Ch 25 Assessing Neurologic System PrepU

When the nurse is assessing a client's mental status as part of the screening neurological examination, which question would be most appropriate to ask? "Can you tell me where you are right now?" "Do you feel like crying often?" "Do you have a history of psychotic disorder?" "Can you tell me about your mood today?"

"Can you tell me where you are right now?" Explanation: The nurse should only assess for orientation to date and place when conducting a mental status assessment as part of the screening neurological examination. Asking details about mood, history of psychiatric disorders, and fluctuations in emotions is better done when conducting a full mental status assessment, not as part of the screening neurological assessment.

A client presents to the health care facility for a routine health checkup. The nurse learns that the client has a long history of cardiovascular disease, including hypertension and carotid artery disease. When assessing this client for potential problems in the nervous system, which question by the nurse is appropriate? "Do you have trouble hearing people when they talk to you?" "Have you noticed any changes in your vision?" "Are you having any dizziness or lightheadedness?" "Have you noticed any weakness in your muscles?"

"Are you having any dizziness or lightheadedness?" Explanation: Clients with carotid artery disease may experience dizziness or lightheadedness, especially with ambulation because of the increased difficulty in circulating enough blood and oxygen to the brain. Trouble hearing and changes in vision may signal cranial nerve dysfunction. Weakness in the muscles of the extremities is an indication of a CVA or nerve injury

The nurse is assessing the neurologic system of an adult client. To test the client's use of memory to learn new information, the nurse should ask the client "What did you have for breakfast?" "How old were you when you began working?" "Can you repeat rose, hose, nose, clothes?" "Can you repeat brown, chair, textbook, tomato?"

"Can you repeat brown, chair, textbook, tomato?" Explanation: Remote memory (past dates and historical accounts) may be impaired in cerebral cortex disorders.

Which area of the brain integrates the understanding of spoken and written words? Wernicke's area Broca's area Basal ganglia Cerebrum

Wernicke's area Explanation: Wernicke's area integrates the understanding of spoken and written words, while Broca's area regulates verbal expression and writing ability. The basal ganglia controls voluntary motor movements, cognition, and emotion. The cerebrum is the part of the brain that contains the cerebral cortex, hippocampus, basal ganglia, and olfactory bulb.

The nurse is caring for a client who suffered a stroke and is able to carry out simple instructions correctly but has trouble writing responses to questions. The nurse plans to review the client's MRI report of the brain and expects to find that which area of the brain has been adversely affected? Wenicke area Broca area Temporal lobe Occipital lobe

Broca area Explanation: The Wernicke area integrates understanding of spoken and written words, whereas the Broca area regulates verbal expression and writing ability. The primary visual area is the occipital lobe at the back of the brain, with visual associative areas that interpret and integrate stimuli. The temporal lobe registers auditory input and is responsible for hearing, speech, behavior, and memory.

A nurse is providing a client with discharge instructions after being diagnosed with seizures. What discharge teaching should the nurse provide? Select all that apply. "Wear a medical identification bracelet." "Take medication as prescribed." "You will need to take safety precautions when using machinery." "Seizure medication may be discontinued if there are no seizures in a week." "You may be evaluated as to whether or not you may safely drive a motor vehicle."

"Wear a medical identification bracelet." "Take medication as prescribed." "You will need to take safety precautions when using machinery." "You may be evaluated as to whether or not you may safely drive a motor vehicle." Explanation: A client who has been diagnosed with seizure disorders should wear a medical identification bracelet. The client needs to take the medication prophylactically to prevent seizures, not when actively seizing. Safety precautions related to driving and operating machinery need to be taken. Each client with a seizure disorder is evaluated for ability/safety to drive a motor vehicle.

The nurse lightly strokes the sides of a client's abdomen, above and below the umbilicus. For which reflex is the nurse testing? Babinski Abdominal Cremasteric Ankle clonus

Abdominal Explanation: Abdominal reflexes are assessed by lightly stroking the abdomen on each side, above and below the umbilicus. This evaluates the function of the spinal levels T8-T10 with the upper abdominal reflex and spinal levels T10-T12 with the lower abdominal reflex. The sole of the foot is stroked to assess for the presence of the Babinski reflex. The inner thigh is stroked when assessing the cremasteric reflex in a male client. The ankle is dorsiflexed when assessing for ankle clonus

A 7-year-old boy is performing poorly in school. His teacher is frustrated because he is frequently seen "staring off into space" and not paying attention. If this is a seizure, it most likely represents which type? Pseudoseizure Tonic-clonic Absence Myoclonus

Absence Explanation: This is a common description and scenario for absence seizures, which are generally brief (fewer than 10 seconds, "petit mal"). They generally occur without warning and do not have a post-ictal confused state. Pseudoseizures are difficult to diagnose but generally involve dramatic-appearing movements, similar to tonic-clonic seizures. Myoclonus represents a single brief jerk of the trunk and limbs.

