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Exam 3: NSG 444/ NSG444 (New 2024/ 2025 Update) Transition to Practice | Qs & As| 100% Correct| Grade A (Verified Answers)- GCU

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  • 17 de octubre de 2024
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ExamI3:INSGI444/INSG444I(NewI2024/I
2025IUpdate)ITransitionItoIPracticeI|IQsI&
IAs|I100%ICorrect|IGradeIAI(VerifiedI
Answers)-IGCU

QUESTION
DuringIanIassessmentIofItheIcranialInervesI(CNs),ItheInurseIfindsItheIfollowing:Iasym
metryIwhenItheIclientIsmiles,IunevenIliftingIofItheIeyebrows,IsaggingIofItheIlowerIeyel
ids,IandIescapeIofIairIwhenItheInurseIpressesIagainstItheIrightIpuffedIcheek.IWhichIcra
nialInerveI(CN)IisIdemonstratingIdysfunction?
CNIIVICNIVIIICNIV
CNIXII

Answer:
ICNIVII
Rationale:IMotorIcomponentIofICNIVIIIwithIdroopingIofIoneIsideIofItheIface,IlowerIe
yelidIsagging,IshowingIteethIandIescapeIofIairIfromIonlyIoneIcheekIthatIisIpressedIin.I
LossIofImovementIandIasymmetryIofImovementIoccurIwithIbothICNSIlesionsI(e.Ig.I,Is
trokeIthatIaffectsIlowerIfaceIonIoneIside)IandIperipheralInervousIsystemIlesionsI(e.Ig.I
Bell'sIPalsyIthatIaffectsIupperIandIlowerIonIoneIsideIofIface).I



QUESTION
TheInurseIisItestingItheIfunctionIofICNIXI.IWhichIactionIdescribesItheIexpectedIrespo
nse?
demonstratesItheIabilityItoIhearIaIconversationIatInormalIvolume
I
sticksIoutItheItongueIatImidlineIwithoutItremorsIorIdeviationIfollowsIanIobjectIwithIthe
irIeyesIwithoutInystagmusIorIstrabismus
movesIheadIandIshouldersIagainstIresistanceIwithIequalIstrength

Answer:

,IMovesIheadIandIshouldersIagainstIresistanceIwithIequalIstrength
Rationale:ICranialInerveIXII(11)IcheckIequalIstrengthIbyIaskingItheIpersonItoIrotateIth
eIheadIforciblyIagainstIresistanceIappliedItoItheIsideIofItheIchinI(Fig.I23-
13).IThenIaskItheIpersonItoIshrugItheIshouldersIagainstIresistanceI(Fig.I23-
14).ITheseImovementsIshouldIfeelIequallyIstrongIonIbothIsides.I



QUESTION
AInurseIisImonitoringIaIclientIwhileIadministeringItheirIoralImedications.ITheIclientIst
artsItoIcoughIandIchokeIonItheIpills.IWhichIcranialInervesI(CN)IshouldItheInurseIsusp
ectIareInotIfunctioningInormally?
CNIVIandIVIIICNIXIIandIXIIICNIIXIandIX
CNIXIandIXI

Answer:
ICNIIXIandIX
Rationale:ICNIIX,IXIcontrolImovementIofItheItongueIandIswallowing.IWhenItheseIareI
affectedIbyIstrokeIorIotherIneurologicalIdisease,ItheIclientIisIatIriskIforIchokingIandIas
piration.IInitialItestingIofItheIswallowingIfunctionIshouldIbeIdoneIwithIaIsipIofIplainIw
aterIandInotifyingIproviderIforIpossibleIreferralItoIspeechItherapyIforIfurtherItestingIsh
ouldIbeIconsidered.I



QUESTION
WhatIassessmentIfindingIisIexpectedIwhenIassessingIaIclient'sIvisualIaccommodation?
a.IchangeIofIeyeIpositionIandIpupillaryIdilationIwhenIlookingIatIaInearIobjectIb.IintactI
peripheralIvisualIfieldsIandIvisualIacuityIinItheIcardinalIfieldsIofIgazeIc.IpupilsIconstri
ctIwhenIlookingIatIaInearIobjectIandIconvergenceIofIeyesId.IinvoluntaryIblinkingIinIres
ponseItoIlightItouchItoItheIcorneal
membrane

Answer:
Ic.IpupilsIconstrictIwhenIlookingIatIaInearIobjectIandIconvergenceIofIeyes
Rationale:ITestIforIaccommodationIbyIaskingItheIpersonItoIfocusIonIaIdistantIobject.IT
hisIprocessIdilatesItheIpupils.IThenIhaveItheIpersonIshiftItheIgazeItoIaInearIobjectIsuch

, IasIyourIfingerIheldIaboutI7ItoI8IcmI(3Iinches)IfromItheIperson'sInose.IAInormalIrespo
nseIincludesI(1)IpupillaryIconstriction,IandI(2)IconvergenceIofItheIaxesIofItheIeyes.I



QUESTION
AInurseIisIassessingItheIquadricepsIreflexIandIdocumentsIitIasIaI4+
bilaterally.IWhatItypeIofIresponseIdidItheInurseIelicit?
veryIbriskIwithIclonus
I
diminished,IlowInormalIaverage,Inormal
briskerIthanIaverage

Answer:
IveryIbriskIwithIclonus
Rationale:I0-
4+IscaleI4+IindicatesIhyperreflexiaIandIclonusIdueItoIdisease.I3+IisIaIbriskerIthanIaver
age/normalIandImayIorImayInotIindicateIdisease.I2+IisInormal,I1+IisIdiminishedIlowIa
ndIcouldIbeIlowerIthresholdIofInormal.I0IindicatesInoIresponseIelicited.I



QUESTION
WhileItestingItheIpupillaryIlightIreflexIduringIaIneurologicalIreassessment,ItheInurseIn
otesIthatIoneIpupilIdoesInotIrespondItoIlightIandIisIlargerIthanItheIotherIpupil.IWhatIsh
ouldItheInurseIconsiderIasIaIpossibleIcause?
medicationIreactionIthatIwillIresolveIwhenIstoppedInormalIresponseIinIapproximatelyI5
%IofItheIpopulationIincreasedIintracranialIpressureIorIcentralInervousIsystemIinjury
onsetIofItypicalImigraineIwithIanIaccompanyingIvisualIaura

Answer:
IincreasedIintracra-InialIpressureIorIcentralInervousIsystemIinjury
Rationale:IChangesImayIbeIsignificantIsignsIofIincreasingIintracranialIpressureIandIsho
uldIbeIassessedIwithIneurologicalIcheckIandIcomparingIbaseline.INormallyItheIrestingI
sizeIisI3,4,5ImmIandIdecreasesIequallyIinIresponseItoIlight.IMedicationsIwillInotIcause
IoneIpupilItoInotIreact.IAnisocoriaIisIpresentIinI5%IofItheIpopulationIandIisIconsistentl
yIpresentIthroughoutItheIlifetimeIandIisInotIaInewIonsetIorIchangeIinIbaseline.I

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