Chapter 43: - PrepU - Nursing Assessment: Neurologic Function

A client presents to the emergency department status post-seizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client? 1- Lumbar puncture 2- Echoencephalography 3- Nerve conduction studies 4- EMG

1

A nurse is performing a neurologic assessment on the client and notes a positive Romberg test. This test for balance is related to which of the following cranial nerves? 1- VIII 2- X 3- III 4- VII

1

The nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session? Select all that apply. 1- Keep a food diary. 2- Maintain a headache diary. 3- Sleep no more than 5 hours at a time. 4- Exercise in a dark room. 5- Use St. John's Wort.

1,2

A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, the nurse anticipates that the liver will: 1- cease function and shunt blood to the heart and lungs. 2- convert glycogen to glucose for immediate use. 3- produce a toxic byproduct in relation to stress. 4- maintain a basal rate of functioning.

2

Lower motor neuron lesions cause 1- increased muscle tone. 2- flaccid muscles. 3- no muscle atrophy. 4- hyperactive and abnormal reflexes.

2

The nurse is performing a detailed mental status assessment of an older adult patient who has a diagnosis of mild Alzheimer's disease. What assessment most accurately gauges the patient's abstract reasoning? 1- "What city and state are we in right now?" 2- "What would you do if you found a stamped envelope on the street?" 3- "If you divide 16 by four and then double it, what do you get?" 4- "How do you believe that Alzheimer's disease is affecting you?"

2

The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. This deficit is related to which of the following cranial nerves? 1- VIII 2- X 3- III 4- VII

2

A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following? 1- "There is a very weak familial tendency." 2- "No familial tendency has been demonstrated." 3- "There is a strong familial tendency." 4- "Only secondary migraine headaches show a familial tendency."

3

A patient is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the patient has? 1- Dysfunction of the spinal accessory nerve 2- Dysfunction of the acoustic nerve 3- Dysfunction of the facial nerve 4- Dysfunction of the vagus nerve

4

A 77-year-old female patient who is recovering in the hospital from a total knee replacement has rung her call bell and told the nurse that she needs pain medication. When assessing the patient's pain, what principle should the nurse bear in mind? 1- Older adults tend to have a blunted pain sensation, so complaints should be followed-up promptly. 2- Older adults frequently confuse pain with other tactile sensations. 3- Pain in older adults is often unrelated to physical harm or pathophysiological processes. 4- The sensation of pain increases with age, so older adults typically feel more pain for a longer period than younger patients.

1

A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position? 1- Head of the bed elevated 45 degrees 2- Prone 3- Supine with feet raised 4- Supine with the head lower than the trunk

1

A nurse is conducting a neurological assessment of a patient who has just been admitted to the unit. In preparation for assessing the patient for pronator drift, what instructions should the nurse provide to the patient? 1- "Please hold your arms straight out with your palms pointing up to the ceiling." 2- "Please close your eyes and then walk a few steps with one foot directly in front of the other." 3- "Please close your eyes and then touch the tip of your nose with one index finger and then the other." 4- "Please lift one leg a few inches off the bed and hold it as still as possible."

1

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis? 1- Risk for aspiration 2- Risk for falls 3- Risk for impaired skin integrity 4- Decreased intracranial adaptive capacity

1

A patient sustained a head injury during a fall and has changes in personality and affect. What part of the brain does the nurse recognize has been affected in this injury? 1- Frontal lobe 2- Parietal lobe 3- Occipital lobe 4- Temporal lobe

1

A critical care nurse is documenting her assessment of a client she is caring for. The client is status post-resection of a brain tumor. The nurse documents that the client is flaccid on the left. What does this mean? 1- The client has an abnormal posture response to stimuli. 2- The client is not responding to stimuli. 3- The client is hyperresponsive on the left. 4- The client is hyporesponsive on the left.

2

A nurse is working in a neurologist's office. The physician orders a Romberg test. The nurse should have the client: 1- touch his or her nose with one finger. 2- close his or her eyes and stand erect. 3- close his or her eyes and discriminate between dull and sharp. 4- close his or her eyes and jump on one foot.