The nurse enters a client's room to administer a prescribed anticoagulant for atrial fibrillation. The client exhibits new onset facial drooping and slurred speech. What is the nurse's priority action? Administer the PO anticoagulant immediately. Assess the client's bleeding time before medication administration. Ask the client to raise both arms in front of the client's body. Assess the client's vital signs and cranial nerves.

Ask the client to raise both arms in front of the client's body. Explanation: Atrial fibrillation increases risk for stroke because quivering atria can lead blood to stagnate and then form small clots. A clot that breaks off can circulate to the brain and block the artery, causing an embolic stroke. In sickle cell disease, blood cells tend to be stickier, causing clots to form more easily in narrowed arteries. This client's symptoms are consistent with a possible stroke. The nurse's priority is to perform a brief focused assessment and notify the healthcare provider right away. Administering the medication and checking the labs are not priorities of care during the acute phase of a stroke. Vital signs should be assessed right away, but it is not necessary to test cranial nerves initially.

While conversing with a 42-year-old client, the nurse notes the client's tendency to repeatedly wink and shrug his shoulders at irregular intervals. The movements do not appear to correlate with the client's conversation. How should the nurse best follow up this observation? Order a CT (computed tomography) of the client's head. Assess the client's immunization history. Assess the client's cranial nerves VIII, IX, and X. Assess the client's medication regimen and history of recreational drug use.

Assess the client's medication regimen and history of recreational drug use. Explanation: The client's movements would likely be characterized as tics, causes of which can include drugs such as phenothiazines and amphetamines. A CT scan is not likely warranted, and CNs VIII, IX, and X do not affect movements of either the eyes or shoulders. An infectious etiology is unlikely, so the client's immunization history is not relevant.

A nurse is preparing to assess a client's cerebellar function. What aspect of neurological function should the nurse address? Remote memory Sensation Mental status exam Balance

Balance Explanation: Balance and coordination are functions of the pyramidal and extrapyramidal tracts of the motor and cerebellar systems. Remote memory and mental status exam provide information about the client's cognitive ability. Testing for sensation would address issues with specific cranial nerves or problems involving the parietal lobe.

After conducting a screening neurological examination, the nurse identifies the client is at risk for a stroke. Which of the following client education should the nurse provide at this time? Select all that apply. Begin smoking cessation Take prescribed antihypertensive medication Limit exercise to 10 minutes daily Warning signs of a stroke Use continuous positive airway pressure (CPAP) device as prescribed.

Begin smoking cessation Take prescribed antihypertensive medication Warning signs of a stroke Use continuous positive airway pressure (CPAP) device as prescribed. Explanation: For the client who is at risk for a stroke, the nurse should provide education regarding smoking cessation, controlling hypertension, using a CPAP device as prescribed, and the warning signs of a stroke. The client who is at risk for a stroke would benefit from a regular exercise program such as brisk walking for at least 30 minutes daily. Limiting exercise to 10 minutes daily would be considered a risk factor.

The nurse is assessing the client's coordination and finds that her movements are clumsy, unsteady, and inappropriately varying in their speed, force, and direction. The nurse notes that client has dysmetria. What would the nurse know this client has? Cerebellar disease Cerebral disease Brainstem disease Basal ganglia disease

Cerebellar disease Explanation: In cerebellar disease, movements are clumsy, unsteady, and inappropriately varying in their speed, force, and direction. The finger may initially overshoot its mark, but finally reaches it fairly well, termed dysmetria. An intention tremor may appear toward the end of the movement

The husband of a 65-year-old female tells the nurse, "My wife is having trouble navigating the steps in our home and needs my help to step down off a curb." What part of the nervous system should the nurse assess for a potential source of the problem? Cerebellum Temporal lobe Cranial nerves Deep tendon reflexes

Cerebellum Explanation: The cerebellum's primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone. The temporal lobe is part of the cerebrum and helps with receiving and interpreting impulses from the ear. The cranial nerves evolve from the brain or brain stem and transmit motor or sensory messages. Deep tendon reflexes are part of the sensory pathway of the spinal cord, which relay an impulse to the motor nerve and then to the muscles

Characteristics of the 12 cranial nerves include all of the following except that: They are paired. They emerge from within the cranium. Each has motor and sensory functions. They facilitate specialized functions.

Each has motor and sensory functions. Explanation: Only some, but not all, cranial nerves possess both sensory and motor functions. They are paired and emerge from within the cranium, with each allowing for the performance of specialized and specific functions.

A young woman comes in with brief, rapid, jerky, irregular movements. They occur at rest or during intentional movements and involve mostly her face, head, lower arms, and hands. How would you describe these movements? Tics Dystonia Athetosis Chorea

Chorea Explanation: These movements represent chorea because they are brief, rapid, unpredictable, and irregular. Tics are irregular but tend to be stereotyped and can be vocalizations (throat clearing), facial expressions, or shoulder shrugs. Athetosis is a slow squirming motion usually affecting the face and distal extremities. Dystonia is similar to athetosis, but the movements are coarser and can involve twisted postural changes.

