological damage.

Question 3

Which of the following is a normal finding when assessing deep tendon reflexes (DTRs)?
A. Absent reflexes in all extremities
B. Reflex grade of +2
C. Reflex grade of +4
D. Reflexes only present with reinforcement

Answer 3

B. Reflex grade of +2
Rationale: A DTR score of +2 indicates a normal reflex response.

Question 4

The nurse is performing a cranial nerve assessment. Which test is used to assess cranial nerve VII (facial nerve)?
A. Ask the client to stick out their tongue
B. Have the client shrug their shoulders
C. Ask the client to smile and raise their eyebrows
D. Test the client’s gag reflex

Answer 4

C. Ask the client to smile and raise their eyebrows
Rationale: Cranial nerve VII controls facial expressions, such as smiling, frowning, and raising eyebrows.

Question 5

During a neurological exam, the client is unable to maintain balance with eyes closed and feet together. Which test does this indicate a problem with?
A. Stereognosis
B. Graphesthesia
C. Romberg test
D. Babinski reflex

Answer 5

C. Romberg test
Rationale: A positive Romberg test (loss of balance when eyes are closed) suggests proprioceptive or vestibular dysfunction.

Question 6

Which finding during a neurological assessment is most concerning and requires immediate action?
A. Mild tremor in the hand
B. Difficulty recalling recent events
C. Sudden unilateral pupil dilation
D. Bilateral grip strength 4/5

Answer 6

C. Sudden unilateral pupil dilation
Rationale: A sudden change in pupil size, especially when unilateral, may indicate increased intracranial pressure or brain herniation—a medical emergency.

Question 7

When assessing sensory function, the nurse uses a cotton ball to lightly touch different areas of the client’s skin. What is this testing?
A. Pain perception
B. Temperature discrimination
C. Light touch
D. Vibration sense

Answer 7

C. Light touch
Rationale: A cotton ball is used to assess light touch, part of the sensory portion of the neurological exam.

Question 8

The nurse asks a client to rapidly alternate turning their palms up and down on their thighs. This test assesses which function?
A. Motor strength
B. Sensory integration
C. Coordination and cerebellar function
D. Reflex integrity

Answer 8

C. Coordination and cerebellar function
Rationale: Rapid alternating movements test cerebellar function, specifically coordination.

Question 9

Which of the following is an expected finding when testing the Babinski reflex in an adult?
A. Extension of the big toe
B. Fanning of all toes
C. Flexion of all toes
D. No response

Answer 9

C. Flexion of all toes
Rationale: A normal Babinski response in adults is flexion (downward movement) of the toes. Extension/fanning is abnormal in adults.

Question 10

A nurse is assessing for stereognosis. Which action is appropriate?
A. Ask the client to identify a familiar object placed in their hand with eyes closed
B. Ask the client to follow a finger with their eyes
C. Touch different areas of the skin with a pin
D. Test deep tendon reflexes

Answer 10

A. Ask the client to identify a familiar object placed in their hand with eyes closed
Rationale: Stereognosis tests the ability to recognize objects by touch, a cortical sensory function.