Neuro Assessment

Cerebellum

An older adult is experiencing an alteration in equilibrium and coordinated muscle movements. The nurse realizes that these functions are controlled by which area of the nervous system? Hint: Anatomy and Physiology Review Cerebrum Hypothalamus Cerebellum Brain stem

2

The nurse is performing the Romberg test and asks the client to stand with the feet together and eyes closed. The nurse notes the findings are normal. Which finding is expected during this assessment? 1. Swaying from side to side. 2. Exhibiting minimal swaying. 3. Feeling moderately dizzy. 4. Having complete loss of balance.

Brain stem

What part of the brain is responsible for vital signs?

extension of the arm at the elbow

When assessing the triceps reflex, the nurse would expect to see: Hint: Reflexes supination of the hand flexion of the arm at the elbow movement of the upper arm extension of the arm at the elbow

Cranial nerve 10

responsible for facial sensation and temporal and masseter strength

Cranial nerve 7

responsible for sense of taste and facial expressions

Cranial nerve 1

Responsible for sense of smell

3

The nurse is assessing a client to determine tremors associated with Parkinson disease. Which clinical manifestation does the nurse anticipate during the assessment? 1. Fasciculations. 2. Chorea. 3. Rhythmic shaking. 4. Athetoid movements.

Cranial nerve 3

assessment of papillary reactivity and extrinsic muscles of eyes

Cranial nerve 2

optic nerve

VII (facial)

A client has a flattened nasolabial fold and drooping of the mouth on the left side. The nurse understands the cranial nerve (CN) most likely to be involved is CN: Hint: Cranial Nerves V (Trigeminal) VII (Facial) XII (Hypoglossal) XI (Accessory)

loss of ability to smell or detect odors

A client has a history of anosmia over the past 3 months. The nurse knows that this condition is: Hint: Cranial Nerves related to swallowing difficulty associated with ataxia difficulty with tongue movements loss of ability to smell or detect odors

Glossopharyngeal (1X) and vagus (X)

A client with a head injury is demonstrating dysphagia and dysphasia. The nurse understands that the cranial nerve/nerves involved with this symptom is/are: Select all that apply. glossopharyngeal (IX) vagus (X) accessory (XI) facial (VII) trigeminal (V)

myelitis

A client, seen previously for herpes zoster, comes into the clinic with ongoing neurologic changes including back pain and sensory/motor function changes. The nurse realizes that this client may be experiencing: Hint: Infections of the Neurologic System myasthenia gravis Lyme disease meningitis myelitis

nervousness

During the neurologic assessment, the nurse finds that a client is unable to calculate mathematical problems; however, the remainder of the assessment is normal. This finding suggests to the nurse that the client may be experiencing: Hint: Mental Status altered cognitive status depression dementia nervousness

positive Romberg's test

The nurse asks a client to stand with feet together and arms at the side with eyes closed. The client immediately starts to sway and moves feet farther apart. The nurse would document this as a: Hint: Perform Romberg's Test negative Romberg's sign positive Romberg's sign cerebellar dysfunction vestibular dysfunction

3

The nurse is admitting a client with suspected meningitis and notes a positive Brudzinski sign has been noted in the history and physical. Which clinical manifestation would validate this assessment finding? 1. Seizure activity. 2. Neck pain and stiffness. 3. Flexion of the legs and thighs. 4. Neck extension.

3

The nurse is admitting a client with suspected meningitis. During the assessment, the nurse asks the client to flex the chin down toward the chest. The client verbalizes pain and stiffness during this action. How will the nurse document this finding in the medical record? 1. Muscle spasms. 2. Neck strain. 3. Nuchal rigidity. 4. Brudzinski's sign.

3

The nurse observes drainage from a client's ears after a head injury, and suspects a cerebral spinal fluid (CSF) leak. Which description of the fluid supports the nurse's suspicion? 1. Yellow without sediment. 2. Blood-tinged without sediment. 3. Clear, colorless. 4. Pink without sediment.

plantar flexion of the foot

During an assessment of an adult client's plantar reflex, the nurse notes a normal response. The nurse understands that a normal response is demonstrated by: Hint: Techniques and Normal Findings; Reflexes a positive Babinski response dorsiflexion of the foot plantar flexion of the foot fanning of the toes

Hypalgesia

During the assessment of sensory function of a client, the nurse learns that the client has decreased pain sensation. How should the nurse document this finding? Hint: Techniques and Normal Findings; Sensory Function Anesthesia Analgesia Hypalgesia Hypoesthesia

Hopkins Competency Assessment Test

During the neurologic assessment of a client the nurse would like to include questions to assess the client's ability to make healthcare decisions. Which tool can the nurse use to perform this assessment? Hopkins Competency Assessment General Health Questionnaire Mini-mental State Examination Cornell Scale for Depression in Dementia

fasciculation

Near the conclusion of the neurologic examination, the nurse notices an involuntary, rapid muscle contraction of the client's left quadriceps muscle. The nurse identifies this assessment finding as a: Hint: Problems with Motor Function fasciculation tic tremor myoclonus

4

The community health nurse is preparing a program geared toward primary prevention of hypertension. When preparing the program, what activities will aid the nurse in meeting the goals of primary prevention? 1. Providing dietary counseling for clients with hypertension. 2. Offering free blood pressure screening to participants. 3. Having a contest for participants to win an automatic blood pressure cuff for home use. 4. Providing literature to discuss modifiable risk factors.