The nurse is examining a child with severe cerebral palsy. On sudden movement of the child's foot dorsally, a sustained "beating" of the foot against the nurse's hand ensues. What does this represent? A focal seizure Clonus Extinction Reinforcement

Clonus Explanation: Clonus is a sustained rhythmical "beating" that correlates with CNS disease and hyperreflexia. A focal seizure could be virtually ruled out by stopping the stimulus and watching the phenomenon stop. Extinction is a term applied to sensory testing in which one side of a simultaneous, bilateral stimulus is not felt because of damage to the cortex. Reinforcement applies to enhancing reflex examination by distracting the client (e.g., pulling his hands against each other).

A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment? Vital signs Neurologic system Cardiac function Coordination

Coordination Explanation: The cerebellum's primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone. Therefore, a priority assessment area would be coordination. The other options listed are distracters.

A client sustains an injury to the brain stem. What is the most important assessment parameter that the nurse should perform for this client? Movement of all extremities Depth of respirations Level of consciousness Sensation in extremities

Depth of respirations Explanation: The brain stem controls many functions. The medulla oblongata contains the nuclei for the cranial nerves and has centers that control and regulate respiratory function, heart rate and force, and blood pressure. Movement and sensation of the extremities is controlled by various functions of the nervous system. Level of consciousness occurs when the brain does not receive enough oxygen.

When documenting assessment of the nervous system, a nurse should keep in mind what important principle? Validate data before documenting Describe the response Chart only objective data Label behaviors to prevent errors

Describe the response Explanation: When documenting assessment data on the nervous system, it is important for the nurse to describe the response rather than labeling the behavior.

A client has a disorder of the hypothalamus. The nurse recognizes that this structure is found in which area of the brain? Brain stem Diencephalon Cerebrum Cerebellum

Diencephalon Explanation: The diencephalon lies beneath the cerebral hemispheres and consists of the thalamus and hypothalamus. The cerebrum is divided into the right and left cerebral hemispheres and consists of four lobes (frontal, parietal, temporal, and occipital). The lobes are composed of a substance known as gray matter, which mediates higher-level functions such as memory, perception, communication, and initiation of voluntary movements. Located between the cerebral cortex and the spinal cord, the brain stem consists of mostly nerve fibers and has three parts: the midbrain, pons, and medulla oblongata. The cerebellum, located behind the brain stem and under the cerebrum, also has two hemispheres. Although the cerebellum does not initiate movement, its primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone.

The nurse performs a neurological assessment and determines the Glasgow Coma Scale (GCS) score is 15. What is the nurse's best action? Notify the healthcare provider. Re-assess in 15 minutes. Document the findings. Ask the client to open eyes on command.

Document the findings. Explanation: A GCS score of 15 is the maximum score indicating the client's neurological status is normal. Therefore, the nurse should document the findings. This information makes all the remaining options incorrect

When assessing a client's coordination by asking the client to touch the nose with the finger, what should a nurse keep in mind about a client's movements? Uncoordinated movements can be expected in the elderly Dominant side will be more coordinated than nondominant side Most clients will hesitate before touching the nose to check their position As the client repeats the maneuver, movements will be less accurate

Dominant side will be more coordinated than nondominant side Explanation: A nurse should ask a client to touch the tip of the nose with the right index finger, then the left. This should be repeated three times. Movements should be smooth and performed without hesitation. The nurse should keep in mind that the client's dominant side will be more coordinated than the nondominant side. The elderly client may be slower but the movement should still be smooth and accurate. Movements should not become less accurate as the client repeats the maneuver.

Nursing students are doing a class presentation on stroke. What is the term they would use for deficits in speech articulation? Aphasia Nystagmus Dysarthria Dystonia

Dysarthria Explanation: Deficits in articulation are referred to as dysarthria.

The nurse is assessing the biceps tendon reflex of a client. Place the following steps in the order the nurse should perform them. 1 Encourage the patient to relax, then position the limbs properly and symmetrically. 2 Hold the reflex hammer loosely between the thumb and index finger so that it swings freely in an arc within the limits set by the palm and other fingers. 3 With the wrist relaxed, strike the tendon briskly using a rapid wrist movement. 4 Note the speed, force, and amplitude of the reflex response and grade the response. 5 Compare the response of one side with the other.

Encourage the patient to relax, then position the limbs properly and symmetrically. Hold the reflex hammer loosely between the thumb and index finger so that it swings freely in an arc within the limits set by the palm and other fingers. With the wrist relaxed, strike the tendon briskly using a rapid wrist movement. Note the speed, force, and amplitude of the reflex response and grade the response. Compare the response of one side with the other. Explanation: The nurse should perform the steps in the following order: (1) Encourage the patient to relax, then position the limbs properly and symmetrically; (2) Hold the reflex hammer loosely between the thumb and index finger so that it swings freely in an arc within the limits set by the palm and other fingers; (3) With the wrist relaxed, strike the tendon briskly using a rapid wrist movement. The strike should be quick and direct, not glancing; (4) Note the speed, force, and amplitude of the reflex response and grade the response. Always compare the response of one side with the other. Reflexes are usually graded on a 0 to 4 scale.

