← Study guidesNUR 120 · Exam 3 Study Guide · updated Oct 8, 2026

NUR 120 · Health Assessment

Exam 3 Study Guide

Respiratory · ABGs · Neurological · Cranial Nerves · Musculoskeletal

Format: 40 multiple-choice questions plus one picture question, and the blueprint says what the picture is: where you listen to lung sounds.
Weighting, straight from the blueprint: Respiratory 12 · Neurology 8 · Cranial nerves 8 · Musculoskeletal 8 · ABGs 4. Respiratory is nearly a third of the paper on its own, so it comes first. The ABGs follow it because they build on it — the same lungs, measured in a blood sample — and the three equal eight-question blocks come after them.
Two instructions on the blueprint worth reading twice. The cranial-nerve questions are described as “just like the quiz”, and you may write the acronym on the test. And on the ABGs: NO COMPENSATION, in capitals. Read it precisely: you will not be asked to classify a gas as partially or fully compensated, which removes the hardest part of interpretation. It does not promise that only one number will be abnormal — the blueprint's own named case, Mr Sweet, has a low bicarbonate and a low CO₂.
Reading: Taylor Ch 40 Oxygenation, with ATI Engage Fundamentals Respiratory; for the neurological and cranial-nerve parts, Taylor Ch 45 Sensory and Ch 34 Activity. The course documents come first throughout; the textbook fills gaps and is marked where it does.

About the blue stars. Across the four decks behind this exam there are six drawn emphasis marks — three five-point stars and three arrows — and all six are collected on the next page, with each part developing its own. The neurological deck carries five of them. The ABG deck carries one, on a slide that prints the word MEMORIZE and whose speaker note says “Should memorize!!”; its star sits just off the edge of the slide, so it may not show when the slide is projected. The respiratory and musculoskeletal decks carry no drawn marks, but both put points in red text, and each of those is flagged where it lands. A blue box in this guide means one of two things, and it always says which: the deck marked it, or the blueprint names it.

Memorize these first

Everything the Decks Marked

Six marks, two decks. This page collects them so you can find them in one place the night before; each one is developed properly in its own part later. Nothing on this page is optional — a drawn star or arrow is this course's way of saying the content beside it is coming, and one of the six sits on a slide that prints the word MEMORIZE.

Normal ABG values — the slide says MEMORIZE ABG deck slide 4 · a star beside the slide, and “MEMORIZE” printed on it


pH	7.35 – 7.45	Below 7.35 is acidosis, above 7.45 is alkalosis. The range is narrow because enzymes stop working outside it.
PaCO₂	35 – 45 mmHg	The respiratory number, controlled by the lungs, which respond in minutes. CO₂ acts as an acid.
HCO₃⁻	22 – 26 mEq/L	The metabolic number, controlled by the kidneys, which take hours to days. HCO₃ acts as a base.
PaO₂	80 – 100 mmHg	Does not affect acid–base balance. It is read separately, for oxygenation.
Hypoxemia	60–79 / 40–59 / <40	Mild / moderate / severe. Three bands, straight from the same slide.

The one line that makes the arrows make sense CO₂ is an acid. HCO₃ is a base. So a rising CO₂ pushes the blood acid, and a rising bicarbonate pushes it alkaline — the two numbers run in opposite directions against the pH. The deck's own speaker note offers a trick for the one that feels backwards: write the CO₂ range as 45–35 rather than 35–45, so the high end is on the left where the acid is.

The two cranial-nerve acronyms — and you may write them on the test Neuro deck slide 8 · drawn star

“On Old Olympus’ Towering Top, A Finn And German Viewed Some Hops.”
“Some Say Money Matters, But My Brother Says Big Brains Matter Most.”

Two sentences, one order. The second one answers a whole category of question by itself.
#	Acronym word	Nerve	S/M/B word	Which
I	On	Olfactory	Some	Sensory
II	Old	Optic	Say	Sensory
III	Olympus'	Oculomotor	Money	Motor
IV	Towering	Trochlear	Matters	Motor
V	Top	Trigeminal	But	Both
VI	A	Abducens	My	Motor
VII	Finn	Facial	Brother	Both
VIII	And	Vestibulocochlear	Says	Sensory
IX	German	Glossopharyngeal	Big	Both
X	Viewed	Vagus	Brains	Both
XI	Some	Accessory	Matter	Motor
XII	Hops	Hypoglossal	Most	Motor

Muscle strength, 0 to 5 — the blueprint names “strength ratings” Neuro deck slide 45 (drawn star), merged with musculoskeletal deck slide 15

Recorded as a fraction. The denominator is always 5; the numerator is what you found.
Grade	What you see	The deck’s other wording
5/5	Full ROM against gravity and full resistance	Normal · 100%
4/5	Full ROM against gravity and moderate resistance	Good · 75%
3/5	Full ROM against gravity only — can lift the arm, cannot hold it against resistance	Fair · 50%
2/5	Full ROM with the joint supported; cannot work against gravity	Poor · 25%
1/5	Contraction you can feel on palpation, but the joint does not move	Trace · 10%
0/5	No visible contraction at all	Zero · 0%

The hinge of the whole scale is gravity Everything from 3/5 upward works against gravity; everything at 2/5 and below does not. That one line sorts the scale faster than memorising six definitions. The two decks word the middle grades slightly differently — the neurological deck says 2/5 is “full ROM but not against gravity”, the musculoskeletal deck says “complete ROM with the joint supported” — and they mean the same thing. The starred version is the neurological deck’s.

Mental status — the blueprint names short-term memory and judgment Neuro deck slide 15 · drawn arrow

What you assess	How
Level of consciousness	Alert → lethargic → obtunded → stuporous → comatose. Learn the order; it is a scale, not a list. LOC is the earliest and most sensitive indicator of neurological change.
Recent memory short-term	Repeat a set of numbers or a list of objects. This is the one the blueprint names.
Remote memory	Ask something long past and verifiable — date of birth.
Judgment	Ask how they would respond to a specific situation. Also named on the blueprint. It is a scenario question, not a knowledge question.
Calculation	Count backward by 7 from 100.
Abstract thinking	Interpret a cliché — a concrete, literal answer is the abnormal one.
Insight	Their perception of their own illness.
Thought process / content	Process is how they think — rapid topic changes, nonsense words. Content is what — delusions, hallucinations.

The other two arrows are cranial-nerve slides The neurological deck's remaining two marks sit on CN II, optic (slide 30) and CN VII, facial (slide 38). Both are developed in Part 4. CN II is also named in the blueprint's own list of cranial-nerve hints, so it is marked twice over; VII is not on that list, and the arrow is its only emphasis. The two arrows point at particular tests. On II it is confrontation: sit facing the client, with your own vision as the baseline, four fields for each eye. On VII it is strength: the client squeezes the eyes tightly shut and you try to open them.

Where the lobes are, and the one the blueprint asks about

Landmarks and Lobes

The blueprint asks one anatomical question and tells you exactly which: “Middle lobe: where is it? Where do I auscultate lung sounds for this lobe? Remember to depict which side, Left or Right lung.” That phrasing is doing you a favour — it is the whole question, written out. Learn the answer in one sentence and the rest of the lobe anatomy becomes orientation rather than memorisation.

The middle lobe — the blueprint writes this question out for you Respiratory deck slide 8

There is a right middle lobe and there is no left one. The right lung has three lobes (upper, middle, lower); the left has two (upper and lower), because the heart takes the space. The right middle lobe is assessed from the front — it does not reach the back, so listening posteriorly will never find it. The deck adds the practical note that it often sits under the breast, which makes it the hardest field to hear in women.

So: right lung · anterior. Standard anatomy, not the deck, places it at roughly the fourth to sixth rib at the midclavicular line. If a question offers you a posterior landmark for the middle lobe, it is wrong on the face of it.

The rest of the lobe and landmark detail, which is orientation rather than recall.
Point	Detail
Right lung	Three lobes — upper, middle, lower.
Left lung	Two lobes — upper and lower. No middle lobe.
Apex	The very top. The right apex sits about 2.5 cm higher than the left, because the liver pushes the tissue up on that side.
Base	The very bottom.
Posterior view	Mostly lower lobes. This is where most of your listening happens.
Anterior view	Mostly upper lobes, plus the right middle lobe.

What you ask before you listen

Subjective Data and Risk

The history here has one number in it worth knowing how to produce, and one question that opens everything else. The number is the pack-year history; the question is simply “how is your breathing?”, which the deck lists first because the client's own perception is the starting point for everything that follows.

The history, grouped the way the deck runs it.
Area	What you ask
Present concern	Difficulty breathing, cough, chest pain. “How is your breathing?”
The symptoms	Dyspnea · orthopnea (breathless lying flat) · paroxysmal nocturnal dyspnea (wakes them at night) · cough · sputum — characteristics · wheezing · functional ability.
Smoking	Pack-year history = packs per day × years smoked. Second-hand exposure counts as a risk too.
Past history	Chronic lung problems, pneumonia, allergies, medications, flu and pneumonia vaccination.
Occupation and environment	Exposures, radon, allergens.
Cultural	Recent immigration raises TB risk. Home practices that put smoke in the air, such as incense.
Lifespan	Pregnancy — the uterus presses on the diaphragm, so breathlessness is expected. Infants — colds, aspiration safety, whether the parents know CPR. Older adults — lung changes, tires more easily.

What you can see before you touch anyone

Inspection, and the Signs That Travel

Most of the respiratory assessment is decided before the stethoscope comes out. The deck builds inspection around one idea — the body shows you how hard breathing is — and the signs it lists are the ones that appear in stems as scene-setting rather than as the question. Learn them and a scenario stops being a wall of text.

What you look for, and what it means when you find it.
Finding	What it tells you
Position	Upright with hands at the sides is normal. The tripod position — leaning forward on the arms — means they are recruiting accessory muscles.
Pursed-lip breathing Nasal flaring	Both are work of breathing. Nasal flaring in an infant is a significant sign.
Level of consciousness	Restless, combative or disoriented is a hypoxia sign, not a behaviour problem. This is the one most often misread.
Skin colour	Cyanosis or pallor. Cyanosis is a late sign.
Clubbing of the nails	Chronic hypoxia — it takes months to develop, so it tells you about the past, not today.
Rate and I:E ratio	Normal adult rate 12–20. Inspiration to expiration should be 1:2.
Accessory muscles Retractions	Trapezius, sternocleidomastoid, scalenes. Primary muscles are the diaphragm and the external intercostals — accessory muscles mean the primaries are not coping.
Chest shape	Barrel chest (chronic air trapping) · kyphoscoliosis · pectus excavatum (funnel) · pectus carinatum (pigeon) · flail chest. All compromise excursion.

The sounds that are supposed to be there

Normal Breath Sounds, and Where Each One Belongs

Three normal sounds, and the examinable part is not what they sound like but where they belong. Each one is normal in its own place and abnormal everywhere else — so “bronchial breath sounds in the lower lobe” is an abnormal finding even though bronchial is a normal sound. That is the shape of the question.

From the Week 8 worksheet, which supplies the “where heard” column the deck leaves out.
Sound	What it sounds like	Where and when	The catch
Vesicular	Soft, low-pitched, gentle rustling	Most lung fields. Inspiration about three times longer than expiration	The expected sound over nearly all of the lungs
Bronchovesicular	Medium-pitched, blowing	Near the main bronchi — between the scapulae and beside the sternum. Inspiration and expiration equal	Unexpected if heard far out in the lung fields
Bronchial	Loud, high-pitched, hollow or tubular	Over the trachea and larynx. Expiration longer than inspiration	Abnormal over peripheral lung tissue — it suggests consolidation

The I:E ratio sorts all three Vesicular: inspiration is longer. Bronchovesicular: they are equal. Bronchial: expiration is longer. Read the three down in that order and the pattern is a slide from one extreme to the other — which matches where you hear them, from the periphery in to the trachea.

This is not the same thing as the 1:2 I:E ratio under inspection. That ratio times the breath itself — breathing out takes about twice as long as breathing in. The sound ratios here time what you hear through the stethoscope, and over most of the lung the outflow is nearly silent, which is why vesicular inspiration sounds three times longer.

The sounds that are not supposed to be there

Adventitious Sounds, and What You Do About Each

The blueprint asks for three things about these: what they sound like, where they are heard, and the interventions. The interventions are the half that gets skipped, and they are the half an application question is built from — the stem gives you a sound and asks what the nurse does. The table below is the Week 8 worksheet's, which is where the blueprint is pointing.

Sound, meaning, and the action. The last column is what the exam asks for.
Sound	What it sounds like	What it means	What you do
Crackles rales	Popping or bubbling, primarily on inspiration. The deck lists fine and coarse crackles	Fluid, secretions, or collapsed alveoli popping open	Check SpO₂, effort, edema, weight trend, fluid balance. Sit them upright, cough and deep breathe. Report new or worsening crackles. If overload is suspected, anticipate a diuretic.
Wheezes sibilant	High-pitched, musical or squeaky. Inspiration and expiration — the worksheet adds that it is often louder on expiration	Air moving through narrowed airways	Check work of breathing, SpO₂, rate, asthma or COPD history. Upright, controlled breathing. Anticipate a bronchodilator, then reassess the sounds after the treatment.
Rhonchi sonorous wheeze	Low-pitched, coarse, snoring or gurgling	Secretions in the larger airways	Cough first — reposition, hydrate if allowed, reassess after coughing. Then humidification, nebuliser, suction, respiratory therapy.
Pleural friction rub	Harsh, grating, rubbing. Inspiration and expiration	Inflamed pleural surfaces rubbing	Assess pain with inspiration, depth, SpO₂. Position for comfort, do not force repeated deep breaths if painful, report promptly. Think inflammation, infection, PE.
Stridor	High-pitched, harsh, crowing. Inspiration and expiration — the worksheet says most often on inspiration	Upper airway narrowing or obstruction	Urgent. Stay with the patient. Keep them upright, assess the airway, SpO₂ and ability to speak, notify immediately. Anticipate rapid response.
Absent or diminished	Little or no sound over an area, compared with the other side	Air is not reaching that part of the lung	The deck marks it emergent. Compare with the other side, check SpO₂ and work of breathing, and notify promptly.