2, 4

The nurse is assessing a client that experienced a head injury using the Glasgow Coma Scale. Which findings are scored using the best motor response portion of the scale? Standard Text: Select all that apply. 1. No response with eyes to commands. 2. Abnormal flexion to pain. 3. Pupil response sluggish. 4. Abnormal extension to pain. 5. Pupils fixed and dilated.

2

The nurse is assessing cognitive function in a client who experienced a cerebral vascular accident (CVA). Which should the nurse focus on during the assessment process? 1. Ability to smell items while eyes are closed. 2. Orientation to time, place, and person. 3. Ability to walk with a smooth, steady gait. 4. Ability to speak clearly.

1

The nurse is assessing cranial nerve XI (spinal accessory). Which statements would the nurse say to the client in order to complete this assessment? 1. "Shrug your shoulders and turn your head against my hand." 2. "Stick out your tongue and move it from side to side." 3. "Taste these foods and decide which is sweet and which is sour." 4. "Smell these items and identify what they are."

4

The nurse is assessing the patellar reflex on a client and obtains no reflexive activity. The client is alert and oriented. Which action by the nurse is the most appropriate? 1. Document the findings as normal. 2. Notify the healthcare provider immediately. 3. Look at the medication records for central nervous system depressants. 4. Retest the reflex after having the client use distraction during the exam.

4

The nurse is caring for a client experiencing vertigo and plans to perform the Romberg test during the assessment. Which instruction from the nurse regarding this test is the most appropriate? 1. "Touch your finger to your nose, alternating hands." 2. "Walk across the room by placing one foot in front of the other, heel to toes." 3. "Walk on your toes, then on your heels, then on your toes again." 4. "Stand with your feet together, arms at sides, and eyes open."

The frontal lobe of the cerebrum for the control of emotions

The nurse is caring for a client having problems with emotional appropriateness as a result of a brain injury. Based on this data, which area of the brain has been damaged?

Brain stem

The nurse is caring for a client with a traumatic brain injury (TBI). The client begins to experience bradycardia. Which area of the brain is likely responsible for the changes in heart rate?

1

The nurse is interviewing a client and notes that the left eyelid is drooping. Which term will the nurse use when documenting this finding in the medical record? 1. Ptosis. 2. Nystagmus. 3. Strabismus. 4. Myopia.

4

The nurse is interviewing a client who tells the nurse of experiencing decreased sensation on the left side of the body. After confirmation of this subjective data, which term will the nurse use when documenting this finding in the medical record? 1. Anesthesia. 2. Analgesia. 3. Hypalgesia. 4. Hypoesthesia.

2

The nurse is interviewing a client with suspected Lyme disease. Which question is the priority in this situation? 1. "When was your last seizure?" 2. "Have you been hiking or camping lately?" 3. "What has your temperature been running?" 4. "Do you have an appetite?"

2

The nurse is observing a client's ambulation abilities and notes a scissors gait. Based on this data, which does the nurse suspect? 1. Parkinson disease. 2. Multiple sclerosis. 3. Myasthenia gravis. 4. Muscular dystrophy.

1, 3

The nurse is performing a neurological assessment and needs to assess for vibration, as well as sharp and dull sensation. Which objects will the nurse use to complete this assessment? Standard Text: Select all that apply. 1. Tuning fork. 2. Paper clip. 3. Safety pin. 4. Cotton ball. 5. Tongue blade.

2

The nurse is performing a neurological assessment on a client and needs to use stereognosis. Which instruction would the nurse provide for the client? 1. "Tell me if you feel one or two objects touching you with your eyes closed." 2. "Identify the object in your hand with your eyes closed." 3. "Identify the number being traced in your hand with your eyes closed." 4. "Open and close your hand each time I tell you to."

3

The nurse is performing a neurological assessment on a client experiencing anosmia (sense of smell). Which cranial nerve does the nurse assess to further investigate this issue? 1. Trochlear (cranial nerve IV). 2. Trigeminal (cranial nerve V). 3. Olfactory (cranial nerve I). 4. Oculomotor (cranial nerve III).