The nurse assessing a client understands that which of the following could be due to increased intracranial pressure? Select all that apply. Headache that subsides after arising Blurred vision Ptosis Headache that subsides when lying Difficulty swallowing

Headache that subsides after arising Blurred vision Explanation: A headache that subsides after arising and changes in vision may be related to increased intracranial pressure. Ptosis is seen with weak eye muscles. Difficulty swallowing may be related to brain injury.

The nurse suspects the client has increased intracranial pressure due to meningitis. What should the nurse assess? Neck mobility Decreased level of consciousness Confusion Extraocular movements

Neck mobility Explanation: Neck mobility should be assessed if the nurse suspects meningitis. Extraocular movements, confusion, and decreased level of consciousness is not part of the meningeal assessment.

A nurse assesses a client for pupillary response of the eyes and finds a unilateral dilated pupil that is unresponsive to light or accommodation. The nurse recognizes that which cranial nerve is responsible for the damage of pupillary response? I III V II

III Explanation: Cranial nerve III is responsible for the damage to pupillary response. Cranial nerve I disorders cause damage to sense of smell. Cranial nerve V is responsible for the function of masseter muscle contraction. Cranial nerve II disorders damage vision due to retinal detachment or due to a lesion in the nerve.

What should the nurse assess to test the function of the temporal lobe? Impulses from the ear Communication Tactile sensation Ability to read

Impulses from the ear Explanation: The function of the temporal lobe is assessed by testing for impulses from the ear. To assess the function of the parietal lobe, the nurse should test for tactile sensation. Assessment of the frontal lobe is done by testing the client's communication. To assess the function of the occipital lobe, the nurse should test the ability to read.

A nurse is reviewing a client's health record while interviewing her. The nurse sees in the client's record a score of 3+ on the biceps reflex test from her previous visit. The nurse understands that this finding indicates which of the following? Increased or brisk, but not pathologic Exaggerated; indicator of possible upper motor neuron lesion Present but decreased Normal

Increased or brisk, but not pathologic Explanation: Normal reflex scores range from 1+ (present but decreased) to 2+ (normal) to 3+ (increased or brisk, but not pathologic). Absent or markedly decreased (hyporeflexia) deep tendon reflexes (rated 0) occur when a component of the lower motor neurons or reflex arc is impaired and may be seen with spinal cord injuries. Markedly hyperactive (hyperreflexia) deep tendon reflexes (rated 4+) may be seen with lesions of the upper motor neurons and when the higher cortical levels are impaired.

A 37-year-old insurance agent comes to the office with a report of trembling hands. She says that for the past 3 months when she tries to use her hands to fix her hair or cook they shake badly. She says she doesn't feel particularly nervous when this occurs, but she worries that other people will think she has an anxiety or alcohol disorder. She admits to having some recent fatigue, trouble with vision, and difficulty maintaining bladder control. Her past medical history is remarkable for hypothyroidism. Her mother has lupus and her father is healthy. She has an older brother with type 1 diabetes. She is married with three children. She denies tobacco, alcohol, or drug use. On examination, when she tries to reach for a pencil to fill out the health form, she has obvious tremors in her dominant hand. What type of tremor is most likely? Resting tremor Postural tremor Intention tremor

Intention tremor Explanation: Intention tremors are absent at rest or in a postural position and only occur with intentional movement of the hands. This is seen in cerebellar disease (stroke or alcohol use) or in multiple sclerosis. This client's tremor, fatigue, bladder problems, and visual problems suggest multiple sclerosis.

The nurse assesses the motor system as part of the full neurological examination. In order to effectively assess this system, which of the following instructions should be given to the client? Instruct the client to state the current date and place Instruct the client to flex and extend the right elbow Instruct the client to smile Ask the client to close the eyes

Instruct the client to flex and extend the right elbow Explanation: Instructing the client to flex and extend the right elbow is assessing strength, which is a part of the motor system assessment. Instructing the client to state the current date and place is part of the mental status assessment. Instructing the client to smile and close the eyes is part of the cranial nerve assessment

A client reports that she is experiencing a tremor when she reaches for things. This worsens as she nears the "target." When the examiner asks the client to hold out her hands, no tremor is apparent. What type does this most likely represent? Intention Postural Resting Nervous

Intention Explanation: Because it worsens as the target is approached, this represents an "intention" tremor. In this client, one may suspect cerebellar pathway disease, possibly from multiple sclerosis (one could also look for an intranuclear ophthalmoplegia). A postural tremor occurs when a certain position is maintained; resting tremors occur can occur with diseases such as Parkinson's. These do not occur during sleep.

The nurse is reviewing the plan of care for a client with peripheral neuropathy. Which intervention by the client should the nurse be concerned about? Inspect feet daily using a mirror. Test bath water temperature with the hands. Limit use of a heating pad to 15 minutes at a time. Wear clean white cotton socks.