Rhonchi clears with a cough. That is the distinguishing feature. It is the one adventitious sound that can be made to go away at the bedside, and the deck says so. If a stem has you hear a coarse low-pitched sound and then asks what to do first, the answer is almost always have them cough and listen again — not suction, not call anyone. Crackles depend on which kind. Crackles from fluid will not clear — a cough cannot lift fluid out of the alveoli. Crackles from collapsed alveoli, which is what a post-operative client who has been breathing shallowly produces, can clear once the alveoli are re-inflated. Which is why re-auscultating after the intervention is not just checking your work — it tells you which mechanism you were dealing with.

Stridor is not a lung-sound question, it is an airway emergency Every other row in that table starts with assessment. Stridor starts with “stay with the patient.” If an option has you leave the bedside to fetch something or document the finding, it is wrong. Ability to speak is the fastest airway assessment there is — a patient who can speak in full sentences is moving air.

The picture question, almost certainly

Breathing Patterns

The blueprint promises one picture question and says it is about where you listen to lung sounds. The deck's last slide is a chart of ten breathing patterns, each drawn as a waveform with a one-line caption, and the blueprint separately says “respiratory patterns — look at handouts.” Between them, these are the two most likely things to be shown a picture of, so both are here: the patterns below, and the auscultation sequence after them.

The ten patterns, drawn for this guide from the deck's own descriptions rather than traced from its image. Compare Biot with ataxic: Biot's humps are all the same height and only the gaps are irregular; ataxic is irregular in height and in spacing. Air trapping is the only one whose baseline climbs. Drag the figure sideways to see the rest of it.

The ten patterns on the chart, with the shape to recognise.
Pattern	Rate and depth	What it looks like, and when
Normal	Regular and comfortable, 12–20 a minute	Even waves, even gaps
Bradypnea	Slower than 12	Normal shape, wide gaps. Opioids, raised intracranial pressure
Tachypnea	Faster than 20	Normal shape, crowded. Fever, pain, anxiety, hypoxia
Hyperventilation hyperpnea	Faster than 20 and deep	Tall and crowded. Blows off CO₂ — drives respiratory alkalosis
Sighing	Normal, with a deeper breath mixed in	Even waves interrupted by an occasional tall one. Often anxiety
Air trapping	Increasing difficulty getting the breath out	The baseline climbs, because they cannot fully exhale. COPD
Cheyne–Stokes	Cycles of increasing then decreasing depth, with apnea between	Waxes, wanes, then a flat gap, repeating. Heart failure, end of life, brain injury
Kussmaul	Rapid, deep and laboured	Uniformly tall and tightly packed. The body blowing off CO₂ to compensate for metabolic acidosis — think DKA
Biot	The deck's caption: “irregularly interspersed periods of apnea in a disorganized sequence of breaths”	Bursts of even breaths separated by flat stretches
Ataxic	*Irregular in depth and* rhythm**	Disorganised — no two breaths alike

Biot versus ataxic is the pair a picture question would use They look alike at a glance and the distinction is one word. In the deck’s drawing, Biot’s breaths are all much the same depth and only the pauses are irregular, while the caption for ataxic breathing reads “irregular and varying depths of respiration”. If the waveform's peaks are all the same height, it is Biot. If they are all different heights, it is ataxic. Both are ominous brainstem signs.

Kussmaul is the one that links two parts of this exam Kussmaul respirations are the lungs compensating for metabolic acidosis — rapid and deep, blowing off CO₂ to raise a falling pH. That makes it the single finding that ties Part 1 to Part 2: when you meet Mr Sweet in the ABG part, in DKA with a pH of 7.33, this is the breathing pattern he has. A stem can come at it from either direction.

Doing it, in order

Auscultation Technique and the Acute Patient

Two practical sequences close this part. The first is how you listen, which is what a picture of the chest with numbered circles is testing. The second is what you do when the assessment goes badly — and the deck gives that one as an ordered list, which makes it a ready-made “what do you do first” question.

Press Start and the figure will ask you to find a site.

Sixteen numbered sites, each tinted by the lobe it reaches. The right middle lobe appears on the anterior panel and nowhere else — which is the blueprint's question, drawn. Work side to side at each level, apices to bases: the other lung is your control. Drag the figure sideways to see the rest of it.

How to listen, from the Week 8 worksheet.
Step	Detail
Use the diaphragm	Pressed firmly against bare skin. Never through clothing.
Mouth breathing	Ask them to breathe in and out through the mouth, slightly deeper than usual.
One full breath per site	A whole inspiration and expiration at every position before moving on.
Ladder pattern	Side to side, comparing one lung against the other at the same level, working apices down to bases. The comparison is the point — the other lung is your control.
Anterior as well	Trachea, anterior and lateral chest — and the right middle lobe, which exists only here.

Acute shortness of breath — the order the deck gives

Prioritising is key. 1. Elevate the head of the bed. 2. Assess pulse, blood pressure, oxygen saturation and lung sounds. 3. Administer oxygen, and possibly inhalation therapy. 4. Remain calm — anxiety increases the work of breathing, so your composure is an intervention. 5. Alert the emergency response team if the situation deteriorates.

Note what comes first. Repositioning precedes assessment here, which is unusual — it is because sitting a breathless patient up costs nothing, takes two seconds and immediately improves ventilation. Not marked in the deck, but it is a numbered list in a course that writes “what do you do first” questions.

What NO COMPENSATION actually buys you

Reading a Gas in Four Steps

The blueprint says NO COMPENSATION in capitals, and it is the most generous sentence on the whole document. Compensation is where ABG interpretation gets genuinely hard — partial this, fully compensated that, working out which system is the culprit and which is the rescuer. None of that is on this exam. What you are asked for is the name of the imbalance — which system, which direction — not how far the body has gone toward correcting it. That reduces interpretation to a four-step routine you can run in about fifteen seconds.

One caution, because this guide used to overstate it. “No compensation” does not mean the second number will always be normal. A compensating system moves, and you will see it move — in Mr Sweet, below, the bicarbonate is 12 and the CO₂ is 25. Step 4 is what carries you through: only the number moving the same way as the pH names the imbalance. A number moving the other way is the rescue, not the disease.

The four steps — the handout’s own wording ABG worksheet, page 1 · deck slide 17


1	Look at the pH. Is it on the acid side, the alkaline side, or normal? <7.35 acid · >7.45 alkaline
2	Look at the PaCO₂ — this is the respiratory number. High means acid, low means alkaline.
3	Look at the HCO₃ — this is the metabolic number. Low means acid, high means alkaline.
4	Which one matches the pH? That one names the imbalance. The deck’s longer version adds two more steps — which one is opposite the pH (that is compensation, and it is off this exam) and whether the PaO₂ is normal.

Say it out loud as a sentence “The pH is acid. The CO₂ is acid. They match — so it is respiratory acidosis.” Every single answer on this part has that shape. The word that names the system is the word that goes in front of the word that names the direction: CO₂ → respiratory, HCO₃ → metabolic; pH down → acidosis, pH up → alkalosis.

The four imbalances, as a grid. Learn the two columns, not the four rows. “Normal” is the worksheet’s “normal until compensation” — the other number can move.
	pH	PaCO₂	HCO₃	Matches the pH
Respiratory acidosis	< 7.35	> 45	normal	CO₂
Respiratory alkalosis	> 7.45	< 35	normal	CO₂
Metabolic acidosis	< 7.35	normal	< 22	HCO₃
Metabolic alkalosis	> 7.45	normal	> 26	HCO₃

The scenarios handout also reports SaO₂, the oxygen saturation: normal is 92–100%. Like the PaO₂, it is read for oxygenation and plays no part in naming the imbalance.

Why each one happens, and what you do

Causes and Interventions

The blueprint asks you to “interpret ABGs and determine the best nursing intervention” — so naming the imbalance is only half of each question. The causes are worth learning as stories rather than lists, because a stem will give you the story and expect you to produce the gas, or give you the gas and expect the story.

Cause, mechanism and action, by imbalance.
Imbalance	The problem	Causes	Interventions
Respiratory acidosis	Retaining CO₂ — hypoventilation	COPD, narcotic or sedative overdose, alcohol, cardiac arrest, pneumonia, atelectasis, respiratory muscle weakness, pulmonary edema, trauma, a ventilator set too slow	Improve ventilation. Deep breathing, reverse the sedation, treat infection, adjust vent settings, BiPAP. The kidneys will retain bicarbonate, over days.
Respiratory alkalosis	Blowing off CO₂ — hyperventilation	Anxiety and breathing too fast — standard texts add pain, fever, early sepsis and over-ventilation	Slow the breathing. Coach it, rebreathe into a paper bag, sedate if ordered. Treat the reason they are breathing fast.
Metabolic acidosis	Producing acid, or losing base	DKA, lactic acidosis, shock, cell death, starvation, severe diarrhoea (losing bicarbonate), renal failure	Treat the cause. IV sodium bicarbonate, nutrition, antidiarrhoeals. The lungs compensate by Kussmaul breathing.
Metabolic alkalosis	Producing or retaining bicarbonate, or losing acid	Severe vomiting or NG suctioning (losing stomach acid), diuretics, hypokalaemia, excess licorice, excessive antacids, steroids	Treat the cause — antiemetics, replace potassium and fluid, stop the offending agent.

Acidosis depresses the brain; alkalosis excites it The lecture draws an arrow to this and underlines it: acidosis has a depressant effect on the central nervous system, and alkalosis an excitatory one, and you will see it in clients with any of the four imbalances. It is why Mr Worried’s fingers tingle before you have read a single number.

When both numbers agree with the pH Rare on this paper, but the worksheet prints one, so it is worth being able to recognise. If the CO₂ is high (acid) and the bicarbonate is low (also acid), both systems are pushing the same way and the answer is a combined respiratory and metabolic acidosis. The handout's example is pH 7.20 · CO₂ 59 · HCO₃ 16 — the over-sedated diabetic. It is worse than either imbalance alone, because neither system is left to rescue the other. This is the one case the four-step routine cannot name on its own: step 4 asks which number matches the pH, and here both do.

Vomiting and diarrhoea go opposite ways It is the cleanest pair on this topic and it catches people every year. Vomiting loses acid from the stomach, so it causes metabolic alkalosis. Diarrhoea loses bicarbonate from the bowel, so it causes metabolic acidosis. Same system, opposite ends, opposite results. If a stem gives you prolonged vomiting or an NG tube on suction, you already know the answer before you read the numbers.

The two patients the blueprint names

Mr Worried and Mr Sweet

The blueprint mentions “worried/sweet” twice and it reads like a mnemonic. It is not. They are the surnames of the two patients in the case scenarios on the ABG worksheet, and the names describe their diagnoses — one is anxious, one is diabetic. They are worth knowing by name because the blueprint points at them directly, and because between them they cover the two respiratory-versus-metabolic directions.

The two cases, with their actual numbers ABG worksheet, scenarios page · named twice on the blueprint

	The story	The gas	Reading
Mr Worried 52, in the ED	Shortness of breath and tingling fingers. Breathing shallow and rapid. No cardiac or respiratory history, normal blood sugar, no EKG changes. Takes antianxiety medication and has had anxiety attacks before.	pH 7.48 PaCO₂ 28 HCO₃ 22 PaO₂ 85	pH alkaline · CO₂ low, also alkaline · they match → respiratory alkalosis. The tingling is the giveaway before you see a number.
Mr Sweet 24, DKA	Coming to critical care from the ED in diabetic ketoacidosis. Blood glucose on arrival 780. Already on an insulin drip and has had one amp of bicarb. Hourly finger sticks.	pH 7.33 PaCO₂ 25 HCO₃ 12 PaO₂ 89	pH acid · HCO₃ low, also acid · they match → metabolic acidosis. The low CO₂ is his lungs trying to help — that is the Kussmaul breathing from Part 1.

The worksheet leaves both interpretations blank — they are fill-ins, and the handout never prints the answers. The readings above are worked from the values given, which is exactly what the exercise is asking you to do.

And what you do — the worksheet's other question The scenarios page asks for the treatment as well as the reading. Mr Worried: slow the breathing — coach it, have him breathe into a paper bag, give sedation if ordered — and treat the reason he is breathing fast, which is the anxiety. Mr Sweet: treat the cause, which is the DKA. The insulin drip and hourly finger sticks already running are that treatment; IV sodium bicarbonate is the lecture’s other measure for metabolic acidosis, and he has had one amp.

The five practice gases on the worksheet, worked The same handout gives five sets to interpret and prints no answers. Between them they cover all four imbalances and one normal, which is almost certainly where four exam questions come from. Work them yourself first, then check:

1. pH 7.32, CO₂ 35, HCO₃ 20 → metabolic acidosis · 2. pH 7.48, CO₂ 44, HCO₃ 28 → metabolic alkalosis · 3. pH 7.42, CO₂ 38, HCO₃ 24 → normal · 4. pH 7.29, CO₂ 52, HCO₃ 26 → respiratory acidosis · 5. pH 7.49, CO₂ 28, HCO₃ 22 → respiratory alkalosis.

Number 3 is the one to notice. Every value is inside its range, and the answer is that there is nothing wrong. A paper that asks you to interpret five gases will usually hide one normal among them.

One thing on the handout is printed backwards The ABG worksheet's second page summarises how the respiratory system responds, and two of its lines are reversed: it has rapid deep respirations retaining more CO₂ and slow shallow respirations retaining less. That is backwards. Breathing fast and deep blows CO₂ off; breathing slowly retains it. The handout's own next lines — “less CO₂ to combine, therefore less H₂CO₃” — are consistent with the correct version, so it is a slip in two words rather than a misunderstanding. The lecture has the same slip once: a slide says to breathe faster to “blow off CO₂ to increase acid (pH)”, where it means increase the pH. Answer from the physiology, not from those lines.

Four named topics, and nothing else promised

What the Blueprint Asks For

This is the most precisely specified part of the paper. The blueprint lists exactly four things — cerebellar testing application, short-term memory and judgment testing, stereognosis, and positive Romberg — and the word “application” appears against the first of them. Mental status, which covers the memory and judgment half, is also the slide the deck marks with an arrow, so two signals point at the same place. The mental-status table is on the marked-content page at the front; the other three are below.

The deck underlines this in red

Level of Consciousness and the Glasgow Coma Scale

Mental status starts before you test anything. The deck puts it in a callout: assessment of mental status begins when you gather your patient’s history — appearance, behaviour, mood, grooming, hygiene, posture and dress, and whether eye contact and emotion fit the conversation. Level of consciousness is first on the list, and it is the earliest and most sensitive indicator of a change in neurological status.