2

A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by: 1- introducing ice water into the external auditory canal. 2- touching the cornea with a wisp of cotton. 3- turning the client's head suddenly while holding the eyelids open. 4- shining a bright light into the pupil.

3

Cranial nerve IX is also known as which of the following? 1- Glossopharyngeal 2- Vagus 3- Spinal accessory 4- Hypoglossal

1

A nursing educator is talking with nurses about the effects of the aging process and neurologic changes. What would the educator identify as a normal neurological change that accompanies the aging process? 1- Hyperactive deep tendon reflexes 2- Reduction in cerebral blood flow (CBF) 3- Increased cerebral metabolism 4- Hypersensitivity to painful stimuli

2

A patient arrives to have an MRI done in the outpatient department. What information provided by the patient warrants further assessment to prevent complications related to the MRI? 1- "I am trying to quit smoking and have a patch on." 2- "I have been trying to get an appointment for so long." 3- "I have not had anything to eat or drink since 3 hours ago." 4- "My legs go numb sometimes when I sit too long."

1

The critical care nurse is giving end-of-shift report on a client she is caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? 1- Comatose 2- Somnolence 3- Stupor 4- Normal

1

The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to 1- refrain from eating or drinking for now. 2- have their spouse bring in the client's glasses. 3- wear any hearing aids while in the hospital. 4- use the walker when walking.

1

Which lobe of the brain is responsible for concentration and abstract thought? 1- Frontal 2- Parietal 3- Temporal 4- Occipital

1

Which lobe of the brain is responsible for spatial relationships? 1- Parietal 2- Temporal 3- Occipital 4- Frontal

1

Which of the following is a sympathetic nervous system effect? 1- Decreased peristalsis 2- Decreased blood pressure 3- Constricted pupils 4- Constricted bronchioles

1

Which of the following terms is used to describe rapid, jerky, involuntary, purposeless movements of the extremities? 1- Chorea 2- Bradykinesia 3- Spondylosis 4- Dyskinesia

1

Which term describes the fibrous connective tissues that cover the brain and spinal cord? 1- Meninges 2- Dura mater 3- Arachnoid mater 4- Pia mater

1

A high school soccer player sustained five concussions before she was told that she should never play contact sports again. After her last injury, she began experiencing episodes of double vision. She was told that she had most likely incurred damage to which cranial nerve? 1- V (Trigeminal) 2- VI (Abducens) 3- VII (Facial) 4- IV (Trochlear)

2

A middle-aged woman has scheduled an appointment with her nurse practitioner because she has been experiencing intractable muscle weakness in recent weeks. Which of the following characteristics of the patient's weakness should cause the nurse to suspect a neurological etiology? 1- The patient's weakness is most severe in the early morning. 2- The weakness is primarily on the left side of the patient's body. 3- The weakness is not relieved by increasing her food intake. 4- The patient's weakness began around the time of her husband's death.

2

A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate? 1- Abnormal posture 2- Flaccidity 3- Weak muscular tone 4- Decorticate posturing

2

The Glasgow Coma Scale is a common screening tool used for patients with a head injury. During the physical exam, the nurse documents that the patient is able to spontaneously open her eyes, obey verbal commands, and is oriented. The nurse records the highest score of: 1- 20 2- 15 3- 10 4- 5

2

The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect? 1- Dilated pupils 2- Constricted pupils 3- One pupil is dilated and the opposite pupil is normal 4- Roth's spots

2

Which cerebral lobes is the largest and controls abstract thought? 1- Temporal 2- Frontal 3- Parietal 4- Occipital

2

Which term refers to the inability to coordinate muscle movements, resulting difficulty walking? 1- Agnosia 2- Ataxia 3- Spasticity 4- Rigidity

2

Which term refers to the inability to coordinate muscle movements, resulting in difficulty walking? 1- Agnosia 2- Ataxia 3- Spasticity 4- Rigidity

2

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term? 1- Ataxic 2- Dystrophic 3- Helicopod 4- Steppage

3

A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse? 1- "Lying on your left side will be fine during the procedure." 2- "There's no other option but to assume the knee-chest position." 3- "Although the required position may not be comfortable, it will make the procedure safer and easier to perform." 4- "I'll report your concerns to the physician."

