EAQ chapter 23

Which part of the client's brain primarily regulates muscle functioning and coordinates movement?

Cerebellum

Which instruction would the nurse give to a patient while performing the Romberg test?

"Stand with feet together and eyes open then closed."

The nurse is assessing a 5-year-old child using the Glasgow Coma Scale after surgery. What rating should the nurse assign if the child shows a confused verbal response?

4

While assessing the deep tendon reflexes in a patient, the nurse finds that the responses are very brisk and hyperactive, with clonus. Which grade should the nurse enter in the patient's medical record?

4+

In which patient would the nurse expect to find a palmar grasp reflex and a positive Babinski reflex?

An infant

While assessing a patient with lower motor neuron lesion, the nurse sees that the patient has an asymmetric smile and is unable to wrinkle the forehead. Damage to which cranial nerve could cause these findings?

Cranial nerve VII (facial nerve)

While assessing a client the nurse observes abnormal rigidity with pronation of the arms. Which condition should the nurse record in the assessment findings?

Decerebration

While assessing a client the nurse observes abnormal rigidity with pronation of the arms. Which condition should the nurse record in the assessment findings?

Decerebration Abnormal movement with rigidity on extension of the arms and legs, pronation of the arms, and plantar flexion is called decerebration. The condition found in the client related to decerebration should be recorded in the assessment findings

A client has expressive aphasia. The client's family members ask how they can help the client regain as much speech function as possible. Which information should the nurse share with the family?

Encourage the client to speak while allowing time to respond

Which areas of consciousness would a nurse rate while assessing a patient with the Glasgow Coma Scale?

Eye opening Verbal response Motor response

What are the characteristics of lower motor neuron lesions?

Fasciculation Muscular atrophy

Which lobe of the cerebrum includes the client's Broca's speech center?

Frontal lobe

Which part of the brain is associated with personality and intellectual functioning?

Frontal lobe

An older client is diagnosed with Alzheimer disease. For which clinical manifestations should the nurse assess the client?

Loss of recent memory Perceptual disturbances Difficulty learning something new

Which signs would the nurse observe in a patient with Alzheimer disease?

Mood swings Disorientation Loss of initiative

A client comes into the emergency department with neurologic deficits after falling off a ladder. Which client assessment will the nurse perform for the Glasgow Coma Scale?

Motor response to verbal commands

What is the function of a client's cranial nerve VI?

Movement of the eye with lateral rectus muscles

Which condition is characterized with an involuntary and rapid twitching of the client's eyeball?

Nystagmus

Which tests should the nurse perform to assess cerebellar function in a patient?

Romberg test Finger-to-nose test

What are the components of a reflex arc?

Sensory nerve Motor nerve Neuromuscular junction

A client is diagnosed as having expressive aphasia. Which type of impairment does the nurse expect the client to exhibit?

Speaking or writing

An older client experiences a cerebral vascular accident (CVA) and has right-sided hemiplegia and expressive aphasia. The client's children ask the nurse which functions will be impaired. Which abilities does the nurse explain will be affected?

Stating wishes verbally Impaired ability to state wishes verbally is a characteristic of expressive aphasia[1][2] from damage to Broca area in the dominant hemisphere of the brain.

The nurse asks the patient to close the eyes and then places a paper clip on the patient's palm. The patient is asked to recognize the object. Which test is the nurse performing?

Stereognosis

Which statement describes decerebrate rigidity?

The back is hyperextended, and the palms are pronated.

Which sign or symptom would the nurse expect to find in a patient with aphasia?

The patient has lost the ability to understand language.

The nurse is caring for an aging patient with dementia. The patient appears agitated and is pacing and yelling. What does the nurse infer from these findings?

The patient is experiencing pain.

A client is admitted to the hospital with an altered level of consciousness. When assessing this client the nurse understands that level of consciousness extends along a continuum. Place the following words that describe level of consciousness in order from the most alert to the least alert.

2. Alert 4. Confused 1. Lethargic 3. Obtunded

The nurse is performing a neurologic assessment on a client and is completing the Glasgow Coma Scale (GCS). What components make up this assessment tool?

Best verbal response Best motor response Best eye-opening response

Arrange the steps taken by a nurse while assessing the visual level of a client in sequential order.

Direct the client to stand or sit 60 cm away from eye level Ask the client to close his or her left or right eye gently and look directly at the nurse's opposite eye Close the opposite eye to superimpose the field of vision Move a finger equidistant between the nurse and the client outside the field of vision Ask the client to report when he or she is able to see the finger

The nurse flashes light into the eyes of a 5-year-old child and observes ocular misalignment and a deviated gaze. What condition does the nurse expect to find in the child?

Strabismus- crossed eyes