Limit use of a heating pad to 15 minutes at a time. Explanation: Clients with peripheral neuropathy can be easily burned by a heating pad that is too hot. The client should test bath water with hands first to ensure the temperature isn't too hot. Clients should inspect feet using a mirror if needed and wear white socks. This will enable the client to identify blisters, sores, cuts, or splinters that they might not be able to feel. Cotton socks will also help reduce friction on the feet and toes that could lead to blistering.

Which of these factors should a nurse include when teaching about risk reduction for cerebrovascular accidents (CVA) to a group of middle-aged adults within the community? Select all that apply. Increase estrogen levels Reduce smoking Limit alcohol to 1 drink per day for women and 2 for men Lower blood pressure Increase protein intake

Limit alcohol to 1 drink per day for women and 2 for men Lower blood pressure Explanation: Risk reduction for a CVA includes controlling blood pressure, stopping smoking (not just reducing it), limiting alcohol to no more than 1 drink per day for women and 2 drinks for men, exercising, lowering cholesterol and fat intake, controlling blood sugar, and avoiding drugs such as cocaine. Increasing estrogen levels and protein intake are not associated with reducing risk for CVAs.

The nurse is caring for an adult client who suffers from a spinal cord hemisection due to a tumor. The client is unable to feel pain or temperature changes below the level of the tumor. What other symptoms should the nurse teach the family to expect the client to experience? Loss of all motor function below the level of the lesion Individual nerve damage along the corresponding dermatome Sensory loss in the periphery in a very diffuse pattern Loss of position sense, vibration, and motor function on same side of the body

Loss of position sense, vibration, and motor function on same side of the body Explanation: Following a spinal cord hemisection, pain and temperature sensation, are lost below the level of the injury or lesion on the opposite side of the body. Position sense, vibration, and motor function are affected on the same side of the body.

When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence? Cranial nerves, motor/cerebellar, sensory, reflexes, mental status Motor/cerebellar, sensory, reflexes, cranial nerves, mental status Reflexes, sensory, motor/cerebellar, cranial nerves, mental status Mental status, cranial nerves, motor/cerebellar, sensory, reflexes

Mental status, cranial nerves, motor/cerebellar, sensory, reflexes Explanation: The nurse should perform the assessment of the nervous system from a level of higher cerebral integration to a level of lower reflexes

When providing client teaching, what can the nurse assess? Complex cognitive function Patient's ability to handle money Patient's ability to perform ADLs Patient's neurologic prognosis

Patient's ability to perform ADLs Explanation: You use assessment information to identify client outcomes. An outcome related to neurological problems include: Patient improves motor function and becomes independent with activities of daily living (ADLs).

The nurse suspects that a client is experiencing meningitis. Which assessment finding caused the nurse to make this clinical determination? Hips and knees relaxed Neck flexes to the chest Pain behind the knees when fully extended Pain and hip flexion when the neck is flexed

Pain and hip flexion when the neck is flexed Explanation: Pain and flexion of the hips and knees is a positive Brudzinski sign that suggests meningeal inflammation. If the hips and knees remain relaxed and the neck is able to be flexed to the chest, the client is not demonstrating signs of meningeal irritation. Pain behind the knees when fully extended is a normal finding in some people.

The nurse is testing for Kernig's sign in a newly admitted client. What would indicate meningeal inflammation? Pain and resistance to knee extension bilaterally Neck resistance Resistance to neck flexion Hips and knees remain relaxed an motionless

Pain and resistance to knee extension bilaterally Explanation: Pain and resistance to knee extension bilaterally is a positive Kernig's sign. Hips and knees remaining relaxed an motionless is a normal Brudzinski's. Neck resistance is not part of Kernig's assessment.

A client is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would be most appropriate to test? patellar ankle supinator triceps

Patellar

A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding? Right knee +1;Left knee 0 Right knee +2; Left knee +1 Right knee +3; Left knee +2 Right knee +4; Left knee +3

Right knee +2; Left knee +1 Explanation: A normal reflex response is documented as being +2. A diminished reflex response is documented as being +1. A 0 is no reflex response. A +3 is a brisker than average response. A +4 is a very brisk response.

What functions are attributed to sensory impulses? (Select all that apply.) Cessation of cough reflex Stimulation of sneezing Regulation of internal autonomic functions Body position in space Conscious sensation

Regulation of internal autonomic functions Body position in space Conscious sensation Explanation: Sensory impulses not only participate in reflex activity, as previously described, but also give rise to conscious sensation, calibrate body position in space, and help regulate internal autonomic functions like blood pressure, heart rate, and respiration.

A nurse is conducting an assessment of an elderly client's nervous system. The client mentions that he has experienced decreased taste and scent sensations recently. Which of the following should the nurse do at this point? Ask the client whether he has experienced a head injury recently Ask the client whether he has experienced sudden numbness or weakness in his face or arms Record the findings and proceed with the assessment Perform the Weber test with the client

Record the findings and proceed with the assessment Explanation: Decreased taste and scent sensation occurs normally in older adults. Therefore, the nurse should simply record the finding and proceed with the assessment. A head injury could cause nerve damage that would explain loss of such senses, but the client's age is a much more likely cause. Sudden numbness or weakness in the face or arms is a warning sign of a stroke. The Weber test is used to test a client's hearing.