3

A nurse has assessed a patient's orientation during the initial head-to-toe assessment near the beginning of a shift. The patient is able to state his own full name and knows the name of the hospital but is unable to identify the month and the year. How should the nurse best document this assessment finding? 1- "Patient is demonstrating signs of decreased neurological function." 2- "Patient is disoriented." 3- "Patient is oriented to person and place, but unable to state month and year." 4- "Patient is oriented to person, oriented to place, but not oriented to time."

3

A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patient's foot is abruptly dorsiflexed, it continues to "beat" two to three times before setting into a resting position. How would the nurse document this finding? 1- Rigidity 2- Flaccidity 3- Clonus 4- Ataxia

3

A patient has been brought to the emergency department (ED) with signs and symptoms of a stroke and a stat computed tomography (CT) head scan has been ordered. The ED nurse should know that the image that results from CT indicates distinguishing differences based on which of the following variables? 1- Proximity to the CT scanner 2- Variations in tissue density 3- Metabolic activity 4- Oxygen consumption

2

The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart? 1- CN I 2- CN II 3- CN III 4- CN IV

2

A nurse is completing a neurological assessment and determines that the client has significant visual deficits. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit? 1- frontal 2- parietal 3- temporal 4- occipital

4

A 53-year-old man presents to the emergency department with a chief complaint of inability to form words, and numbness and weakness of the right arm and leg. Where would you locate the site of injury? 1- Left frontoparietal region 2- Right frontoparietal region 3- Left basal ganglia 4- Left temporal region

1

What part of the brain controls and coordinates muscle movement? 1- Cerebellum 2- Cerebrum 3- Midbrain 4- Brain stem

1

A patient with a neurological disorder is being assessed by the nurse. The nurse assesses the patient's biceps reflex as diminished. The nurse would be correct in documenting this response as what? 1- 0 2- 1+ 3- 2+ 4- 3+

2

The nurse is caring for a patient who was involved in a motor vehicle accident and sustained a head injury. When assessing deep tendon reflexes (DTR), the nurse observes diminished or hypoactive reflexes. How will the nurse document this finding? 1- 0 2- 1+ 3- 2+ 4- 3+

2

The nurse is doing an initial assessment on a patient recently admitted to the unit with a diagnosis of cerebrovascular accident (CVA). The patient has difficulty copying a figure that the nurse has drawn. The nurse uses this technique to assess for what type of aphasia? 1- Auditory-receptive 2- Visual-receptive 3- Expressive speaking 4- Expressive writing

2

There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields. 1- Cranial nerve I 2- Cranial nerve II 3- Cranial nerve III 4- Cranial nerve IV

2

A nurse is performing a neurologic assessment on a client. The nurse observes the client's tongue for symmetry, tremors, and strength, and assesses the client's speech. Which cranial nerve is the nurse assessing? 1- IV 2- IX 3- VI 4- XII

4

Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways? 1- Enkephalin 2- Norepinephrine 3- Acetylcholine 4- Serotonin

4

Which safety action will the nurse implement for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)? 1- Securely fasten the client's portable oxygen tank to the bottom of the MRI table after the client has been positioned on the table. 2- Check the client's oxygen saturation level using a pulse oximeter after the client has been placed on the MRI table. 3- Note that no special safety actions need to be taken. 4- Ensure that no client care equipment containing metal enters the room where the MRI table is located.

4

A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult slowing transmission of the motor neurons, the nurse would anticipate a delayed reaction in: 1- identification of information due to slowed passages of information to brain. 2- cognitive ability to understand relayed information. 3- processing information transferred from the environment. 4- response due to interrupted impulses from the central nervous system

4

Age-related changes in the neurologic system must be carefully assessed. Which of the following changes does the nurse expect to find in some degree depending on the patient's age and medical condition? Select all that apply. 1- Hyper-reactive deep tendon reflexes 2- Decreased muscle mass 3- Increased sensitivity to heat and cold 4- Stage IV sleep is prolonged 5- Increased sensitivity of taste buds 6- Reduced papillary responses