The deck’s scale, in order. Grey definitions are standard usage; the deck gives the names.
Level	What it means
Alert	Awake, and oriented to person, place, time and situation.
Lethargic	Drowsy; wakes to a normal voice and drifts off again.
Obtunded	Wakes only to touch or a shake, and responds slowly.
Stuporous	Requires painful stimuli to respond — in red on the slide.
Comatose	Unresponsive. You may see posturing.

For a client who cannot follow the usual tests, the Glasgow Coma Scale scores the best response to a stimulus in three areas — eye opening, verbal and motor — and adds them up.

The three scales. Always record the best response you can get.
Score	Eye opening	Verbal	Motor
6			Obeys commands
5		Coherent and oriented	Localizes the stimulus
4	Spontaneous	Incoherent and disoriented	Withdraws from the stimulus
3	To voice	Inappropriate words	Abnormal flexion — decorticate
2	To pain	Sounds, but no words	Abnormal extension — decerebrate
1	None	None	None

Three numbers to keep: 15, 8 and 3 15 is the best possible score — full consciousness. 3 is the lowest, because every scale starts at 1. 8 means coma. The deck’s bands: below 8, severe head injury or coma; 9 to 12, moderate head injury; 13, minor head trauma. The score tracks the depth of coma, so a falling score is a deteriorating client.

Coordination and balance

Cerebellar Testing

The cerebellum does not move anything by itself — it coordinates. So every test for it asks the client to do something that needs smoothness rather than strength, and the abnormal result is clumsiness in someone whose muscles are perfectly strong. That is the distinction a question will be built on: weak is motor, clumsy is cerebellar.

The deck’s four cerebellar tests.
Test	How	Normal
Finger to nose	Arms extended, touch finger to nose, alternating hands, then repeat with the eyes closed	Smooth, coordinated, accurate
Heel to toe walk	Walk a straight line placing the heel of one foot directly in front of the toes of the other	Straight line, no loss of balance
Romberg	Feet together, arms at the sides, eyes closed	Minimal sway for 5 seconds
Gait	Always assess gait — watch them walk	Steady, smooth, coordinated

Positive Romberg — named on the blueprint, and the word is counter-intuitive Neuro deck slides 39 and 47 · named on the blueprint

Positive means abnormal. They sway badly, step, or have to be steadied once the eyes close. A normal Romberg is standing with minimal sway for about five seconds. In ordinary English “positive” sounds like good news, and that is exactly why it gets asked.

Why the eyes have to close. Staying upright uses three inputs: vision, the vestibular system, and proprioception — your sense of where your own joints are. Vision can cover for a failure in either of the other two, so a client with a real deficit can look completely steady with their eyes open. Closing the eyes removes the compensation and exposes the deficit.

Stand close enough to catch them. A test that deliberately provokes unsteadiness is your responsibility while it runs.

Romberg is filed twice in the deck, and on this exam the deck decides The deck puts Romberg under CN VIII on slide 39 and under cerebellar function on slide 47. So if a question asks which assessments test cerebellar function and Romberg is among the options, include it — that is the course's own filing, and it is the answer to give.

Beyond the deck, for understanding rather than for answering. Standard neurology treats Romberg primarily as a test of proprioception, with the vestibular system second, and teaches that the Romberg sign — a marked worsening the moment the eyes close — is classically absent in cerebellar disease, because a cerebellar client is already unsteady with the eyes open and there is no compensation left to remove. In practice many cerebellar clients do sway more with the eyes shut, so treat that as a tendency rather than a rule. The useful bedside version: unsteady only once the eyes close points at proprioception or the vestibular system; unsteady the whole time points at the cerebellum.

Testing sensation you cannot see

Stereognosis and the Discrimination Tests

The blueprint names stereognosis by itself, which is a strong hint for one word. It belongs to a small family of tests the deck groups as discrimination — higher-level sensory tests, all done with the eyes closed, all asking whether the brain can interpret a sensation rather than merely feel it. That is the idea worth holding: these are not tests of the nerve, they are tests of the cortex that reads it.

The discrimination tests. All are performed with the eyes closed.
Test	What you do	What it is really testing
Stereognosis	Place a familiar object in the hand — a coin, a key, a paperclip — and ask them to identify it by feel alone	Recognising size, shape, weight, texture and form without looking. Inability is astereognosis.
Graphesthesia	Draw a letter or a number on the palm with a blunt point and ask them to name it	The same idea in a different channel — interpreting a traced shape.
Two-point discrimination	An opened paperclip; find the narrowest distance at which they still feel two points	Sensory acuity. It varies enormously by body part — fingertips are far finer than the back.
Position sense proprioception	Move a finger or toe up or down and ask which way it moved	Joint position. Needs intact vestibular and cerebellar function too — which is the link back to Romberg. If vibration sense is intact, position sense need not be tested: it is the same pathway, and the deck says so in red.
The basic four	Light touch, pain (sharp/dull), temperature, vibration — performed on all four extremities	The peripheral sensory pathways themselves, before you test interpretation.

Why the eyes close for every one of these It is the same principle as Romberg, applied to the hands instead of the feet. Vision would do the job for them. A client who can see the coin does not need to feel it, and the test would pass whether or not the sensory pathway works. Any sensory test that can be passed by looking is not a sensory test — which is a rule worth carrying, because it also explains “no peeking” in the trigeminal examination and the occluded nostril in the olfactory one.

Dermatomes, and the client with an epidural A client receiving pain medication through an epidural or spinal catheter must have the sensory level checked by dermatome, working up the leg. Three landmarks: T4 is the nipple line, and loss of sensation above it means respiratory arrest; T10 is the umbilicus; T12 is the groin. Recovery from the anaesthetic runs in a descending fashion — higher structures recover first.

Posture, and the two words that get swapped

Decorticate and Decerebrate

The blueprint lists these under Musculoskeletal, but they are neurological findings and they belong here with the rest of the brain. They are abnormal posturing in response to a stimulus in a client who is not following commands, and they matter because which one you see tells you how deep the injury is.

Two postures, and the memory hook that keeps them apart.
Posture	What you see	How bad
Decorticate	Arms flexed, drawn in toward the chest, wrists and fingers curled; legs extended	“COR” for core — the arms come in to the core. Damage above the brainstem. The less grave of the two.
Decerebrate	Arms extended and rigid, held in at the sides with the forearms turned palms down; legs extended	Brainstem involvement. The worse sign.

A change from decorticate to decerebrate is a deterioration This is the version of the question that tests whether you know which is worse rather than which is which. Moving from flexion to extension means the injury has reached deeper — it is getting worse and it must be reported immediately. Moving the other way, from decerebrate to decorticate, is improvement. The Glasgow motor scale scores them the same way round: abnormal flexion 3, abnormal extension 2.

The vocabulary the neurological items are written in

The Neurological Terms

The week's preparation worksheet lists these as terms to define, and the neurology and cranial-nerve questions share them, so they turn up in the stems of both. Three of them are findings that look like cranial-nerve problems and are not — the two aphasias and ataxia — and those are the ones worth your attention.

From the preparation worksheet’s key-terms list. Definitions are standard nursing usage.
Term	What it means
Expressive aphasia	Cannot produce language — knows the word, cannot say it. Cortical, not a cranial nerve.
Receptive aphasia	Cannot understand language. Speech may be fluent and make no sense. Also cortical.
Ataxia	Uncoordinated movement or gait — a cerebellar sign, not a nerve lesion. Easily confused with the balance half of VIII.
Hemiparesis	Weakness down one side of the body.
Paresthesia	Abnormal sensation — numbness, tingling, “pins and needles”.
Nuchal rigidity	Stiff neck, resistant to flexion — a meningeal sign.
Decorticate posturing	Arms flexed in to the core. Think “cor” for core. The less grave of the two.
Decerebrate posturing	Arms extended and rigid. The worse sign, and the blueprint names the pair.
Level of consciousness	The deck’s own scale: alert, lethargic, obtunded, stuporous, comatose.
Babinski plantar reflex	Run a blunt object from the heel up the outer sole and across the ball of the foot to the great toe. Normal: the toes flex. Abnormal: the great toe dorsiflexes and the toes fan. One of the reflexes, with corneal and gag, that the deck uses to judge the higher CNS.
CNS / PNS / ANS	Central — brain and spinal cord. Peripheral — everything else, cranial nerves included. Autonomic — the involuntary half of the peripheral system.

Where the cranial nerves sit, since the exam asks about the divisions The twelve cranial nerves are part of the peripheral nervous system, not the central one — even though they leave the brain directly and two of them are really brain tracts. CNS is brain and spinal cord only. It is a one-mark question and it is easy to get backwards.

The same eight questions you have already sat once

What the Blueprint Names

The blueprint could not be plainer: the cranial-nerve questions are “just like the quiz”, and it asks for the same three things — the number, the name, and the application of the nerve testing. It then names six of the twelve by name, plus PERRLA, as hints: optic, spinal accessory, hypoglossal, trigeminal, vestibulocochlear and olfactory. The table below is what each hint is pointing at. Everything after it is the Quiz 2 material, carried across whole, so nothing learned for the quiz is spent. And you may write the acronym on the test, which is why the two acronyms come first.

The six nerves the blueprint names, and PERRLA under III, with the detail each hint is pointing at.
Nerve	What the blueprint wants
I Olfactory	Eyes closed, one nostril at a time, familiar non-irritating odour. An irritant such as ammonia stimulates V instead and proves nothing.
II Optic	Two tests. Acuity — a chart, or print at 14 inches. Fields — confrontation, four per eye, your own vision as the baseline. Deck slide 30 carries a drawn arrow.
III Oculomotor	PERRLA, in full later in this part. Plus most eye movement and lifting the eyelid — which is why III failing gives ptosis.
V Trigeminal	Sensory: light touch, sharp/dull, hot/cold over forehead, cheek and jaw, eyes closed. Motor: palpate the temporal and masseter muscles while they clench.
VIII Vestibulocochlear	Hearing — occlude one ear, present a quiet sound from out of sight. Balance — Romberg, which is also named under Neurology.
XI Spinal accessory	Shrug and turn the head, both against resistance. No resistance, no strength grade.
XII Hypoglossal	Protrude the tongue at the midline, then side to side. After a CVA it deviates toward the weak side.

Memorize this first — you are allowed to write it down

The Two Acronyms

Start here, and start today. The blueprint gives you permission to write the acronym on the test, which means the twelve words below are the only thing on this topic you are guaranteed to have in front of you. Everything else you need has to hang off them. Learn them as two parallel lists of twelve: the first gives you the names in order, the second gives you sensory, motor or both in the same order. Write both down the moment the paper is in front of you, before you read a single question, and the recall half of the cranial-nerve questions is already answered.

The acronym slide — the deck draws a star on it Deck slide 8 · drawn star

Two mnemonics, one order. Read the table down, not across.
#	Acronym word	Nerve	S/M/B word	Which
I	On	Olfactory	Some	Sensory
II	Old	Optic	Say	Sensory
III	Olympus'	Oculomotor	Money	Motor
IV	Towering	Trochlear	Matters	Motor
V	Top	Trigeminal	But	Both
VI	A	Abducens	My	Motor
VII	Finn	Facial	Brother	Both
VIII	And	Vestibulocochlear (deck: Auditory)	Says	Sensory
IX	German	Glossopharyngeal	Big	Both
X	Viewed	Vagus	Brains	Both
XI	Some	Accessory (deck: Spinal accessory)	Matter	Motor
XII	Hops	Hypoglossal	Most	Motor

Say both sentences out loud, as sentences

“On Old Olympus’ Towering Top, A Finn And German Viewed Some Hops.”
“Some Say Money Matters, But My Brother Says Big Brains Matter Most.”

The second one is the one students skip, and it is the cheaper of the two: it answers a whole category of question on its own. Any item that asks whether a nerve is sensory, motor or both is answered by counting words, and you are permitted to have the words with you.

The acronym forces two names on you — use them The first mnemonic only works if you call VIII “Auditory” (for And) and XI “Spinal accessory” (for Some). That is not a coincidence — it is why the deck's own slides use those two names. The formal names are vestibulocochlear and accessory, and a question may use either. Learn both labels for both nerves and the mnemonic costs you nothing; learn one and a stem using the other can strand you.

Where the second acronym goes wrong Read the pattern out: S S M M B M B S B B M M. It doubles up at each end and then, from IV right through to IX, it never repeats itself once — M B M B S B, six nerves of pure alternation. That stretch is where essentially every mistake with this mnemonic happens, and the worst of it is the run “But My Brother” — V both, VI motor, VII both. Recite those three cold and the rest of the sentence looks after itself.

The acronym gives you first letters — the options will not On the quiz one question was a blank to fill in. On this exam the cranial-nerve questions are multiple choice, but the options still use the full names and the numbers, and the acronym gives you the first letter of each name and nothing more. Three nerves start with O, two with T, and the long names look alike at a glance, so know them on sight — Glossopharyngeal, Vestibulocochlear, Hypoglossal, Trigeminal, Trochlear, Abducens — and the Roman numerals beside them, since the blueprint asks for the CN number. The drill at the end of this part is built for exactly this.

The whole topic on one page

The Master Table

This is the table to photograph and keep on your phone. Every row holds the four things the instructor asked for — number, name, sensory or motor, and the test — and nothing else, so it stays readable. The sections after it take the same twelve rows and open each one out into what normal and abnormal look like, so if a row here feels thin, its full treatment is further down.

All twelve. The last column is the version to have on recall.
#	Name	Type	What it does	How you test it
I 1	Olfactory	Sensory	Smell.	Eyes closed, one nostril at a time.
II 2	Optic	Sensory	Visual acuity and visual fields.	Acuity AND fields. Each eye, then both.
III 3	Oculomotor	Motor	Pupil constriction, most eye movement, upper eyelid elevation.	PERRLA. Light in from the SIDE. Direct, then consensual.
IV 4	Trochlear	Motor	Eye movement downward and inward.	Down and in. Tested with III and VI.
V 5	Trigeminal	Both	Sensation to the face; the muscles of chewing.	Three branches: forehead, cheek, jaw. Clench the teeth, palpate the muscles.
VI 6	Abducens	Motor	Lateral eye movement.	Lateral. Abducens = abduct = away.
VII 7	Facial	Both	Facial movement; taste on the anterior two-thirds of the tongue.	Make faces. Salt and sweet, front of the tongue.
VIII 8	Vestibulocochlear also “Auditory”	Sensory	Hearing and balance.	Hearing AND balance. Romberg. Occlude one ear, stay out of sight.
IX 9	Glossopharyngeal	Both	Taste on the posterior third of the tongue; swallowing, gag, speech sounds.	“Ah.” Gag. Swallow. Sour and bitter, back of the tongue.
X 10	Vagus	Both	Swallowing, speech sounds; sensory limb of the gag.	Tested WITH IX. Listen for hoarseness.
XI 11	Accessory also “Spinal Accessory”	Motor	Turning the head; shrugging the shoulders.	Shrug and turn the head — AGAINST RESISTANCE, both sides.
XII 12	Hypoglossal	Motor	Tongue movement.	Protrude at midline, then side to side. CVA → deviates to the paralysed side.

