Page 410 - Saunders Comprehensive Review For NCLEX-RN

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.
Test-Taking Strategy: Note the subject, Romberg’s sign. You can easily answer
this question if you can recall that the client’s balance is tested in this test.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Health Assessment/Physical Exam: Neurological
Health Problem: N/A
Priority Concepts: Clinical Judgment; Mobility
Reference: Ignatavicius, Workman, Rebar (2018), p. 850.

92. Answer: 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.
Test-Taking Strategy: Focus on the subject, the characteristics of Cheyne-Stokes
respirations. Recalling that periods of apnea occur with this type of respiration will
help direct you to the correct answer.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Health Assessment/Physical Exam: Thorax and Lungs
Health Problem: N/A
Priority Concepts: Clinical Judgment; Gas Exchange
Reference: Lewis et al. (2017), p. 1324.

93. Answer: 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.
Test-Taking Strategy: Focus on the subject, a conductive hearing loss. Noting the
relationship of the word conductive in the question and transmission in the correct

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