Chapter 25: Assessing Neurologic System
During the Romberg test, a client is unable to stand with his feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would identify this as which of the following?
Cerebellar ataxia
The nurse working in the emergency department is assessing an intoxicated driver involved in a motor vehicle crash when the client insists on ambulating to the bathroom. The nurse escorts the client and calls for help while anticipating which abnormal gait in this client that places him at risk for falls?
Cerebellar ataxia
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
The nurse is performing the Romberg test. Which of the following indicate a normal finding?
Client stands erect with minimal swaying
Lifestyle can play a big part in developing risk factors for stroke. Which of the following can greatly reduce a client's risk for stroke? Select all that apply.
Quitting smoking Regularly exercising Maintaining a healthy weight
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?
Record the findings and proceed with the assessment
A nurse is working with a client who suffered nerve damage during surgery for removal of a tumor. The client, who is an artist, lost fine motor control in his hands and can no longer manipulate a paintbrush. Which neural pathway should the nurse suspect to be damaged?
pyramidal tract
The nurse is caring for a client during the immediate postoperative period after abdominal surgery. While performing a "neuro check" the nurse should assess the client's
sensation in the extremities.
What task should a nurse ask a client to perform to assess the function of cranial nerve XI?
shrug shoulders against resistance
The hypothalamus is responsible for regulating
sleep cycles.
When the nurse is assessing the motor function of cranial nerve VII as part of the neurological examination, what should the nurse instruct the client to do?
smile
The Glasgow Coma Scale measures the level of consciousness in clients who are at high risk for rapid deterioration of the nervous system. A score of 13 indicates
some impairment
Sensations of temperature, pain, and crude and light touch are carried by way of the
spinothalamic tract.
The nurse is assessing an older adult client when the client tells the nurse that she has experienced transient blind spots for the last few days. The nurse should refer the client to a physician for possible
stroke
The nurse documents "Romberg test positive" on a client's medical record. What did the nurse most likely assess in this client?
swaying
A nurse is preparing to offer a community education session on anxiety. On which part of the nervous system should the nurse focus during the discussion?
sympathetic nervous system
What should the nurse assess to test the function of the parietal lobe?
tactile sensation
The diencephalon of the brain consists of the
thalamus and hypothalamus
The nurse is planning to test position sensation in an adult female client. To perform this procedure, the nurse should ask the client to close her eyes while the nurse moves the client's
toes up or down.
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?
"Are you having any dizziness or lightheadedness?"
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
"Can you repeat brown, chair, textbook, tomato?"
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?"
A nurse is assessing a client for abnormalities of gait due to a concern that the client is at increased risk for a fall. Which instruction should the nurse give the client first?
"Walk across the room and back."
What should the nurse assess to test the function of the occipital lobe?
Ability to read
The nurse suspects that a client has a lesion in the sensory cortex. Which assessment finding did the nurse use to make this clinical decision?
Absent two-point discrimination on the lower right arm
A client reports the feeling of being unsteady when walking. What is an appropriate action by the nurse to assess for a problem with gait and balance?
Ask the client to walk in a heel-to-toe fashion and watch for an unsteady gait
The nurse has completed a Glasgow Coma Scale assessment and assigns the client a score of three. Which is the best way for the nurse to assess pain in this client?
Assess for nonverbal signs
A nurse observes a client's gait and notes it to be wide based and staggering. The Romberg test results were positive. The nurse recognizes this as what type of abnormal gait?
Cerebellar ataxia
A nurse cares for a client who suffered a cerebrovascular accident and demonstrates the inability to speak clearly. The nurse recognizes that injury has occurred to what portion of the brain?
Broca's area
As adults age, peripheral nerve function and impulse conduction decrease. What is the result of this decrease?
Decreased proprioception
A client sustains an injury to the brain stem. What is the most important assessment parameter that the nurse should perform for this client?
Depth of respirations
A client cannot differentiate between sharp and dull pain sensations when a nurse tests with a safety pin. What is an appropriate action by the nurse?
Determine the ability to differentiate hot and cold temperatures
A client has a disorder of the hypothalamus. The nurse recognizes that this structure is found in which area of the brain?
Diencephalon
While performing a neurological assessment on a 56-year-old male, the nurse identifies the client may be experiencing a stroke. What symptoms would the nurse identified? Select all that apply.
Difficulty following instructions Slurred speech Impaired vision
A nurse cares for a client diagnosed with cranial nerve III disorder. What should the nurse expect to find in the client?
Drooping of eyelids
Upon reviewing the client's medical record, the nurse finds the client has left ptosis. The nurse would assess the client for what?
Drooping of the left eye
Characteristics of the 12 cranial nerves include all of the following except that:
Each has motor and sensory functions.
When testing the biceps reflex, what type of response should the nurse expect if normal?
Elbow flexes and muscle contracts
A 7-year-old child comes to the clinic with her mother, who states that her daughter is doing poorly in school because she has some kind of "ADD" (attention deficit disorder). The nurse asks the mother what makes her think the child has ADD. The mother says that both at home and at school her daughter just zones out for several seconds and licks her lips. She states it happens at least four to six times an hour. She says this has been happening for about 1 year. After several seconds of lip licking, her daughter seems normal again. She states her daughter has been generally healthy with just normal childhood colds and ear infections. The client's parents are both healthy; no other family members have had these symptoms. What type of seizure disorder is most likely?
Generalized absence seizure
A client who was injured by a fall at a construction site has been admitted to the hospital. He has suffered nerve damage such that his gag reflex is no longer intact, requiring him to receive intravenous total parenteral nutrition. Which nerve should the nurse suspect to be involved in this client's injury?
Glossopharyngeal (IX)
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?
