Weekly 5 QA3 1. The nurse is performing a neurological assessment on a client and elicits a positive Rombergs sign.

The nurse makes this determination based on which observation? a. An involuntary rhythmic, rapid, twitching of the eyeballs b. A dorsiflexion of the ankle and great toe with fanning of the other toes. c. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed d. 2. A lack of normal sense of position when the client is unable to return extended fingers to a point reference

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse expects to notes which of the following? a. Regular rapid and deep, sustained respirations b. Totally irregular respiration in rhythm and depth c. Irregular respirations with pauses at the end of inspiration and expiration d. Rhythmic respirations with periods of apnea

3. The nurse notes documentation that a client has conductive hearing loss. The nurse understands that this type of hearing loss is caused by which of the following? a. A physical obstruction to the transmission of sound waves

b. A defect in the cochlea c. A defect in the 8th cranial nerve d. A defect in the sensory fibers that lead to the cerebral cortex 4. While performing a cardiac assessment on a client with in an incompetent heart valve, the nurse auscultates a murmur. Which of the following best describes the sound of a heart murmur? a. Lub-dub sounds b. Scratchy, leathery heart noise c. Gentle, blowing or swooshing noise d. Abrupt, high-pitched snapping noise

5. The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse implements which physical technique to assess for muscle weakness in the eye? a. Test the corneal reflexes b. Test the six cardinal positions of gaze c. Tests visual acuity using a Snellen eye chart d. Tests sensory function by asking the client to close eyes and the lightly touching the forehead, cheeks, and chin. Answers and Rationale 1. C -- In Rombergs 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 Rombergs 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 prioception, and the loss of vestibular function. 2. D -- Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia 3. A A conductive hearing loss occurs as a result of physical obstruction to the transmission of sound waves. 4. C A heart murmur is an abnormal heart sound and is described as a gentle, blowing, swooshing sound. 5. B Testing the six cardinal position of gaze is done to assess to hold the head steady, then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the two eyes.