2,3,6

A 30-year-old primiparous woman has been admitted in early labor. The obstetrical nurse has read on the patient's prenatal record that she has a history of seizures. The nurse should understand that seizures most often occur as a result of: 1- Benign spinal cord lesions 2- Cranial nerve deficits 3- Abnormal activity in the cerebral cortex 4- Faulty integration of sensory impulses by the thalamus

3

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? 1- Prone, with the head turned to the right 2- Supine, with the knees raised toward the chest 3- Lateral recumbent, with chin resting on flexed knees 4- Lateral, with right leg flexed

3

A client is scheduled for an EEG. The client asks about any diet-related prerequisites before the EEG. Which diet-related advice should the nurse provide to the client? 1- Avoid eating food at least 8 hours before the test. 2- Include an increased amount of minerals in the diet. 3- Decrease the amount of minerals in the diet. 4- Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test.

4

A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture? 1- Administer antihistamines to the client. 2- Provide adequate caffeine-rich drinks to the client. 3- Assess the level of consciousness (LOC) and the pupil response of the client. 4- Position the client flat for at least 3 hours.

4

The trochlear nerve controls which function? 1- Movement of the tongue 2- Hearing and equilibrium 3- Visual acuity 4- Eye muscle movement

4

A patient has been diagnosed with a deficiency of the major neurotransmitter acetylcholine. Based on this information, the nurse knows to assess the patient for complications associated with: 1- Fine movements. 2- Sleep patterns. 3- Heart rate and rhythm. 4- Emotional balance.

3

A primary nursing assessment for a patient who has sustained a fracture involving the basilar skull is inspection for: 1- Leakage of CSF from the nose. 2- Ecchymosis of the mastoid process of the temporal bone. 3- Leakage of CSF from the ear. 4- Vomiting and headaches due to increased intracranial pressure.

3

A nurse conducts the Romberg test by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and prevents the client from being injured. In which way should the nurse interpret the client's result? 1- Positive Romberg test, indicating a problem with level of consciousness 2- Negative Romberg test, indicating a problem with body mass 3- Negative Romberg test, indicating a problem with vision 4- Positive Romberg test, indicating a problem with equilibrium

4

A patient who has been diagnosed with colon cancer is scheduled to undergo positron emission tomography (PET) to search for metastases. In preparation for this diagnostic procedure, what teaching point should the nurse provide to the patient? 1- "Sound waves will be refracted throughout your body and a computer will analyze them." 2- "A series of X-rays will be taken that will be combined to create a three-dimensional image your body." 3- "It's very important that all metal objects be removed from your body before the test." 4- "You'll be given a radioactive substance that will be measured during the test."

4

A patient who has suffered a stroke is unable to maintain respiration and is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe? 1- Frontal lobe 2- Occipital lobe 3- Parietal lobe 4- Brain stem

4

The nurse is admitting a patient to the unit who is diagnosed with a lower motor neuron lesion. What clinical manifestations would this patient most likely exhibit? 1- Increased muscle tone 2- No muscle atrophy 3- Hyperactive and abnormal reflexes 4- Absent or decreased reflexes

4

The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve? 1- Cranial nerve I 2- Cranial nerve V 3- Cranial nerve XI 4- Cranial nerve XII

4

To assess a client's cranial nerve function, a nurse should assess: 1- hand grip. 2- orientation to person, time, and place. 3- arm drifting. 4- gag reflex.

4

When learning about the nervous system, students learn that which nervous system regulates the expenditure of energy? 1- Parasympathetic 2- Central 3- Peripheral 4- Sympathetic

4

The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? 1- Myelogram 2- Electroencephalogram 3- Echoencephalography 4- Cerebral angiography

4

The pre-nursing class is learning about the nervous system in their anatomy class. What part of the nervous system would the students learn is responsible for digesting food and eliminating body waste? 1- Central 2- Sympathetic 3- Peripheral 4- Parasympathetic

4

A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements? 1- "A secondary headache is one for which no organic cause can be identified." 2- "A secondary headache is located in the frontal area." 3- "A secondary headache is associated with an organic cause, such as a brain tumor." 4- "A migraine headache is an example of a secondary headache."

3

A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain? 1- III 2- IV 3- V 4- VI

3