III
Which of the following assessment findings would lead the nurse to suspect that a client has Bell's palsy?
Inability to wrinkle the forehead
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
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 flex and extend the right elbow
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?
Intention tremor
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?
Limit use of a heating pad to 15 minutes at a time.
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 position sense, vibration, and motor function on same side of the body
What task should a nurse ask a client to perform to assess the function of cranial nerve XII?
Move the tongue from side to side
The client presents at the clinic with a complaint of weakness that is made worse with repeated effort and improves with rest. The client's complaint is consistent with what health problem?
Myasthenia gravis
The nurse suspects the client has increased intracranial pressure due to meningitis. What should the nurse assess?
Neck mobility
The nurse suspects that a client is experiencing meningitis. Which assessment finding caused the nurse to make this clinical determination?
Pain and hip flexion when the neck is flexed
When testing sensory function of the trigeminal nerve (CN V), which of the following sensations would the nurse assess?
Pain and light touch
A 41-year-old real estate agent comes to the office saying that he feels like his face is paralyzed on the left. He states that last week he felt his left eyelid was drowsy; as the day progressed he could not close his eyelid all the way. Later he felt like his smile became affected also. He denies any recent injuries but had an upper respiratory viral infection last month. Past medical history is unremarkable. He is divorced with one child. He smokes one pack of cigarettes a day, occasionally drinks alcohol, and denies any illegal drug use. His mother has high blood pressure and his father has sarcoidosis. On examination the nurse asks the client to close his eyes. He cannot close his left eye. The nurse asks him to open his eyes and raise his eyebrows. His right forehead furrows but his left remains flat. The nurse then asks the client to give a big smile. The right corner of his mouth raises but the left side of his mouth remains the same. What type of facial paralysis does he have?
Peripheral CN VII paralysis
During morning report the nurse learns that an assigned client needs assistance with ambulation because of spastic hemiparesis. What should the nurse expect when ambulating with this client?
Picture of a guy with a limp and holding a fist with his hand
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 +2; Left knee +1
A nurse is working with a client who is victim of a shooting. The client has an increased pulse rate and pupil dilation and is clearly in stress. The nurse recognizes the "fight-or-flight" response in this client and understands that this represents an activation of which of the following?
Sympathetic nervous system
Which of the following assessments is most likely to provide insight into the function of the client's CN VIII?
Test the client's hearing for lateralization and bone and air conduction.
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
Which action by a nurse demonstrates the correct technique to use the reflex hammer?
Use rapid wrist movement and strike the tendon
The nurse notes that a client does not blink the left eye when the cornea is lightly touched with a cotton wisp. On which cranial nerve should the nurse focus additional assessment?
V
The nurse performs that technique shown when assessing the client. What cranial nerve is the nurse assessing?
VII
During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve?
VIII
The nurse plans to test which cranial nerve when testing an elderly client's hearing status?
VIII
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 Hypoglossal Glossopharyngeal
When conducting a Romberg test, why does the nurse ask the client to stand feet together with eyes open and then closed?
Vision can compensate for loss of position sense.
Which tests are appropriate for a nurse to perform to test cranial nerve VIII?
Whisper, Rinne, and Weber tests
Which assessment procedure should a nurse institute to test a client for stereognosis?
With eyes closed, ask the client to identify a familiar object that is placed in their hand
Which of the following assessment techniques should the nurse use to determine a client's stereognosis?
With the client's eyes closed, place a coin or key in hand and ask him or her to identify the object.
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?
XI
The nurse lightly strokes the sides of a client's abdomen, above and below the umbilicus. For which reflex is the nurse testing?
abdominal
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.
The nurse is assessing an newly admitted client with a seizure disorder. The nurse would asses the client for what?
aura
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
What should the nurse assess to test the function of the frontal lobe?
communication
The cerebrum is divided into right and left hemispheres, which are joined together by the
corpus callosum
The nurse is caring for a client in the hospital and identifies the client to be experiencing acute confusion after cardiac surgery. The nurse recognizes this as what?
delirium
A client visits the clinic and tells the nurse that he has not been feeling very well. The nurse observes that the client's speech is slow, the client has a disheveled appearance, and he maintains poor eye contact with the nurse. The nurse should further assess the client for
depression
The nurse is assessing a 51-year-old morbidly obese client who is seeking care for the recent loss of sensation in his feet and toes. The client also complains of intermittent burning and tingling in his feet that radiate up his legs. For which of the following health problems should the nurse first assess?
diabetic peripheral neuropathy
During assessment, the nurse notes the client has limited movement of his lower extremities and sways when standing with feet together. The nurse identifies that the client is at risk for what?
falls
After testing deep tendon reflexes, the nurse documents 2+. The nurse should evaluate further.
false
The nurse is caring for a client with a history of seizure disorder. The nurse observes the client making severe jerky movements (extending and contracting extremities) and the client loses consciousness. The nurse will identify this as which type of seizure?
generalized seizure
The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the
glossopharyngeal
The portion of the brain that rims the surfaces of the cerebral hemispheres forming the cerebral cortex is the
gray matter.
An ambulance brings an older adult client to the ED. The client's daughter found the client on the floor of the house; the client is almost unresponsive. It is unknown how long the client was on the floor. When performing an acute assessment on the client, which of the following may the health care team omit?
health history
The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam?
hop on one foot
Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions and maintains overall autonomic control?
hypothalamus
The nurse is doing a neurologic screening examination. The nurse should include some aspect of which areas? Select all that apply.
mental status cranial nerves motor system sensory system reflexes
A client reports resting and skipping exercise during a holiday from work. Which part of the nervous system is controlling this client's behavior?
parasympathetic
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