The “type” column is the deck's own classification, and it agrees exactly with the second acronym — sensory, sensory, motor, motor, both, motor, both, sensory, both, both, motor, motor. If your memory of the sentence ever disagrees with this column, the column is right.

Why the order is the order

Where They Leave the Brain

The numbering is not arbitrary, and knowing why turns a list of twelve into four small groups. The nerves are numbered front to back, top to bottom, in the order they leave the brain — so the number tells you roughly where the nerve comes from, and the region tells you which nerves keep company with each other. That is worth more than it sounds: the nerves that leave together get tested together, which is exactly how the deck teaches III, IV and VI, and IX and X.

Start with the real thing. Below is the underside of a brain — the view you get looking at it from beneath, which is the view in which all twelve are visible at once. Follow it from the front of the head backwards and the numbering simply happens in front of you.

Ventral view of the human brain, all twelve nerves labelled. Patrick J. Lynch, medical illustrator; labelled derivative by Beao. Wikimedia Commons, CC BY 2.5. Reproduced under that licence; it is not from the course material. Note the real spacing — the nerves come off in clusters, not at even intervals, which is the next figure’s point. One label to read carefully: this figure says “Cranial Accessory” for XI. That is the cranial root, which joins the vagus and serves the palate and larynx. The nerve you test — trapezius and sternocleidomastoid, shrug and head turn — is the spinal root, which comes up from the cervical cord and is not drawn here.

That is what it looks like. What it means is the table and the figure below: the twelve fall into four groups, and the group tells you what a nerve is likely to be for.

Four groups, and the boundaries are where the brainstem changes.
Region	Nerves	What they have in common
Forebrain	I, II	The two special senses at the front of the head \— smell and sight. Both purely sensory, and neither is a peripheral nerve in the ordinary sense. Strictly: I attaches at the olfactory bulb, an outgrowth of the cerebrum; II attaches at the diencephalon, by way of the optic chiasm. \“Forebrain\” is the label that covers both.
Midbrain	III, IV	Start of the eye movers. Both motor.
Pons	V, VI, VII, VIII	The face and the ear \— feeling the face, moving the face, the last eye mover, and hearing and balance.
Medulla	IX, X, XI, XII	The throat, neck and tongue \— swallowing, speaking and holding the head up. IX, X and XII are the nerves that protect the airway, which is why they outrank the rest when a client is deteriorating. XI is the exception in this group. The accessory nerve you test \— trapezius and sternocleidomastoid \— arises from the upper cervical cord, C1\–C5, and travels up into the skull before leaving it again. It is grouped with the medulla by convention and by its exit, not by its origin.

Press Start and the figure will ask you to find a nerve.

Drag sideways to see the whole figure →

The same twelve, simplified. The dots are roughly where each nerve really leaves — bunched into four clusters, as in the illustration above — and the lines fan out to evenly spaced labels so they can be read. Watch where the lines converge: four onto the pons, four onto the medulla. Each label also carries sensory, motor or both, in grey — the colour in this figure means region and nothing else. Every one of these nerves is a pair, one for each side. Press Start to test yourself: the numerals and names hide while you find the nerve.

The count, as a sanity check 2 from the forebrain, 2 from the midbrain, 4 from the pons, 4 from the medulla. Two, two, four, four. If you are reciting the twelve and lose your place, that pattern tells you which group you are in.

The classification question

Sensory, Motor, or Both

This is a classification question, and classification questions are one of the shapes this course leans on. The trap is always the same: the categories are defined by what the nerve carries, while the distractors are sorted by what the test feels like. Asking a client to smile feels like a sensation question because you are looking at a face; it is motor, because the client is moving a muscle. Ask yourself who is doing the work. If the client is reporting something — what they smell, see, hear, taste or feel — that is sensory. If the client is moving something, that is motor. If the test asks for both in one breath, the nerve is both.

The same twelve, sorted by type rather than by number.
Type	Count	Which	The thing they share
Sensory only	3	I, II, VIII	The three nerves that carry nothing but sensation — smell, sight, hearing-and-balance. You ask; the client reports. Nothing is moved. Taste is a special sense too, and it rides on VII and IX — which is why “the special senses” is not the dividing line here; carrying only sensation is.
Motor only	5	III, IV, VI, XI, XII	Three move the eye, one moves the head and shoulders, one moves the tongue. You ask; the client moves.
Both	4	V, VII, IX, X	All four are about the face and throat, where feeling and moving are inseparable. Each has a taste or sensation job and a muscle job.

Three, five, four — and the one that surprises people VIII is sensory only. Students classify it as both, because balance feels like something you do. You do not: the vestibular apparatus reports head position, and the muscles that then correct your balance belong to other nerves entirely. Romberg looks like a motor test and is a sensory one — which is exactly why closing the eyes changes the result.

The four “both” nerves all have a taste or sensation job If you cannot remember whether a face-or-throat nerve is both, ask what it feels: V feels the face, VII tastes the front of the tongue, IX tastes the back of the tongue, X carries the gag. Every one of the four has an answer. III, IV, VI, XI and XII have none — they are pure movement.

I and II

Smell and Sight

The first two are the odd ones out. Both are purely sensory, both carry a single special sense, and both are really tracts of the brain rather than peripheral nerves. They are also the two most likely to be skipped at the bedside — and the deck makes a point of that, because knowing what was not assessed is itself a finding. Take them together, learn that I is smell and II is sight, and the first two words of the acronym are secure.

I — Olfactory

Blueprint names olfactory testing Deck slide 29


Carries	Sensory Smell — and nothing else. The only cranial nerve that is purely about odour.
How you test it	Eyes closed. Occlude one nostril and test each nostril separately. Offer a familiar, non-irritating odour — the deck uses coffee, soap or fruit; the assessment form uses cologne. Non-irritating matters: an irritant such as ammonia stimulates V instead, so a client with no sense of smell still reacts and the test proves nothing.
Normal	Perceives, and can usually identify, the odour with each nostril separately.
Abnormal	Anosmia — loss of smell: the client cannot detect or identify the odour through one nostril or both. The assessment form adds the exception: a cold can blunt smell without anything being wrong with the nerve. Also expect it to be absent from the chart entirely: the deck points out that an H&P reading “CN 2–12 intact” means smell was never assessed, which is normal practice and not an omission to correct.

II — Optic

Blueprint names optic nerve testing, and the deck draws an arrow on it Deck slide 30 · drawn arrow


Carries	Sensory Visual acuity (how sharp) and visual fields (how wide). Two separate tests, and a question can ask for either.
How you test it	Acuity: Snellen chart, or have the client read print held at 36 cm (14 in.) in good light — the deck's bedside versions are read the clock or how many fingers. Test each eye and both. Fields: confrontation — sit facing the client, use your own vision as the baseline, and bring fingers in through four fields for each eye.
Normal	Reads with each eye and with both eyes; sees your fingers in all four fields at the same time you do.
Abnormal	Acuity: the client cannot read the print, or count your fingers, with one eye or with both. Fields: a visual field deficit — they miss your fingers in a field where you can see them. The deck teaches the field deficit as something you notice before you test it: the client does not eat the food on half the tray, or does not see the telephone on one side. Test acuity with the client's glasses on if they wear them; blurring that the glasses correct is a focusing problem, not a nerve one. Fields are a different question: reading glasses do not change how far out a finger can be seen, so they can stay on for confrontation.

Optic is two tests, and a question can ask for either Acuity is how sharp the vision is — a chart, or print at a set distance. Fields are how wide it is — confrontation, four fields per eye, with your own vision as the baseline. Students revise acuity and forget fields, and fields are the half with the memorable bedside sign: a client who eats only half the tray has a field deficit, not a poor appetite. The nursing response follows from it: put the call bell, the tray and anything else the client needs in the field they can see, and teach them to turn the head and scan toward the side they have lost. Safety comes first; a call bell in the blind field cannot be used.

“CN 2–12 intact” is not a typo The deck flags this because you will see it in real charts. It means the examiner assessed eleven nerves and did not test smell — which is ordinary practice, since routine screening rarely includes an odour. It is not an error to correct and not an abnormal finding. If a stem shows you that phrasing, the question is almost certainly testing whether you know which nerve is missing from it.

III, IV and VI

The Three That Move the Eye

These three are inseparable in practice: you test them with one penlight, in one movement, and the deck teaches them on a single slide for that reason. All three are motor only. The division of labour is worth having cold, because it is the most compressible fact in the whole topic — IV takes down and in, VI takes out to the side, and III takes everything else, plus the pupil and the eyelid. Learn the two small ones and III is defined by subtraction.

III — Oculomotor

Blueprint names PERRLA — testing, application, consensual reaction Deck slides 32–34


Carries	Motor Pupillary constriction — this is the PERRLA nerve — plus most of the eye movement and elevation of the upper eyelid.
How you test it	Reaction to light: bring a bright penlight in from the side, not from the front. Watch the pupil you lit (direct), then watch the other one (consensual). Accommodation: have the client focus on something distant, then on the penlight held near. Pupil size is measured in mm, and the speed is charted as brisk or sluggish. Eye movement is tested with IV and VI as the six cardinal fields of gaze.
Normal	PERRLA — pupils equal, round, reactive to light and accommodation. Brisk.
Abnormal	Anisocoria — unequal pupils. Also sluggish reaction, and ptosis (the upper eyelid droops, because III is what holds it up). When III is lost completely, all three show at once: the lid droops, the pupil is large and does not react, and the eye rests turned down and out — because only IV and VI are left pulling on it.

IV — Trochlear


Carries	Motor One muscle, one direction: the superior oblique, which turns the eye downward and inward.
How you test it	Not tested on its own. It is one of the three nerves you assess together as the six cardinal fields of gaze — hold a penlight about a foot away, ask the client to follow it with the eyes only, and move it through the six positions.
Normal	Both eyes move together, in parallel alignment, into every field.
Abnormal	The eye will not track down and in. Watch also for nystagmus — rapid involuntary eye movement — and for diplopia (double vision) reported by the client. The double vision is worst looking down — reading, or going down stairs.

Deck slides 34–35.

VI — Abducens


Carries	Motor One muscle, one direction: the lateral rectus, which turns the eye outward. Abducens — abduct — away from the midline.
How you test it	With III and IV, through the six cardinal fields of gaze. Check for nystagmus while you do it.
Normal	Both eyes coordinated, moving in unison with parallel alignment.
Abnormal	The eye will not move laterally; the client may report diplopia. With nothing pulling it outward, the eye may sit turned in toward the nose, and the double vision is worst looking toward the weak side.

Deck slides 34–35.

Two words, and III is whatever is left Trochlear — down and in. Abducens — abduct — out. Both names carry their own answer: abduct already means away from the midline. Everything else the eye does, together with constricting the pupil and holding the eyelid up, is III.

One movement tests three nerves — so “which nerve” needs the direction The six cardinal fields of gaze is a single manoeuvre that assesses III, IV and VI at once, and a stem that says only “the client follows the penlight through the six fields” has not narrowed anything down. Look for the direction. Down and in is IV. Out to the side is VI. Anything else, or the pupil, or the lid, is III. If no direction is given, the answer is all three.

V and VII

Feeling the Face, and Moving It

Here is the pairing students most often collapse, and the distinction is clean once you have said it once: V feels the face, VII moves it. Both are sensory and motor, both are tested on the face, and a stem can put them side by side precisely because the tests look alike to anyone who has not sorted them out. The sorting question is the one from earlier in this part — who is doing the work? If you are touching the client and they report what they feel, you are testing V. If you are asking them to make a face, you are testing VII.

V — Trigeminal

Blueprint names trigeminal testing Deck slides 36–37


Carries	Both Sensory: light touch, pain and temperature to the face, in three branches — forehead, cheek, jaw. Motor: the muscles of mastication — opening, clenching and chewing.
How you test it	Motor: palpate the temporal and masseter muscles while the client clenches their teeth, and note the strength. Sensory: eyes closed — the deck's words are “no peeking” — then light touch with a wisp of cotton, sharp versus dull with something like a paperclip, and hot versus cold. Test all three branches on both sides.
Normal	Equal sensation to all three branches bilaterally; distinguishes sharp from dull and warm from cold; strong, symmetrical jaw.
Abnormal	Sensory loss over one branch or one side: the client does not feel the cotton, or cannot tell sharp from dull or hot from cold. A weak or deviating jaw: the muscle under your fingers stays soft on one side when they clench. If the corneal reflex is tested, no blink.

Worth separating out The corneal reflex belongs to V — but read the deck's qualifier carefully: it is only assessed in a comatose client, or if a sensory or motor deficit has already been noted. You do not touch a wisp of cotton to the eye of an alert client as routine screening. The assessment form still lists it first among the V techniques — while the client looks upward, lightly touch the lateral sclera to bring on a blink, with a positive corneal reflex as the normal response — so an option describing it is a V test. The deck's qualifier is about when you do it, not which nerve it belongs to.

VII — Facial

The deck draws an arrow on this slide Deck slide 38 · drawn arrow


Carries	Both Motor: the muscles of facial expression. Sensory: taste — salt and sweet — on the anterior 2/3 of the tongue.
How you test it	Observe the face at rest first, noting any asymmetry. Then ask the client to raise and lower the eyebrows, wrinkle the forehead, frown, smile to show the teeth, puff out the cheeks, and close the eyes tightly — then test strength by trying to open them. Taste is tested with salt and sweet on the front of the tongue.
Normal	Symmetrical movement through all of it; eyes close with strength; distinguishes the tastes.
Abnormal	Facial asymmetry or droop, most often on one side; the client cannot keep one eye closed against resistance. Whole side weak, forehead included = the nerve itself (peripheral VII, e.g. Bell’s palsy). Forehead spared, lower face only = a central lesion, such as a stroke, in the opposite hemisphere.