A client is admitted to the health care facility with new onset of right-sided paralysis, slurred speech, and lethargy. A nurse obtains in the history that the client has uncontrolled hypertension and smokes 2 packs of cigarettes a day. Which nursing diagnosis is priority for the client upon admission? Risk for Aspiration Unilateral Neglect Impaired Verbal Communication Risk for Altered Skin Integrity

Risk for Aspiration Explanation: Due to the client's decreased mental status and slurred speech, he is at greatest risk for aspiration. Measures must be implemented by the nurse to prevent aspiration, such as NPO, elevating the head of bed, and assessment of lung sounds. Impaired Verbal Communication is a psychosocial issue, and physiologic problems take precedence over mental health at this point in time. Unilateral neglect is not as much of a priority as is the risk for aspiration. There is no indication that there is a risk for altered skin integrity.

Upon assessment, the nurse suspects the client is having a stroke. What symptoms might the nurse have found? Select all that apply. Slurred speech Severe headache Left arm weakness Tremors Unsteady gait

Slurred speech, severe headache, and left arm weakness Explanation: Symptoms of a stroke appear suddenly and include numbness or weakness of the face, arm or leg, confusion, difficulty speaking or understanding speech, and difficulty walking, or loss of balance. An unsteady gait and tremors would not be symptoms of a stroke.

A nurse is instructing a client who has recently experienced a transient ischemic attack (TIA) on warning signs of a stroke that the client should be aware of in case they occur and she needs to call 911. Which of the following should the nurse mention? Select all that apply. Sudden numbness or weakness of the face Sudden chest pain Sudden confusion, trouble speaking, or understanding speech Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe headache with no known cause

Sudden numbness or weakness of the face Sudden confusion, trouble speaking, or understanding speech Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe headache with no known cause Explanation: Except for sudden chest pain, which is a symptom of a heart attack, not a stroke, all of the symptoms listed are associated with a stroke.

A nurse is instructing a client who has recently experienced a transient ischemic attack (TIA) on warning signs of a stroke that the client should be aware of in case they occur and she needs to call 911. Which of the following should the nurse mention? Select all that apply. Sudden numbness or weakness of the face Sudden chest pain Sudden confusion, trouble speaking, or understanding speech Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe headache with no known cause

Sudden numbness or weakness of the face Sudden confusion, trouble speaking, or understanding speech Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe headache with no known cause Explanation: Except for sudden chest pain, which is a symptom of a heart attack, not a stroke, all of the symptoms listed are associated with a stroke

Which of the following assessments is most likely to provide insight into the function of the client's CN VIII? Ask the client to shrug both shoulders upward against the examiner's hands. Ask the client to raise his or her eyebrows, frown, and close both eyes tightly. Test the client's ability to identify a familiar smell with his or her eyes closed. Test the client's hearing for lateralization and bone and air conduction.

Test the client's hearing for lateralization and bone and air conduction. Explanation: CN VIII is the acoustic nerve; function is thus tested by assessing the client's hearing. Shoulder shrugging tests CN XI; frowning and closing the eyes depend on CN VII. CN I is tested by assessing the client's ability to identify smells.

A client is visiting the health care facility for follow-up care for a stroke. Today he has increased muscle tone, some involuntary movements, an abnormal gait, and a slowness of response in movements. He most likely has involvement of which of the following? The corticospinal tract The cerebellum The cerebrum The basal ganglia

The basal ganglia Explanation: These findings are typical of disease in the basal ganglia

The nurse is assessing an client after a fall. What could indicate damage to the spinal cord? Tingling Seizures Sensory deficit Dizziness

Tingling Explanation: Injury to the spinal cord could manifest by loss of sensation, tingling or burning. Seizures, dizziness and a sensory deficit are not associated with a spinal cord injury.

A client is clenching the jaw closed to avoid taking a prescribed oral medication. The nurse can use this observation to confirm the client is demonstrating motor function of which cranial nerve? Trigeminal Facial Glossopharyngeal Vagus

Trigeminal Explanation: The motor function of the trigeminal nerve includes the temporal and masseter muscles, both used with jaw clenching. The motor function of the facial nerve controls facial expression and closing the eyes and the mouth. The motor function of the glossopharyngeal nerve controls the pharynx. The motor function of the vagus nerve controls the palate, pharynx, and larynx

A client is clenching the jaw closed to avoid taking a prescribed oral medication. The nurse can use this observation to confirm the client is demonstrating motor function of which cranial nerve? Trigeminal Facial Glossopharyngeal Vagus

Trigeminal Explanation: The motor function of the trigeminal nerve includes the temporal and masseter muscles, both used with jaw clenching. The motor function of the facial nerve controls facial expression and closing the eyes and the mouth. The motor function of the glossopharyngeal nerve controls the pharynx. The motor function of the vagus nerve controls the palate, pharynx, and larynx.