Utilize reinforcement techniques that enhance reflex

The nurse is performing an assessment on a middle-aged client and is unable to elicit a patellar reflex. How should the nurse proceed with this examination? Hint: Techniques and Normal Findings; Reflexes Utilize reinforcement techniques that enhance the reflex. Complete the remainder of the assessment, and then reassess the reflexes. Consider this a normal finding for a client of this age. Stop the assessment and refer immediately to the health care provider.

2

The nurse is preparing a neurological health seminar for the staff on the unit. Which statement would the nurse include in the teaching plan? 1. Older adults experience fewer accidents and injuries. 2. Alcohol or drug use increases the risk for accidents and injury. 3. Head injuries are more common in adults than children. 4. Epilepsy occurs only in children under age 15.

1,2,4

The nurse is preparing to conduct a focused interview on a client who is experiencing back pain. Which questions will the nurse include in this focused interview? Standard Text: Select all that apply. 1. "How long have you been experiencing this pain?" 2. "What activities seem to increase your pain?" 3. "Are your children physically active?" 4. "What things do you do to relieve your pain?" 5. "Are you receiving worker's compensation?"

1

The nurse is providing discharge instructions to the mother of a child admitted for fever of unknown origin. Which of the following statements, if made by the mother, would indicate the need for further instruction? 1. "I should use Tylenol or aspirin to bring down the temperature." 2. "I should contact the doctor if I cannot wake up my child." 3. "I should observe how much my child urinates." 4. "I should monitor my child's intake of fluids throughout the day."

1

The nurse is providing education to a group of pregnant women. Which should the nurse stress as the greatest tool in the prevention of low-birth-weight babies? 1. Early prenatal care. 2. Eating a balanced diet. 3. Avoiding stress. 4. Regular exercise.

1, 2

The nurse is reviewing the cranial nerves prior to a PRN shift on a neurological unit. Upon the review, the nurse notes that some of the nerves are exclusively sensory nerves. Which cranial nerves belong to this group? Standard Text: Select all that apply. 1. Olfactory nerve (cranial nerve I). 2. Optic nerve (cranial nerve II). 3. Trochlear nerve (cranial nerve IV). 4. Trigeminal nerve (cranial nerve V). 5. Facial nerve (cranial nerve VII).

3

The nurse is reviewing the history and physical on a client and notes a history of syncope. Based on this finding, which should the nurse implement for this client? 1. Soft diet. 2. Seizure precautions. 3. Fall precautions. 4. Intake and output.

2

The nurse notes fanning of the toes when the sole of the foot is stimulated during assessment of the plantar reflex. Which is appropriate for the nurse to use when documenting this finding in the medical record? 1. Hyperreflexia. 2. Babinski response. 3. Brudzinski sign. 4. Nuchal rigidity.

4

The nurse notes that a client has difficulty with ambulation due to an unsteady gait. Which term will the nurse use to document this finding in the medical record? 1. Flaccidity. 2. Paralysis. 3. Hemiparesis. 4. Ataxia.

1

The nurse performing reflex testing on a client uses the reflex hammer to gently strike the forearm about two inches above the wrist. Which reflex is the nurse assessing with this technique? 1. Brachioradialis. 2. Biceps. 3. Triceps. 4. Achilles.

hypertension, diabetes, stress

The nurse understands risk factors for cerebral vascular accident (stroke) include: Select all that apply. Hint: Patient Education hypertension diabetes use of aspirin lead poisoning stress

"How old is the home you live in", "What was the birth weight of your child", "When your child has a fever what meds do you give to reduce it", "Is you child up to date on childhood immunizations"

Which questions should the nurse include when gathering information from the parent regarding a preschooler's neurological health? Select all that apply. Hint: Focused interview Questions; Patient Education "How old is the home that you live in?" "What was the birth weight of your child?" "When your child has a fever, what medication do you give to reduce it?" "Do you apply sunscreen to your child's skin on a regular basis?" "Is your child up-to-date on childhood immunizations?"

1

While interviewing a client the nurse notes the client's eyes moving involuntarily. Which term will the nurse use to document this finding in the medical record? 1. Nystagmus. 2. Presbyopia. 3. Anosmia. 4. Polyneuritis.

kinesthesia

With the client's eyes closed, the nurse moves the client's finger up and down and asks the client to identify the direction of the movement. The nurse is assessing: Hint: Techniques and Normal Findings; Sensory Function stereognosis topognosis kinesthesia graphesthesia

Cranial nerve 10

innervates the muscles of the throat and mouth for swallowing and talking

Cranial nerve 12

responsile for movement of tongue for swallowing, movement of food during eating, chewing, and speech

Cranial nerve 4

trochlear nerve; assessment would require assessing the movement of the eyes. following an object such as examiners fingers