Where standard anatomy differs. The territory is real; the flavours are not. VII really does carry taste from the anterior two-thirds. But salt-and-sweet-at-the-front, sour-and-bitter-at-the-back is the old “tongue map”, and it is wrong — every taste is detected across the whole tongue. It is still printed in nursing texts and it is in the deck, so answer with the deck’s labels; just do not carry the map into physiology.

V against VII — the split to have cold Deck slides 36–38 · VII carries a drawn arrow

If the stem says…	The nerve is…
A wisp of cotton to the forehead, cheek and jaw	V — sensory
Clench the teeth while you palpate the jaw muscles	V — motor
Sharp versus dull, or hot versus cold, on the face	V — sensory
Smile, frown, raise the eyebrows, puff the cheeks	VII — motor
Squeeze the eyes shut while you try to open them	VII — motor
Taste, front of the tongue — salt and sweet	VII — sensory
Taste, back of the tongue — sour and bitter	IX — not VII
The corneal reflex	V — but read the next box

Closing the eyes belongs to VII, not V Both nerves have business at the eye and it catches people out. V carries sensation from the eye's surface — which is why touching the cornea provokes a blink. VII closes the lid — it is the muscle. So the corneal reflex needs both: V to feel it, VII to perform it. If a stem asks you to squeeze the eyes shut against resistance, that is strength, and strength is VII.

VIII

Hearing and Balance

One nerve, two jobs, and the name tells you both: vestibulo- is balance, -cochlear is hearing. It is sensory only, which surprises people, and its balance half is the cranial-nerve finding that turns most directly into a fall risk rather than a neurological curiosity — which is why it sits inside a lab block about falls. The blueprint names its testing by name, with a question mark beside it, and it also names positive Romberg separately under neurology. That is the same test counted twice; learn it once, properly.

VIII — Vestibulocochlear (the deck also calls it Auditory)

Blueprint names vestibulocochlear testing Deck slide 39


Carries	Sensory Two jobs in one nerve, and the name says so: the cochlear half is hearing, the vestibular half is balance.
How you test it	Hearing: have the client occlude one ear; standing out of their sight, so they cannot lip-read, present a quiet sound a few centimetres away — the form uses a ticking watch — and ask what they hear. Repeat on the other ear. Balance: the Romberg test — feet together, arms at the sides, eyes closed, and they should stand with minimal sway for 5 seconds. Always assess gait. Note any nystagmus or reports of spinning or dizziness.
Normal	Hears equally in both ears; stands steady on Romberg. Gait is recorded in the same breath because you watch it in the same moment, but gait is cerebellar, not VIII. The assessment form does list gait under VIII, so if a cranial-nerve item offers gait as a VIII test, that is the form’s answer.
Abnormal	Hearing loss on one side; a positive Romberg — which means they sway or lose balance once the eyes close, and is a falls problem, not just a neurological finding; nystagmus; vertigo — reports of spinning or dizziness.

Worth separating out Positive Romberg is the one to have cold. The blueprint names it under Neurology as well, and “positive” is counter-intuitive — a positive result is the abnormal one. The eyes closing is the whole point of the test: vision has been covering for two systems at once — the vestibular one and proprioception, the sense of where your joints are — and closing the eyes takes the cover away from both. The course files Romberg twice — under VIII and under cerebellar function — so if a question lists it as a cerebellar test, that is the course’s own answer. Standard neurology treats Romberg mainly as a test of proprioception, and teaches that the sign is classically absent in cerebellar disease, because a cerebellar client is already unsteady with the eyes open. Many cerebellar clients do sway more with the eyes shut, so treat that as a tendency, not a rule.

What makes a Romberg “positive” Feet together, arms at the sides, eyes closed, standing with minimal sway for 5 seconds. Positive means abnormal — they sway, step, or need to be steadied. The word is counter-intuitive and the exam knows it. The reason the eyes must close is the whole mechanism: vision has been compensating for the vestibular system and proprioception all along, and shutting it off is what exposes the deficit. Stand close enough to catch them. A test that risks a fall is still your responsibility while you run it.

IX and X

The Throat, Tested as One

The deck assesses these two together, on one slide, because their jobs overlap almost completely — both are sensory and motor, both are about swallowing, gagging and speaking. For most purposes “IX and X” is a single answer, and a stem that describes saying “ah” or checking a gag is pointing at the pair. There are, however, exactly two findings that separate them, and those two are what a question has to use if it wants one nerve rather than both.

IX — Glossopharyngeal


Carries	Both Sensory: taste — sour and bitter — on the posterior 1/3 of the tongue. Motor: swallowing, the gag reflex, and speech sounds.
How you test it	Tested together with X. Ask the client to say “ah” and watch the soft palate and uvula rise symmetrically; have them yawn to see the same movement. Elicit the gag by stroking both sides of the soft palate. Note the ability to swallow.
Normal	Soft palate and uvula rise symmetrically; gag present; swallows without difficulty.
Abnormal	Asymmetrical palate rise; absent gag; dysphagia — and the first sign of that is often coughing after a sip of water.

Deck slide 40.

Where standard anatomy differs. Standard anatomy splits the gag the other way. It makes IX the sensory (afferent) limb — the side that feels the touch — and X the motor (efferent) limb that performs the lift, and it gives swallowing and voice to X, leaving IX just one small muscle. The deck assigns swallowing, gag and speech to IX as motor; answer the deck’s way on this paper. Nothing in the sensory/motor/both column changes either way — both nerves are Both on either account.

X — Vagus


Carries	Both Motor: swallowing and speech sounds. Sensory: the gag reflex. Overlaps IX so completely that the deck assesses the two as one nerve.
How you test it	Tested together with IX. On top of “ah”, gag and swallow, listen to the quality of the voice — is there hoarseness?
Normal	Swallows without difficulty and speaks audibly, without hoarseness.
Abnormal	Hoarseness — the finding that belongs to X specifically — plus dysphagia, and a uvula that pulls to one side.

Deck slide 40.

Where standard anatomy differs. See the note on IX: standard anatomy gives the motor half of the gag, the swallow and the voice to X, and the sensory half to IX. The deck has it the other way round and the deck is the exam answer.

Worth separating out IX and X are the pair most likely to be asked as a pair. If a stem gives you one finding and asks which nerve, use this split: taste at the back of the tongue is IX; hoarseness is X; gag and swallow are both, which is why the deck tests them together.

The two findings that tell IX from X Taste at the back of the tongue — sour and bitter — is IX. Hoarseness is X. Everything else on this pair — the palate rising to “ah”, the gag, the swallow — involves both, and the honest answer to “which nerve?” is both. Memorise the two exceptions and you can answer every version of this item.

Coughing after a sip of water is not a cough It is the earliest sign of dysphagia, and it is a priority finding, not a note for later. The course's own neuro case study turns on exactly this detail. If a stem offers you a new cough after fluids alongside a list of other findings, the expected action is to stop oral intake and keep the client NPO until swallowing has been evaluated — not to thicken the fluids yourself, not to offer a straw, and not to document and carry on. A nerve finding that threatens the airway outranks every other nerve finding on the page. A wet, gurgling voice after swallowing is the same warning. So is food pocketed in one cheek, which brings in two more nerves: VII holds the cheek against the teeth, and XII’s tongue sweeps the food clear.

XI and XII

Shoulders, Head and Tongue

The last two are motor only and are the easiest marks on the paper, provided you attach the right qualifier to each. Both are named in the blueprint. For XI the qualifier is “against resistance”; for XII it is “at the midline”. Drop either word and a correct-sounding option becomes the wrong one, which is precisely how these two get examined.

XI — Accessory (the deck also calls it Spinal Accessory)

Blueprint names spinal accessory testing Deck slide 41


Carries	Motor Pure motor, and only two movements: turning the head and shrugging the shoulders. It innervates the trapezius and sternocleidomastoid.
How you test it	Both movements against resistance. Ask the client to shrug the shoulders against resistance from your hands, and to turn the head to the side against resistance from your hand — then repeat on the other side. Compare strength and symmetry.
Normal	Shrugs and turns the head against resistance, with equal strength on both sides.
Abnormal	Weakness or asymmetry on one side: the client cannot shrug, or cannot hold the head turn, against your resistance as strongly as on the other side. The shoulder on the weak side may also sit lower at rest.

Worth separating out “Against resistance” is the examinable half. The blueprint names spinal accessory testing by name, and an option that has the client shrug with nothing opposing them is testing range of motion, not the nerve. No resistance, no strength grade.

And the two halves of XI report on opposite sides. The shrug is ipsilateral — the right shoulder grades the right XI. The head turn is contralateral: the right sternocleidomastoid turns the head to the left, so resisting a turn to the left is grading the right side. One nerve, two movements, opposite sides — and neither the deck nor the assessment form says so.

XII — Hypoglossal

Blueprint names hypoglossal testing Deck slide 42


Carries	Motor Pure motor, and the clue is in the name: hypo-glossal — under the tongue. It innervates the muscles of the tongue.
How you test it	Ask the client to protrude the tongue at the midline, then move it from side to side. For strength, have them push the tongue against the inside of the cheek while you resist from the outside.
Normal	Tongue protrudes at the midline and moves freely in every direction, with strength.
Abnormal	After a CVA the tongue deviates to the side of the paralysis. Also dysarthria — slurred, poorly formed speech, because the tongue shapes the sounds.

Worth separating out The direction rule points at the muscle, not at the brain. The tongue always deviates toward the weak side — that part is true of a nerve lesion and of a stroke alike. But in a cortical stroke the weak side is the opposite side from the brain lesion, so a tongue deviating right means a left-hemisphere infarct. If a stem asks which side is weak, follow the tongue; if it asks which hemisphere, cross over. A lower-motor-neuron XII lesion also wastes and twitches the tongue on that side; a stroke does not.

Which way does the tongue go? The deck states it plainly: after a CVA the tongue deviates to the side of the paralysis. The mechanism is worth a sentence, because it makes the direction impossible to reverse — the healthy side still pushes, the weak side does not, so the strong half shoves the tongue across towards the weak half. Pair it with the other two findings from the same case: slurred speech and a weaker grip on one side. Three unilateral findings together are a stroke presentation, not three separate nerve problems.

Six letters, and the blueprint wants all three of its parts

What the Letters Stand For

Every other hint in the blueprint names a nerve. This one names an acronym, and then asks for three different things from it — “PERRLA: testing, application, consensual reaction.” That is a strong signal: it is the most likely single source of a cranial-nerve question, and the consensual reaction is called out separately because it is the part students cannot explain. Start with the letters, because two of the six are the same letter doing different work.

PERRLA — the blueprint names it, and names three things it wants from it Deck slides 32–33


P	Pupils	Both of them. Size is recorded in millimetres, and the two are compared.
E	Equal	The same size as each other. Unequal pupils are anisocoria.
R	Round	Regular in outline, not oval or irregular.
R	Reactive	They respond. The speed is charted as brisk or sluggish — those are the two words to use.
L	to Light	They constrict when light hits them — and both constrict, which is the consensual half below.
A	and Accommodation	They constrict and converge as the gaze shifts from far to near. Accommodation is the eye’s ability to re-focus as an object’s distance changes.

The deck spells the word “consenual” on slide 33 and also offers indirect as an alternative term. The spelling to use is consensual; both consensual and indirect are correct names for the same thing, and a question may use either.

Three responses, one penlight

Direct, Consensual and Accommodation

Three separate observations come out of one manoeuvre, and the blueprint asks for them. The sequence that makes them easy to keep apart is: light one pupil and watch that pupil, light one pupil and watch the other one, then put the light down and change the distance. The first two differ only in which eye you are looking at — which is why the second one has its own name and its own line in the blueprint.

Three responses. The middle one is the one the blueprint calls out.
Response	What you do	What you watch for
Direct	Bring the penlight in from the side and shine it on one pupil.	That pupil constricts. Charted brisk or sluggish.
Consensual also “indirect”	Shine the light on one pupil again — but watch the other eye.	The unlit pupil constricts too, and by the same amount. This is the finding the blueprint names.
Accommodation	Have the client focus on something distant, then on a near object; move an object in towards the nose.	Pupils constrict for near and dilate for far, and converge as the object comes in.

Why the unlit pupil moves at all — and the nerve this hands you This is the point of the consensual reaction, and it is the one explanation worth having in your own words. Light arrives on one nerve and leaves on another. The signal goes in along II, the optic nerve, crosses to both sides inside the brain, and comes back out along III, the oculomotor nerve, to both pupils. One eye is lit; two eyes respond. The deck files PERRLA under III, and III is the answer to “which nerve?” — it does the constricting. The role of II here is what explains the consensual reaction, and it is worth knowing for exactly that reason.

Bring the light in from the side Approaching from the front makes the client look straight at the penlight, which triggers accommodation at the same moment you are trying to read the light reflex — so both pupils constrict and you cannot tell which response you just saw. From the side keeps the two tests separate. An option that shines a light directly into a client's line of sight is describing poor technique, however familiar it sounds.

“Equal and reactive” does not mean “normal size” PERRLA records whether the pupils match and whether they work. It does not record whether they are a normal size — that is why the size goes in millimetres as a separate number. Two pupils can be equal, round and briskly reactive and still both be abnormally large or abnormally small. Document the number as well as the acronym.

The application half

What You Physically Do

The instructor's phrasing was “the application of the nerve testing”, and that word is doing work. A question will rarely ask “what is cranial nerve XI?”. It will describe a nurse asking a client to shrug their shoulders against resistance and ask which nerve is being assessed — or give you the nerve and ask which action tests it. So the direction that matters most is from the action back to the number. The figure below runs that way round.

Press Start and the figure will describe a test; click the nerve it belongs to.

Drag sideways to see the whole figure →

The bedside test for each nerve, drawn schematically. Press Start to test yourself — the game asks in the direction the exam asks: here is the action, name the nerve. The test labels hide while you choose.

Reading the result

How to Tell a Nerve Is Damaged

Knowing how to run a test is only half of “the application of the nerve testing”. The other half is knowing what a failed test looks like while you are running it — because that is what a stem describes. It will rarely say “the client has a damaged trochlear nerve”; it will say the eye did not follow the penlight down and in, and ask which nerve. The table below puts the sign of damage next to the test, for all twelve, in one place.