A client presents to the health care clinic with reports of difficulty swallowing. Which cranial nerves will provide the nurse with information related to the problem? Select all that apply. Vagus Abducens Trochlear Hypoglossal Spinal accessory Glossopharyngeal

Vagus, hypoglossal, and glossopharyngeal Explanation: Difficulty swallowing can be a finding with CVA, Parkinson's disease, myasthenia gravis, Guillain Barre, or cranial nerve dysfunction. The cranial nerves that the nurse should be aware of are IX (glossopharyngeal), X (vagus), and XII (hypoglossal). Cranial nerve VI (abducens) controls lateral eye movement. Cranial nerve XI (spinal accessory) innervates the neck and shoulder muscles.

Which action by a nurse demonstrates the correct technique to use the reflex hammer? Strike the tendon then palpate for a response Instruct the client to tense the muscles before striking Tap the tendon gently to avoid pain and tingling Use rapid wrist movement and strike the tendon

Use rapid wrist movement and strike the tendon Explanation: When using a reflex hammer, the nurse should use rapid wrist movement and strike the tendon briskly. Tapping gently will not cause the tendon to shorten and the reflex will not occur. The tendon should be palpated before striking the hammer to know the area. The nurse should encourage the client to relax the muscles because tenseness can inhibit a normal response.

The nurse plans to test which cranial nerve when testing an elderly client's hearing status? VIII VII VI V

VIII Explanation: Cranial nerve VIII contains sensory fibers for hearing and balance

The client is diagnosed with a peripheral neuropathy. The nurse knows that often the first sensation lost in a peripheral neuropathy is what? Light touch Pain Vibration Temperature

Vibration Explanation: Vibration sense is often the first sensation to be lost in a peripheral neuropathy.

When conducting a Romberg test, why does the nurse ask the client to stand feet together with eyes open and then closed? Repetition affects position sense. Clients feel safer after testing with eyes open. Vision can compensate for loss of position sense. Vestibular defects become evident with eyes closed.

Vision can compensate for loss of position sense. Explanation: In clients with ataxia from loss of position sense, vision compensates for the sensory loss. A client who stands well with eyes open but loses balance with eyes closed is exhibiting a positive Romberg sign. Client safety, vestibular defects, or the effects of repetition do provide the rationale for conducting the Romberg test in the stated manner.

Which of the following assessment techniques should the nurse use to determine a client's stereognosis? With the client's eyes closed, trace a number on the client's hand and ask him or her to identify the number. With the client's eyes closed, place a coin or key in hand and ask him or her to identify the object. Using two ends of an open paper clip, touch two points on the client's finger pad simultaneously and identify the minimal distance that the client can discriminate between the points. Briefly touch a point on the client's skin and ask the client to open his or her eyes and point to the place touched.

With the client's eyes closed, place a coin or key in hand and ask him or her to identify the object. Explanation: Stereognosis is the ability to identify a familiar object by feeling it. It is tested by placing an object in the client's hand for identification while he or she has the eyes closed. The other assessment techniques assess for number identification, two-point discrimination, and point localization

A nurse is performing a focused cranial assessment on a client. The nurse observes that the client is unable to shrug their shoulders. The nurse documents this as a dysfunction of which cranial nerve? VII VIII XII XI

XI Explanation: Cranial nerve XI controls shoulder strength. Cranial nerve VII controls right and left facial muscle strength. Cranial nerve VIII controls hearing. Cranial Nerve XII controls (motor) tongue movement

The nurse is assessing the neurologic system of an adult client. To test the client's motor function of the facial nerve, the nurse should ask the client to purse the lips. ask the client to open the mouth and say "ah." note the presence of a gag reflex. observe the client swallow a sip of water.

ask the client to purse the lips. Explanation: When testing motor function ask the client to smile, frown and wrinkle forehead, show teeth, puff out cheeks, and purse the lips.

The nurse is assessing a client with known damage to the sympathetic pathways in the hypothalamus. Which assessment finding should the nurse expect? bilaterally small pupils pinpoint pupils mid-position fixed pupils one large pupil

bilaterally small pupils Explanation: The nurse should expect bilaterally small pupils in a patient with known damage to the sympathetic pathways in the hypothalamus. Pinpoint pupils suggest a hemorrhage in the pons or may be due to the effects of morphine, heroin, or other narcotics. Mid-position fixed pupils suggest damage in the midbrain. One large pupil warns of herniation of the temporal lobe, causing compression of the oculomotor nerve and midbrain, and is commonly seen in diabetic patients with infarction of CN III. Diabetic CN III palsy often spares pupillary function.

While assessing the neurologic system of a confused older adult, the nurse observes that the client is unable to recall past events. The nurse suspects that the client may be exhibiting signs of depression. anxiety. attention deficit disorder. cerebral cortex disorder.

cerebral cortex disorder. Explanation: Remote memory (past dates and historical accounts) may be impaired in cerebral cortex disorders.