Damage shows up in one of three ways The client cannot do it at all — no smell, no gag, the eye will not go there. One side does not match the other — a bigger pupil, a drooping half of the face, a weaker shoulder, a tongue off the midline. It works, but slowly or weakly — a sluggish pupil, a shrug you can push down. Every one of the three is judged against something: the client's other side, and the client's own earlier assessment.

The test, and what damage looks like while you run it.
Nerve	During the test you…	Damage looks like
I — Olfactory	Offer an odour to each nostril, eyes closed.	Cannot smell or name it through one nostril or both — anosmia.
II — Optic	Have them read print, each eye then both; bring fingers in through four fields.	Cannot read it with one eye; misses your fingers in a field where you can see them. On the ward: leaves half the tray.
III — Oculomotor	Shine the penlight in from the side; watch both pupils; check accommodation.	Unequal pupils (anisocoria), a sluggish or absent constriction, a drooping lid (ptosis).
IV — Trochlear	Move the penlight through the six fields of gaze.	The eye will not follow down and in; double vision.
V — Trigeminal	Cotton, sharp and dull, hot and cold on forehead, cheek and jaw; palpate the jaw as they clench.	Does not feel it, or cannot tell sharp from dull, over one branch or one side; a weak clench on one side.
VI — Abducens	Move the penlight through the six fields of gaze.	The eye will not move out to the side; double vision.
VII — Facial	Watch the face at rest, then ask for faces; try to open the closed eyes.	One side droops or lags — a lopsided smile, a cheek that will not puff — and the eye will not stay shut against your fingers.
VIII — Vestibulocochlear	A quiet sound at one ear at a time; Romberg with the eyes closed.	Hears it on one side only; sways or steps once the eyes close (positive Romberg); nystagmus, or reports of spinning.
IX — Glossopharyngeal	“Ah”, the gag, a swallow; sour or bitter at the back of the tongue.	The palate rises unevenly; no gag; coughs after a sip of water; cannot taste at the back.
X — Vagus	The same “ah”, gag and swallow — and listen to the voice.	Hoarseness; the uvula pulls to one side; difficulty swallowing.
XI — Accessory	Shrug and turn the head, both against your resistance, both sides.	You can push the shrug down or overcome the head turn on one side.
XII — Hypoglossal	Tongue out at the midline, side to side, then against the cheek.	The tongue deviates to one side — toward the weak side; a weak push; slurred speech.

A failed test is not always a damaged nerve Before you name a nerve, rule out the ordinary explanation. A cold blunts smell, and the assessment form says so. Trouble finding or understanding words is aphasia, which is the brain, not a cranial nerve; slurred words from a client who knows exactly what they mean is the nerves. And a finding that was already there at the client’s earlier assessment is their baseline, not new damage. Wax in the ear canal muffles hearing before any nerve is involved, so look in the ear before blaming VIII. A small, stable difference in pupil size that is on every earlier record is common and harmless; the same difference appearing since the last check is not. Blurred print that clears with the client’s own glasses is a focusing problem, not an optic nerve one. Unsteadiness with the eyes open as well as closed points at the cerebellum rather than VIII — a tendency rather than a rule. And a whole side of the face weak with the forehead spared is a stroke above the nerve, not the facial nerve itself.

A new sign of damage is reported, not just charted The week's neuro case turns on this. A client who was clear at the earlier check now has slurred speech, a weaker grip on one side and coughs after a sip of water. Each is a cranial-nerve or motor finding on its own; together, and new, they are an acute change in neurological status. Keep the client NPO because the cough threatens the airway, and notify the provider or rapid response team immediately — not rest and reassess later. What makes a finding urgent is that it is new, so the comparison with the client's own baseline is part of the test. One more pattern belongs here: both pupils turning sluggish together points at the brain rather than at one nerve, and is a sign of rising pressure inside the skull. Report it at once — though a falling level of consciousness is the earlier and more sensitive sign, and usually comes first.

Doing all twelve without a list in your hand

The Order You Actually Work In

Nobody assesses cranial nerves in numerical order, because it would mean picking up and putting down the same penlight four times. In practice you work by equipment and by region, and several nerves come out of one action. This matters for the exam in a specific way: it is why a single stem can legitimately be testing more than one nerve, and why “all of the above” style answers about III, IV and VI are often right.

Grouped the way the assessment actually runs.
You pick up…	And you assess…	In one action
Nothing	VII, XI, XII	Observation and plain instructions — make a face, shrug, stick out your tongue. The quickest three, and the ones most often done without the client realising they are being tested.
A penlight	III, IV, VI	PERRLA, then the six cardinal fields of gaze. One light, two tests, three nerves.
Something to read	II	Acuity, then fields by confrontation — no equipment needed for the second half.
A wisp of cotton	V	Light touch to forehead, cheek and jaw, eyes closed. Then clench the teeth, for the motor half.
Your voice	VIII	A whisper or a quiet sound at one ear at a time, from out of sight.
A tongue blade	IX, X	“Ah” for the palate, then the gag, then watch a swallow and listen to the voice.
An odour	I	Usually skipped entirely — see “CN 2–12 intact” earlier in this part.
Floor space	VIII, then the cerebellum	Romberg is the balance half of VIII, and the part that belongs to fall risk. Gait is cerebellar, not VIII — you watch it in the same moment, which is why the assessment form groups them, but a stem asking which system owns an unsteady gait wants the cerebellum. If it asks which cranial-nerve test the form pairs gait with, that is VIII.

Compare sides, always, and let the client be their own control Every cranial nerve is paired, and nearly every abnormal finding in this guide is described as asymmetry rather than as an absolute — one pupil bigger, one side of the face weaker, one shoulder lower, the tongue off the midline. There is no normal range to look up. The reference value is the client's other side, which is why the assessment form says to repeat each test on both sides and compare. “Compared with the other side” belongs in the answer and in the chart.

Turning a finding into a sentence

Saying It in Chart Language

Documentation is not a topic of its own on this exam’s blueprint, but the words below are how the cranial-nerve items will be phrased, so reading them is revision all the same. The pattern throughout is the one this course keeps returning to: write what you observed, not what you concluded. “Facial asymmetry noted, left side” is an observation. “Client had a stroke” is a diagnosis, and it is not yours to record.

The vocabulary a question will use, and what it describes.
Term	What it means
PERRLA	Pupils equal, round, reactive to light and accommodation — with the size in mm alongside it.
Brisk / sluggish	How fast a pupil reacts. These are the two charting words.
Anisocoria	Unequal pupils.
Ptosis	Drooping of the upper eyelid — a III finding, since III holds the lid up.
Diplopia	Double vision — reported by the client, so subjective, and pointing at the eye movers.
Nystagmus	Rapid involuntary eye movement, looked for during the six fields of gaze.
Anosmia	Loss of smell — nerve I.
Dysphagia	Difficulty swallowing — IX and X. First sign is often coughing after fluids.
Dysarthria	Slurred or poorly formed speech — a problem with the muscles of speech, so XII, X and VII. The client knows what they want to say.
Aphasia	A language problem, not a muscle one — expressive (cannot produce the words) or receptive (cannot understand them). Not a cranial nerve finding; it is cortical. Covered with the neurological terms in Part 3.

Dysarthria and aphasia are not the same finding Both come out as “trouble talking” and the distinction is a classic two-way item. Dysarthria is mechanical — the tongue, palate and lips are not forming the sounds, so the speech is slurred but the thought behind it is intact. Aphasia is linguistic — the words themselves are not available, or not understood. Dysarthria is a cranial nerve problem; aphasia is a brain problem. A stem describing slurred speech in a client who clearly knows what they mean is pointing at the nerves.

Say these out loud before you move on

Which nerve, and is it sensory, motor or both: shrug against resistance? XI, spinal accessory. Motor only. And the resistance is the point.

You shine a light in the right eye and the left pupil constricts. What is that called, and which two nerves made it happen? The consensual (indirect) reaction. In along II, out along III.

A client cannot taste the sour solution placed at the back of the tongue. Which nerve? IX, glossopharyngeal. Front of the tongue, salt and sweet, would be VII.

Which three nerves are sensory only? I, II, VIII — smell, sight, hearing and balance. The three that carry nothing but sensation.

The tongue deviates to the left. Which nerve, and which side is weak? XII. The left — it deviates towards the paralysed side.

What does a positive Romberg mean, and why must the eyes be closed? Abnormal — they sway or lose balance. The eyes are closed because vision has been compensating for the vestibular system and proprioception.

Which nerve moves the eye down and in? Out to the side? IV trochlear; VI abducens. Everything else is III.

A chart reads “CN 2–12 intact”. What was not tested? Smell — nerve I. Routine, not an error.

Following the penlight, the left eye will not move out toward the left ear. Which nerve is damaged? VI, abducens, on the left. Out to the side is VI.

The client shrugs against your hands and the right shoulder gives way. Which nerve, and how do you chart it? XI, spinal accessory, right side. Shrug weaker on the right against resistance, compared with the left.

Recall, not recognition

Twelve Cards, as Deep as You Choose

Reading this guide is recognition; the exam asks for recall, and the gap between the two is where marks go missing. The deck below closes it. Start with only “The name” ticked and go through the twelve in both directions until the order is automatic — that alone covers the acronym you are allowed to write down. Then tick one more column and run it again. The card gets harder, the deck does not get longer, and you will find out quickly that naming a nerve and knowing how to test it are two different pieces of knowledge. Cards you miss come back; cards you have go away. Nothing is saved, so the deck is new every time you open the page.

What should the card ask you for?

Show me the and I will recall the rest.

Self-graded on purpose — only you can tell whether you actually recalled it or merely recognised it once the answer was showing. Be strict with yourself in here and the paper will feel easy. The drill does not print; the tables above it do.

Key terms

myalgiaarthralgiaarticulation subluxationcontractureataxia crepitusatrophyhypertrophy polydactylysyndactylytalipes equinovarus abductionadductioncircumduction dorsiflexionplantar flexioninversion eversionpronationsupination kyphosislordosisscoliosis synovial jointhinge jointspasticity fasciculationMorse Fall Scalenuchal rigidity

Vocabulary

Terminology

Eight of the forty questions on this exam are here, and the blueprint names five topics inside them. Start with the vocabulary, because the assessment guide is written in it and several of these words appear in the stems rather than in the answers.

Term	Meaning
Myalgia	Muscle pain
Arthralgia	Bone or joint pain
Articulation	Where two bones come together — a joint
Subluxation	Bone out of place (partial dislocation)
Contracture	Difficult to stretch — shortened tendons
Ataxia	Irregular movements — cerebellar disorders
Crepitus	Grating sensation or sound in a joint
Atrophy	Decreased size due to disuse — soft, boggy
Hypertrophy	Firm, enlarged due to strengthening exercise
Polydactyly / Syndactyly	Extra digits / fused digits
Talipes equinovarus	Clubfoot

Muscle tone terms: atony (lack of normal tone/strength) · hypotonicity (decreased tone) · spasticity / hypertonicity (stiff, awkward movements) · spasm (sudden violent involuntary contraction) · fasciculation (involuntary twitching) · tremors (involuntary contraction).

Structure

Bones, Joints, Muscles and Connective Tissue

206 bones. They provide the framework of the body, protect vital organs, and are the primary storage and regulation site for calcium and phosphate. Bone marrow is the primary site of red blood cell production. Classified as short (carpal), flat (sternum, ribs), irregular (vertebrae), long (femur). Two types: compact (shaft and outer layer) and cancellous (spongy — ends and center).

Joint classification — by the type of cartilage. Know the three-way split and one example each.
Type	Mobility	Example
Fibrous (synarthrotic)	Immovable	Skull sutures
Cartilaginous (amphiarthrotic)	Slightly movable	Costal cartilage — between sternum and ribs
Synovial (diarthrotic)	Freely movable	Bones covered with cartilage meeting at a cavity; synovial fluid is the lubricant. Ball-and-socket (hip, shoulder), hinge (elbow, knee), pivot, saddle, condyloid, gliding

Connective tissue — a clean matching set.
Tissue	Function
Cartilage	Reduces friction
Tendons	Connect muscle to bone
Ligaments	Connect bone to bone; stabilize the joint
Bursae	Fluid-filled sacs cushioning bones and ligaments that may rub
Meniscus	Cartilage disc between bones — shock absorber
Fascia	Flat sheets protecting muscle fibers, attaching muscle to bone, carrying nerves and vessels

Skeletal muscle movement is stimulated by the CNS and is voluntary; smooth and cardiac muscle are involuntary. The musculoskeletal system depends on the neurologic system — which is why musculoskeletal findings always require a paired neurologic assessment.

Terms of movement

The blueprint’s example is “ROM testing: ie. flexion”, so know each term as a movement you could ask a client to make.

The deck lists the terms; the definitions are standard usage.
Term	The movement, and one to ask for
Flexion / extension	Bending a joint, which closes its angle / straightening it. Bend the elbow; straighten it.
Hyperextension	Straightening beyond the neutral line. Tip the head back.
Dorsiflexion / plantar flexion	Toes pulled up toward the shin / foot pointed down.
Abduction / adduction	Moving away from the midline / toward it. Lift the arm out to the side; bring it back.
Internal / external rotation	Turning a limb inward / outward around its own axis.
Pronation / supination	Turning the forearm palm down / palm up.
Inversion / eversion	Turning the sole inward / outward.
Circumduction	Moving a limb in a circle. Circle the arm at the shoulder.
Protraction / retraction	Moving a part forward / back. Jut the jaw out; pull it in.
Elevation / depression	Raising / lowering. Shrug the shoulders up; drop them.
Opposition	Thumb to little finger.

The safety point in red on the slide After a hip replacement, maintain abduction. Adduction past midline risks dislocating the prosthesis.

Assessment

Subjective and Objective Data

The same subjective-then-objective order as the respiratory assessment in Part 1, pointed at bones and muscles this time. The history here is doing one job above all the others: finding out whether this patient has already fallen — because nothing predicts a fall as well as a previous fall, which is also the reasoning behind the Morse scale later in this part.

Subjective

What you ask about — grouped, because the history runs in this order.
Area	What you ask
Current symptoms	Pain in joints or muscles; stiffness, swelling, weakness, twitching
Events	Recent falls and trauma, and functional status — the highest-yield item in the whole history
Past medical	Neurologic disorders · past surgeries on muscles, bones or joints · arthritis, gout
Activity	Physical problems limiting activity · sports and activities undertaken
Lifestyle	Smoking and alcohol — both affect bone density and healing
Family history	Bone cancer · rheumatoid arthritis · osteoporosis · scoliosis

Medications with musculoskeletal effects — a compact, very testable list.
Medication	Effect
Corticosteroids	Muscle weakness, osteoporosis
Potassium-depleting diuretics	Muscle cramping and weakness
Statins	Muscle aches
Fluoroquinolones	Joint pain

Postmenopausal women: ask about maximum height (compare with current — gradual height loss occurs with age), calcium supplements, and bone density.

Objective — inspection

What you look at, roughly head to toe and then in motion.
What	What you are looking for
Symmetry	Compare side against side for deformity, swelling, lesions, lacerations and muscle size. The patient is their own control
Height	Compared with their past maximum — gradual loss occurs with age
Posture and alignment	Observed sitting and standing
Spine curvatures	Kyphosis, lordosis, scoliosis — the table below
Gait, balance, coordination	Watch them walk; this is also a fall-risk assessment
Range of motion	Active first — what they can do unaided
Muscle strength	Graded 0–5, below

Curvature	Description
Kyphosis	Exaggerated thoracic convexity — a rounded upper-back hump. Common in older adults
Lordosis	Exaggerated inward lumbar curve. Normal in pregnancy
Scoliosis	Lateral S-shaped curve
Genu varum	Bowlegs — a gap running the full length between the legs while the ankles stay together. Named only in the deck's speaker notes, with an instruction to say the name aloud because the figure does not label it
Genu valgum	Knock-knees — thighs and knees meet, and the gap opens below the knee and widens down to the feet

Scoliosis assessment — the lab sequence, and a worksheet question Inspect and palpate the spine from the back · instruct the client to bend at the waist with arms reaching toward the toes · inspect and palpate down the spine with thumb and forefinger · inspect and palpate again with the client standing. Expected finding: no tenderness, spinal vertebrae midline. Bending forward reveals the rib hump. The four normal curves of the spine are cervical, thoracic, lumbar and sacral.

Palpation and range of motion

Assess joints for warmth, inflammation, edema, stiffness, crepitus, deformity, tenderness and limitations. Ask for active ROM first; assess passive ROM only if active is limited and clinically appropriate.

Stated in red — and it is a safety answer Do not move a joint past its point of pain or resistance. Never force movement. Any option that involves pushing through resistance is wrong.

Specific joints: temporomandibular — three fingers on the jaw, open and close, protract and retract the mandible; a click suggests improper alignment. Neck — palpate for crepitus, note rotation. Wrists and hands — carpal tunnel is assessed with the Phalen test and Tinel test.

Grading

Muscle Strength and Neurovascular Status

Two graded scales, and one checklist that is genuinely urgent. Strength is scored 0–5 and is mostly documentation. The neurovascular check is the one that finds a limb in trouble, and it is the reason a patient in a cast is assessed on a schedule rather than when they complain.

Muscle strength grading, 0/5 to 5/5 MSK deck slide 15 · assessment guide

Grade	%	Label	Description
5/5	100%	Normal	Complete ROM against gravity with full resistance — the expected finding
4/5	75%	Good	Complete ROM against gravity with moderate resistance
3/5	50%	Fair	Complete ROM against gravity only
2/5	25%	Poor	Complete ROM with the joint supported; cannot perform against gravity
1/5	10%	Trace	Muscle contraction detectable — no movement of the joint
0/5	0%	Zero	No visible muscle contraction

The pivot is gravity: 3/5 is the grade at which the patient can just overcome it. Above 3 adds resistance; below 3 requires gravity to be eliminated.

Neurovascular check — the 5 P's plus

Assess pain, pallor, pulses, paresthesia, paralysis, plus temperature, capillary refill, movement and sensation — all distal to the area of concern.

Acute injury — the red-lettered rule Nurses do not attempt to correct a misalignment — doing so could cause a compound injury. Assess colour, temperature, capillary refill and pulses distal to the injury.

Report: new or worsening pain · deformity, swelling, redness, warmth or suspected fracture · new weakness or inability to bear weight · numbness, tingling, loss of sensation, inability to move fingers or toes · cool, pale, cyanotic or mottled extremity · absent or diminished pulses compared with the opposite side · delayed capillary refill · unsafe gait.

Normal reference values used in the guide's sample documentation: pulses 2+ bilaterally, capillary refill less than 3 seconds, strength 5/5 in all extremities.

Fall safety

The Morse Fall Scale

Braden turned pressure-injury risk into a number; Morse does the same for falls. Worth noticing as you read: the two scales run in opposite directions — a low Braden is bad, a high Morse is bad — and mixing them up is the easiest mark to drop on either one.

Morse Fall Scale — score bands MSK deck slides 19–21 · in blue on the slide · UPMC's implemented tool

Score	Risk
Range	0 to 125
0	No risk for falls
Under 25	Low risk
25 to 45	Moderate risk
Over 45	High risk

A high score means risk of fall. Note the direction is the opposite of Braden, where a low score is bad. Assessed daily in acute care.

The point the slide makes in its own red text The total score indicates how likely a fall is, but not how to protect the patient. The goal is to identify WHY the patient is at risk. You select interventions to address each area of risk, then communicate the tailored plan to the whole care team — nurses, nursing assistants, physical therapists, physicians, patients and family. Fall prevention starts with the whole care team working from the same plan.

Interventions by area of risk — matching an intervention to the right risk area is the likely question form.
Area of risk	Interventions
History of falling	Safety precautions; communicate risk status via plan of care, change-of-shift report and signage; document the circumstances of the previous fall
Secondary diagnosis	Consider illness, medication timing, and side effects — dizziness, frequent urination, unsteadiness
Ambulatory aid	Aid at the bedside if appropriate; consider a physical therapy consult
IV therapy / saline lock	Toileting and rounding schedule; instruct the patient to call for help with toileting; review IV medication side effects
Gait	Assist out of bed; consider physical therapy consult
Mental status	Bed or chair alarm; place the patient in a visible location; encourage family presence; frequent rounding

Context and care

Lifespan, Labs, Problems and Interventions

Four short reference tables that did not belong anywhere else. Skim them. The only items likely to be tested are the ones that connect to something already taught — calcium and vitamin D to bone density, creatine kinase to muscle damage, and immobility to the fall risk the Morse scale measures.

Stage	Findings
Pregnancy	Lordosis — lumbar curvature, shifting the center of gravity; raises balance, fall and back-pain risk
Infancy–adolescence	Muscular growth; strengthening with use, atrophy with disuse, hypertrophy with weight lifting. Assess for scoliosis
Older adults	Kyphosis, osteoporosis

Cultural and gender considerations: males have larger, stronger bones; females are at higher risk of osteoporosis — specifically Caucasian women. Osteoporosis has no cure; the goal is prevention. Working conditions matter — heavy lifting and repetitive motion cause musculoskeletal injury.

Labs and diagnostics.
Test	Indicates
Creatine kinase (CK)	Muscle damage
Lactate dehydrogenase (LDH)	Tissue damage
ESR, CRP, rheumatoid factor	Inflammatory markers
X-ray	Bones
CT and MRI	Soft tissue

Problems and their interventions.
Problem	Interventions
Impaired physical mobility	Non-skid footwear; assist with transfer and ambulation; reposition every 2 hours
Activity intolerance	Determine the cause (SOB, hypotension, dizziness); plan activities with rest periods; rise slowly to prevent orthostatic hypotension
Impaired walking	Follow weight-bearing restrictions (collaborative); use cane or walker; obtain appropriate assistance; limit obstacles — IV tubes, chest tubes
Self-care deficit	Assess ability to perform ADLs; encourage independence as much as possible; use adaptation devices

Self-test — Part 5

Tendon or ligament — which connects bone to bone? Ligament. Tendons connect muscle to bone.

Name the three joint types by mobility, with an example each. Fibrous/synarthrotic — immovable, skull sutures. Cartilaginous/amphiarthrotic — slightly movable, costal cartilage. Synovial/diarthrotic — freely movable, hip and knee.

A patient completes full ROM against gravity but tolerates no resistance. Grade? 3/5 — fair, 50%.

What position is the patient placed in to screen for scoliosis, and what is the expected finding? Standing, then bending at the waist with arms reaching toward the toes. Expected: no tenderness, vertebrae midline.

Name the four normal curves of the spine. Cervical, thoracic, lumbar, sacral.

A Morse score of 50 — what risk level, and does high mean better or worse? High risk. On Morse a high score is worse — the opposite direction from Braden.

What movement must be maintained after hip replacement? Abduction.

Which lab indicates muscle damage? Creatine kinase (CK). LDH indicates tissue damage.

A patient's limb is deformed after a fall. Do you realign it? No — never. Assess colour, temperature, capillary refill and pulses distal to the injury and report.

What the blueprint adds on top

The Five Named Musculoskeletal Topics

The sections above are the assessment as the lab deck teaches it. The blueprint then names five things specifically, and two of them are not really musculoskeletal at all — posturing is a brain finding and lives in Part 3, and safety teaching across the lifespan is a teaching question wearing a musculoskeletal coat. Both are listed here so the mapping is explicit.

The blueprint’s five, and where each one is answered.
Named topic	Where it is, and what to know
Decerebrate / decorticate posturing	Part 3, with the rest of the brain. Decorticate = flexed to the core, less grave. Decerebrate = extended, worse.
Strength ratings	The starred 0–5 scale on the marked-content page. 3/5 is the hinge — at 3 and above they beat gravity.
ROM testing, e.g. flexion	Active first — what they can do unaided. Passive only if active is limited, and never past the point of pain or resistance.
Posture across the lifespan	Pregnancy → lordosis (the lumbar curve deepens). Adolescence → scoliosis, which is what you screen for. Older adults → kyphosis, and height loss.
Safety teaching across the lifespan	The table below.

Safety teaching, by age group. The blueprint names young adult, elderly, inpatient and community.
Group	What you teach, and why
Young adult	Injury prevention — sport and recreation, safe lifting and repetitive strain at work, seat belts, protective equipment. This group is injured by activity, so the teaching is about doing it safely rather than doing less.
Older adult	Fall prevention — and it is environmental as much as physical. Remove loose rugs and clutter, light the route to the bathroom, grab bars, non-slip footwear, review medications that cause dizziness. Plus calcium, vitamin D and weight-bearing exercise for bone density. Osteoporosis has no cure — the goal is prevention.
Inpatient	Assess fall risk daily in acute care. Bed in the low position, call bell within reach, non-skid footwear, bed or chair alarm for a confused client, place them where they can be seen, frequent rounding, a toileting schedule. Answer the call bell promptly — most inpatient falls happen on the way to the bathroom.
Community	Home hazard assessment, assistive devices fitted and actually used, physical therapy referral, vision checked, and a plan for what to do if they fall and cannot get up.

Muscle groups tested against resistance, from the lab deck. The blueprint says “ROM testing: ie. flexion”.
Group	How it is tested
Sternocleidomastoid	Hands on the side of the head; the client turns the head against your resistance. Also cranial nerve XI.
Deltoid	Arm abducted and held up against downward pressure.
Biceps / triceps	Flexion and extension at the elbow against resistance.
Wrist, fingers, grip	Hand grasp — equal and strong? The quickest screen there is, and the one most often documented.
Hip	Raise the straight leg against resistance; then abduction and adduction against your hands.
Quadriceps	Prevent extension — the client straightens the knee while you resist.
Hamstring	Prevent flexion — the client bends the knee while you resist.
Ankle and foot	Dorsiflexion and plantarflexion against resistance.

Every one of these is graded on the same 0–5 scale The scale is the starred content; this list is where you apply it. Two details are worth keeping: the quadriceps and hamstring are tested by asking the client to resist you rather than to move freely — the deck's words are prevent extension and prevent flexion — and the sternocleidomastoid appears in three different parts of this exam: here as a muscle group, in Part 4 as cranial nerve XI, and in Part 1 as an accessory muscle of respiration.

Fall risk: the score tells you how likely, not what to do The deck makes this point explicitly about the Morse Fall Scale and it generalises to every risk tool in this course. A total score predicts; the subscales direct. Two clients can both score 55 and need completely different plans — one because of an unsteady gait, the other because of confusion. So the question “what intervention does this client need?” is never answered by the total. Go to the area that produced the points.