The nurse is preparing to percuss a client's reflexes in his arms. To use the reinforcement technique, the nurse should ask the client to clench his jaw. stretch the opposite arm. hold his neck toward the floor. straighten his legs forward.

clench his jaw. Explanation: A reinforcement technique causes other muscles to contract and thus increases reflex activity, assists in eliciting a response if no response can be elicited.

The cerebrum is divided into right and left hemispheres, which are joined together by the corpus callosum. diencephalon. medulla oblongata. pons.

corpus callosum. Explanation: The cerebrum is divided into the right and left cerebral hemispheres, which are joined by the corpus callosum—a bundle of nerve fibers responsible for communication between the hemispheres

When the nurse is assessing a client who is comatose, which actions should be included in the assessment? Select all that apply. determining level of consciousness assessing airway, breathing, and circulation obtaining the medical history repositioning of the neck checking pupillary light reflex

determining level of consciousness assessing airway, breathing, and circulation obtaining the medical history Explanation: Level of consciousness (LOC) will assist the nurse in determining which interventions are safest. Assessing airway, breathing, and circulation are a priority in preserving life when the cause of a neurological condition is not known. Obtaining the medical history provides information about the possible underlying cause of the condition. Repositioning of the neck and checking pupillary light reflexes are considered the two cardinal "DON'T's" of assessing the client who is comatose. Repositioning the neck can worsen a possible trauma to the head/neck. Dilating the pupils can prevent discovering an important clue into the cause of the trauma. For true changes in pupillary response, further diagnostic tests such as a CT scan need to be prescribed.

The portion of the brain that rims the surfaces of the cerebral hemispheres forming the cerebral cortex is the gray matter. cerebellum. diencephalon. brainstem.

gray matter. Explanation: The lobes are composed of a substance known as gray matter, which mediates higher-level functions such as memory, perception, communication, and initiation of voluntary movements. Consisting of aggregations of neuronal cell bodies, gray matter rims the surfaces of the cerebral hemispheres, forming the cerebral cortex.

A nurse is performing a comprehensive assessment of an 80-year-old client. The nurse documents which of the following normal age-related changes? Select all that apply. presbycusis decreased vision intentional tremors decreased sense of taste and smell increased muscle mass, decreased fat

presbycusis decreased vision intentional tremors decreased sense of taste and smell Explanation: Intentional tremors and decreased hearing, vision, smell, and taste are normal age-related changes. Decreased muscle mass and increased fat are normal age-related changes, not increased muscle mass and decreased fat.

The symptom that would alert the nurse to a problem with cranial nerve III would be ptosis difficulty clenching jaw absent blinking vertigo

ptosis Explanation: Ptosis is seen with damage to cranial nerve III.

What task should a nurse ask a client to perform to assess the function of cranial nerve XI? shrug shoulders against resistance move tongue side to side swallow water walk in heel-to-toe fashion

shrug shoulders against resistance Explanation: The function of cranial nerve XI can be assessed by asking the client to shrug his or her shoulders against resistance. Asking the client to move the tongue from side to side assesses function of the hypoglossal nerve, Cranial nerve XII. The nurse asks the client to swallow water to assess the function of cranial nerves IX and X. Asking the client to walk in heel-to-toe fashion helps in assessment of balance

Which body functions are related to the hypothalamus? Select all that apply. withdrawing a hand from a hot stove sweating on a hot day feeling worried about an exam experiencing a regular menstrual cycle learning a new dance move

sweating on a hot day feeling worried about an exam experiencing a regular menstrual cycle Explanation: The hypothalamus is responsible for regulation of temperature, governing emotions, and secretion of hormones. Withdrawing a hand from a hot stove involves production of sensory impulse; this is the role of the thalamus. Learning a dance move requires coordination of movement; this is the role of the cerebellum.

What should the nurse assess to test the function of the parietal lobe? impulses from the ear communication tactile sensation ability to read

tactile sensation Explanation: To assess the function of the parietal lobe, the nurse should test for tactile sensation. Assessment of the frontal lobe is done by testing the client's communication. To assess the function of the occipital lobe, the nurse should test the ability to read. The function of the temporal lobe is assessed by testing for impulses from the ear.

What should the nurse assess to test the function of the parietal lobe? impulses from the ear communication tactile sensation ability to read

tactile sensation Explanation: To assess the function of the parietal lobe, the nurse should test for tactile sensation. Assessment of the frontal lobe is done by testing the client's communication. To assess the function of the occipital lobe, the nurse should test the ability to read. The function of the temporal lobe is assessed by testing for impulses from the ear.

The nurse is preparing to assess a client's cranial nerves using a screening neurologic examination. Which of the following should the nurse include in this assessment? Select all that apply. visual fields and fundoscopic examination eye movements hearing finger proprioception facial strength

visual fields and fundoscopic examination eye movements hearing facial strength Explanation: When assessing the cranial nerves using a screening neurologic examination, the nurse should assess visual fields and fundoscopic examination, pupillary light reflex, eye movements, hearing, and facial strength. Finger proprioception would be a part of the sensory system assessment.