The marked items, one more time

If you memorise nothing else

Item	Answer
Normal ABG values	pH 7.35–7.45 · PaCO₂ 35–45 mmHg, the respiratory number, an acid · HCO₃ 22–26 mEq/L, the metabolic number, a base · PaO₂ 80–100 mmHg, oxygenation only
Hypoxemia	PaO₂ 60–79 mild · 40–59 moderate · below 40 severe
The two cranial-nerve sentences	On Old Olympus’ Towering Top, A Finn And German Viewed Some Hops gives the names. Some Say Money Matters, But My Brother Says Big Brains Matter Most gives sensory, motor or both. You may write them on the test.
Muscle strength	5 full resistance · 4 moderate resistance · 3 against gravity only · 2 only with gravity eliminated · 1 a flicker you can feel, no movement · 0 nothing. 3/5 is the hinge: at 3 and above they beat gravity
Level of consciousness	Alert → lethargic → obtunded → stuporous → comatose. A scale, not a list, and the earliest and most sensitive sign of neurological change
Short-term memory · judgment	Repeat a set of numbers or a list of objects · ask how they would respond to a specific situation
Optic, cranial nerve II	Acuity and fields, each eye and then both
Facial, cranial nerve VII	Make faces · taste, salt and sweet, on the front of the tongue

Other numbers worth knowing

Number	What it belongs to
40 + 1	Multiple-choice questions, plus one picture question about where you listen to lung sounds
12 · 8 · 8 · 8 · 4	Respiratory · neurology · cranial nerves · musculoskeletal · ABGs
3 lobes · 2 lobes	Right lung · left lung. There is no left middle lobe
4th to 6th rib	The right middle lobe, at the midclavicular line, anterior only — standard anatomy, not the deck
2.5 cm	How much higher the right apex sits than the left
12–20 · 1:2	Normal adult respiratory rate · inspiration to expiration. Below 12 is bradypnea, above 20 tachypnea
Packs × years	Pack-year history: packs per day times years smoked
7.33 · 25 · 12	Mr Sweet’s pH, CO₂ and bicarbonate. Metabolic acidosis, in DKA
7.48 · 28 · 22	Mr Worried’s pH, CO₂ and bicarbonate. Respiratory alkalosis, from anxiety
15 · 8 · 3	Glasgow Coma Scale: best · coma · lowest. Eye scores to 4, verbal to 5, motor to 6
T4 · T10 · T12	Dermatomes after an epidural: nipple line, where loss above it means respiratory arrest · umbilicus · groin
5 seconds	A normal Romberg: minimal sway, feet together, eyes closed
100, back by 7	The calculation test in mental status
14 inches	Reading print to test acuity when there is no chart
Two, two, four, four	Where the cranial nerves leave: forebrain I–II · midbrain III–IV · pons V–VIII · medulla IX–XII
206	Bones in the body
0 to 125	Morse range. 0 no risk · under 25 low · 25 to 45 moderate · over 45 high
2+ · under 3 seconds · 5/5	Normal pulses · capillary refill · strength, in the sample documentation

Sequences and decision rules

Situation	Rule
Reading a gas	pH → PaCO₂ → HCO₃ → which one matches the pH names the imbalance. CO₂ = respiratory, HCO₃ = metabolic
Both numbers match the pH	A combined respiratory and metabolic acidosis — worse than either alone
Acute shortness of breath	Head of bed up → pulse, blood pressure, saturation, lung sounds → oxygen → remain calm → alert the emergency team if it deteriorates
Auscultating	Diaphragm on bare skin · mouth breathing · one full breath per site · side to side, apices to bases · the front too, for the right middle lobe
Coarse, low-pitched sound	Rhonchi. Have them cough, then listen again
Stridor	Stay with the patient, upright, assess the airway and ability to speak, notify immediately
Wheezes	Anticipate a bronchodilator, then reassess the sounds after the treatment
PERRLA	Penlight in from the side · direct, then consensual: light one pupil, watch the other · accommodation, far then near · document the size separately
Decorticate → decerebrate	Flexion to extension = deterioration, report immediately. The other way is improvement
Range of motion	Active first. Passive only if active is limited, and never past pain or resistance
A deformed limb after a fall	Never realign it. Colour, temperature, capillary refill and pulses distal to the injury, and report
Morse score	The total predicts; the subscales direct. Choose interventions from the area that produced the points

The traps

Trap	Correct answer
A posterior landmark for the middle lobe	Wrong on its face. Right lung, anterior
Bronchial sounds in a lower lobe	Abnormal, though bronchial is a normal sound. Each sound is normal only in its own place
Restless, combative, disoriented	A hypoxia sign, not a behaviour problem. Cyanosis is late; clubbing is chronic
Biot versus ataxic	Peaks all the same height = Biot · all different = ataxic · a climbing baseline = air trapping
Tingling fingers	Alkalosis excites the nervous system; acidosis depresses it
Kussmaul	The lungs compensating for metabolic acidosis — Mr Sweet’s breathing
“No compensation”	Does not mean the other number is normal. A number moving against the pH is the rescue, not the disease
Vomiting · diarrhoea	Vomiting loses acid → metabolic alkalosis · diarrhoea loses bicarbonate → metabolic acidosis
Five practice gases	Expect one normal among them
The worksheet’s reversed lines	Fast, deep breathing blows CO₂ off; slow breathing retains it
Positive Romberg	Means abnormal. Counts as a cerebellar test on this exam, and also sits under VIII
Stuporous	Requires painful stimuli to respond. Comatose is unresponsive
Vibration intact	No need to test position sense — same pathway
Weak or clumsy	Weak is motor; clumsy is cerebellar
Stereognosis	Identify an object by feel, eyes closed. Any sensory test passable by looking is not a sensory test
Ammonia for smell	Tests V, not I. Use a familiar, non-irritating odour, one nostril at a time
Tongue after a CVA	Deviates toward the weak side
Shrug with no resistance	Proves nothing about XI. Against resistance, both sides
Sternocleidomastoid	Three parts of this exam: an accessory muscle of breathing, cranial nerve XI, and a muscle group graded 0–5
Morse versus Braden	A high Morse is bad; a low Braden is bad
After a hip replacement	Maintain abduction. Adduction past midline risks dislocation

Read the recap

Part 1 · Respiratory Assessment

Recap: Respiratory Assessment

Respiratory is the biggest block on the paper, 12 questions, and it carries the picture question too. Start with the one question the blueprint writes out for you. There is a right middle lobe and no left one. The right lung has three lobes and the left has two, because the heart takes the space. The right middle lobe is heard from the front, roughly the fourth to sixth rib at the midclavicular line, and never from the back. Listening posteriorly mostly reaches the lower lobes.

Most of the assessment is decided before the stethoscope comes out. Tripod positioning, pursed lips, nasal flaring and accessory muscles all mean the work of breathing is up. A restless, combative or confused client is showing a hypoxia sign, not a behaviour problem. Cyanosis is a late sign, and clubbing tells you about months of low oxygen rather than today. The normal adult rate is 12 to 20.

The three normal breath sounds are examined by where they belong. Vesicular is soft and low over most of the lungs. Bronchovesicular is heard near the main bronchi. Bronchial is loud and hollow over the trachea, so bronchial sounds out in a lower lobe are abnormal and suggest consolidation.

For the adventitious sounds, learn what you do as well as what you hear. Crackles are fine popping: sit the client up, have them cough and deep breathe, and report new or worsening crackles. Wheezes are musical and point to narrowed airways, so anticipate a bronchodilator and listen again afterwards. Rhonchi clear with a cough, so coughing and re-listening comes first. A pleural friction rub grates and hurts on inspiration. Stridor is an airway emergency: stay with the patient, keep them upright and notify immediately.

Two picture-shaped topics close the part. Among the breathing patterns, Biot has bursts of even breaths with irregular pauses, ataxic is irregular in both depth and rhythm, and air trapping is the one whose baseline climbs. Kussmaul is rapid, deep breathing that blows off acid in metabolic acidosis. For listening, use the diaphragm on bare skin and compare side to side from the apices down, because the other lung is your control. When a client is acutely short of breath, the deck gives the order: raise the head of the bed first, then assess, then give oxygen, stay calm, and call for help if it gets worse.

Part 2 · Arterial Blood Gases

Recap: Arterial Blood Gases

Only four questions, and the blueprint has taken compensation off the table, which makes these the cheapest marks on the paper. Memorise the normal values, because the slide itself says to: pH 7.35 to 7.45, CO₂ 35 to 45, bicarbonate 22 to 26. CO₂ is the respiratory number and acts as an acid; bicarbonate is the metabolic number and acts as a base. PaO₂ tells you about oxygen, not acid and base.

The routine has four steps. Read the pH, read the CO₂, read the bicarbonate, and ask which one matches the pH. That one names the imbalance. Say it as a sentence: the pH is acid, the CO₂ is acid, they match, so it is respiratory acidosis. No compensation does not promise the other number will be normal. A number moving against the pH is the body trying to help, not the cause.

Then learn each imbalance as a story. Respiratory acidosis is retained CO₂ from hypoventilation, such as COPD or an opioid overdose, and the fix is better ventilation. Respiratory alkalosis is CO₂ blown off by fast breathing, often anxiety, so you coach the breathing. Metabolic acidosis is acid gained or base lost, such as DKA or severe diarrhoea. Metabolic alkalosis is acid lost, such as vomiting or NG suction. Vomiting and diarrhoea go opposite ways, and that pair catches people every year. And acidosis depresses the brain while alkalosis excites it.

The blueprint names two patients. Mr Worried is anxious, breathing fast, with tingling fingers, and his gas is respiratory alkalosis. Mr Sweet is in DKA, and his gas is metabolic acidosis; his low CO₂ is his lungs helping, which is the Kussmaul breathing from Part 1. Among the five practice gases on the worksheet, one is completely normal, and a paper that asks you to interpret several gases will usually hide one like that.

Part 3 · Neurological Assessment

Recap: Neurological Assessment

Eight questions, and the blueprint names every topic: cerebellar testing, short-term memory and judgment, stereognosis and a positive Romberg. Mental status is also the slide the deck marks with an arrow. Level of consciousness runs as a scale from alert to lethargic, obtunded, stuporous and comatose, and it is the earliest sign of neurological change. Test recent memory by having the client repeat numbers or a list. Test judgment by asking how they would respond to a situation. For a client who cannot follow the usual tests, the Glasgow Coma Scale scores the best eye, verbal and motor response: 15 is the best, 3 the lowest, and 8 means coma.

The cerebellum coordinates rather than moves. Its tests are finger to nose, heel to toe walking, Romberg and gait, and the abnormal result is clumsiness in someone with normal strength. Weak is motor; clumsy is cerebellar. A positive Romberg means abnormal: the client sways or steps once the eyes close. Closing the eyes removes vision, which would otherwise cover for a deficit. On this exam, Romberg counts as a cerebellar test, because that is how the course files it.

Stereognosis means identifying a familiar object by feel, with the eyes closed. It and its neighbours, such as graphesthesia, two-point discrimination and position sense, test whether the brain can interpret a sensation, not just feel it. Any sensory test that can be passed by looking is not a sensory test.

Finally, posturing. Decorticate is the arms flexed in to the core, and it is the less grave of the two. Decerebrate is the arms rigid and extended, and it means the brainstem is involved. A change from decorticate to decerebrate is a deterioration, and it is reported immediately.

Part 4 · The Twelve Cranial Nerves

Recap: The Twelve Cranial Nerves

Eight questions, just like the quiz: the number, the name, and how each nerve is tested. You may write the acronym on the test, so write both sentences down first. The first gives the names, from olfactory through hypoglossal. The second, Some Say Money Matters, But My Brother Says Big Brains Matter Most, tells you whether each nerve is sensory, motor or both.

Expect the question to describe a test and ask for the nerve. Smell, one nostril at a time with the eyes closed, is the olfactory nerve; an irritant like ammonia tests the trigeminal instead. Acuity and visual fields are the optic nerve. PERRLA is the oculomotor nerve. The trigeminal nerve is light touch across the forehead, cheek and jaw, plus clenching the teeth. Hearing and Romberg are the vestibulocochlear nerve. A shrug and a head turn against resistance are the accessory nerve. Sticking the tongue out at the midline is the hypoglossal nerve, and after a stroke it deviates toward the weak side.

PERRLA is the hint the blueprint breaks into three parts: testing, application and the consensual reaction. Bring the penlight in from the side. The lit pupil constricts, and so does the other one, which is the consensual response. Then check accommodation, far then near. PERRLA does not record pupil size, so the size is documented separately. The nerves that leave the medulla include three airway nerves, glossopharyngeal, vagus and hypoglossal, and that is why they outrank everything else in a deteriorating client.

Part 5 · Musculoskeletal and Fall Safety

Recap: Musculoskeletal and Fall Safety

Eight questions, and the blueprint names five topics. Strength is graded from 0 to 5, and gravity is the hinge. At 3 out of 5 the client moves fully against gravity but takes no resistance; 4 adds moderate resistance and 5 is full strength. Below 3, the joint has to be supported, down to a flicker of contraction at 1 and nothing at 0. Range of motion is tested actively first, and passively only if active is limited. Never move a joint past pain or resistance. The quadriceps and hamstrings are tested by having the client resist you.

Posture changes across the lifespan. Pregnancy deepens the lumbar curve, which is lordosis. Adolescents are screened for scoliosis by bending forward at the waist. Older adults develop kyphosis and lose height. Safety teaching changes with the audience. Young adults are injured by activity, so teach them to do it safely. Older adults need fall prevention at home, along with calcium, vitamin D and weight-bearing exercise. Inpatients need the bed low and the call bell within reach, with prompt answers to it. People living in the community need a home hazard check and devices they actually use.

The Morse Fall Scale runs the opposite way from Braden: a high Morse score is bad, and over 45 is high risk. The total says how likely a fall is, but not what to do; the intervention comes from the area that scored the points. After an injury, never try to realign a limb. Check colour, temperature, capillary refill and pulses below the injury, and report. After a hip replacement, keep the leg in abduction. And remember that decorticate and decerebrate posturing appear on the blueprint under musculoskeletal, but they are answered from Part 3.

Sources. The course's own material throughout: the respiratory lab deck, the ABG lecture deck and its speaker notes, the neurological assessment lab deck and its five drawn emphasis marks, the musculoskeletal lab deck and the Musculoskeletal Assessment Guide, the cranial nerves assessment form, both ABG worksheets, the Week 8 preparation document (which, despite its name, is where the respiratory vocabulary, the lung-sound guide and the adventitious-sounds-and-interventions table live), and the Exam 3 blueprint. Chapter references are to Taylor, Fundamentals of Nursing — Ch 40 Oxygenation.

What moved here from Exam 2. The whole of Part 5. The Exam 2 blueprint named four areas and no musculoskeletal content, so that material sat in the Exam 2 guide as lab revision; the Exam 3 blueprint gives it eight questions, so it has been lifted across whole. Nothing was rewritten in the move beyond the framing, and the Exam 2 guide and its two papers were cleaned up behind it.

Where the course documents need care. Three places, all flagged in context. First, the ABG worksheet's summary page has two lines reversed — it has rapid deep breathing retaining more CO₂, which is backwards, and the handout's own next lines contradict it; one lecture slide has the same slip. Second, the ABG deck's star sits just off the edge of its slide, so it may not show when the slide is projected; the MEMORIZE and the speaker note are on the slide itself. Third, the deck files Romberg both under CN VIII and under cerebellar function. On this exam the deck's filing is the answer; standard neurology treats it primarily as a proprioceptive test, and the Romberg sign tends to be absent in cerebellar disease.

About the weighting. Respiratory is twelve questions — half as many again as any eight-question block, and three times the ABGs. If time is short, revise respiratory first. The ABGs are four questions and the blueprint has removed compensation from them, which makes them the cheapest marks on the paper: four steps, four possible answers, no partial credit to agonise over.

Part 4 is the Quiz 2 guide’s cranial-nerve material, carried across whole with only its cross-references changed, so the two guides teach the nerves in the same words.

Expect application. The blueprint opens by saying so — “N120 is understanding the concepts and application in the nursing process” — and it asks for the “application” of cerebellar testing and of nerve testing by name. Reading the tables is not enough; the companion practice papers are where that gets built.

Sections set in this smaller grey type are standard nursing content added for completeness, or notes on where a course document and standard practice differ. They are labelled so you always know what came from your instructor and what did not. Where the two conflict, what you were told in class wins.

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