Nursing Assessment: Neurologic Function

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?

"What would you do if you found a stamped envelope on the street?"

The nurse is assisting with a lumbar puncture and observes that when the physician obtains CSF, it is clear and colorless. What does this finding indicate?

A normal finding; the fluid will be sent for testing to determine other factors

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:

Abnormal activity in the cerebral cortex

Which of the following neurotransmitters are deficient in myasthenia gravis?

Acetylcholine

The nurse is completing a neurologic assessment and uses the whisper test to assess which cranial nerve?

Acoustic

A client undergoes a scheduled electroencephalogram (EEG). Which of the following post-procedure activities should the nurse carry out for the client?

Allow the client to rest and shampoo the client's hair.

A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first?

Assess the client for medication allergies.

Lesions in the temporal lobe may result in which type of agnosia?

Auditory

The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve?

CN I

The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart?

CN II

What part of the brain controls and coordinates muscle movement?

Cerebellum

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?

Cerebral angiography

A nurse is preparing a client for a lumbar puncture. The client has heard about post-lumbar puncture headaches and asks what causes them. The nurse tells the client that these headaches are caused by which of the following?

Cerebral spinal fluid leakage at the puncture site

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?

Clonus

Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed?

Clonus

There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields.

Cranial nerve II The three sensory cranial nerves are I, II and VIII. Cranial nerve II (optic) is affected with decreased visual fields and acuity.

A patient scheduled for a magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the patient for the MRI should:

Ensure no metal-containing objects are present. Patient preparation for an MRI consists of removing all metal-containing objects prior to the exam. Withholding stimulants would not affect an MRI; this relates to electroencephalography (EEG). The patient does not need to void prior to MRI. Oral contrast is only used for GI scans.

Cranial nerve IX is also known as which of the following?

Glossopharyngeal

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?

Head of the bed elevated 45 degrees

Which of the following areas of the brain are responsible for temperature regulation?

Hypothalamus

Which lobe of the brain is responsible for spatial relationships?

Parietal

A patient has suffered cerebellar trauma after falling off of a ladder. The patient has been stabilized and is now receiving care on a neurological unit. When planning this patient's care, what nursing diagnosis is most likely to result from an injury to this part of the brain?

Risk for falls

A client who has sustained a head injury to the parietal lobe cannot identify a familiar object by touch. The nurse knows that this deficit is which of the following?

Tactile agnosia

Damage to which area of the brain results in receptive aphasia?

Temporal lobe

Which client should the nurse assess for degenerative neurologic symptoms?

The client with Huntington disease.

The nurse is performing a neurological assessment of a client who has sustained damage to the frontal cortex. Which of the following deficits will the nurse look for during assessment?

The inability to tell how a mouse and a cat are alike

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?

X

The nurse is caring for a client newly diagnosed with multiple sclerosis who is overwhelmed by learning about the disease. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. The nurse should tell the client:

that the covering is called myelin and that it can be discussed further at the next meeting.

Which term describes the fibrous connective tissues that cover the brain and spinal cord?

Meninges The patient is exhibiting signs of expressive aphasia with numbness/tingling and weakness of the right arm and leg. This indicates injury to the expressive speech center (Broca's area), which is located in the inferior portion of the frontal lobe. The motor strip is located in the posterior portion of the frontal lobe. The sensory strip is located in the anterior parietal lobe.

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?

Visual-receptive

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?

"A secondary headache is associated with an organic cause, such as a brain tumor."

A nurse is discussing a lumbar puncture with a nursing student who observed the procedure. The student noticed that the cerebrospinal fluid was blood tinged and asks what that means. The correct reply is which of the following? "It can mean the spinal cord was damaged or a traumatic puncture." "It can mean a subarachnoid bleed or damage to the spinal cord." "It can mean a bleed around the hypothalamus or damage from the needle." "It can mean a traumatic puncture or a subarachnoid bleed."

"It can mean a traumatic puncture or a subarachnoid bleed." The needle is inserted below the level of the spinal cord, which prevents damage to the cord. The cerebral spinal fluid (CSF) should be clear and colorless. Pink or bloody CSF may indicate a subarachnoid bleed or local trauma from the puncture. The hypothalamus is located deep inside the brain and does not affect the color of the CSF.

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:

15

The sympathetic and parasympathetic nervous systems have a direct effect on the circulatory system. Stimulation of the parasympathetic nervous system (PNS) causes which of the following? Blood pressure to increase Blood vessels in the heart muscle to dilate Blood vessels in the skeletal muscles to dilate Heartbeat to decrease

Heartbeat to decrease The parasympathetic nervous system has a constricting effect on the blood vessels in the heart and skeletal muscles; the heartbeat and blood pressure will decrease.

The sympathetic and parasympathetic nervous systems have a direct effect on the circulatory system. Stimulation of the parasympathetic nervous system (PNS) causes which of the following? Heartbeat to decrease Blood vessels in the heart muscle to dilate Blood pressure to increase Blood vessels in the skeletal muscles to dilate

Heartbeat to decrease The parasympathetic nervous system has a constricting effect on the blood vessels in the heart and skeletal muscles; the heartbeat and blood pressure will decrease.

The anatomy instructor is discussing the central nervous system. A student asks where the cerebral cortex is located. What should the anatomy instructor answer? "It is located between the left and right hemispheres of the brain." "It is located at the base of the brain." "It is located on the surface of the cerebrum." "It is located in the center of the cerebellum."

"It is located on the surface of the cerebrum." The cerebral cortex is the surface of the cerebrum. It contains motor neurons, which are responsible for movement, and sensory neurons, which receive impulses from peripheral sensory neurons located throughout the body.

If a client has a lower motor neuron lesion, the nurse would expect the client to exhibit

decreased muscle tone.

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:

dysfunction in the brain stem. Decerebrate posturing indicates damage of the upper brain stem. Decorticate posturing indicates cerebral dysfunction. Increased intracranial pressure is a cause of decortication and decerebration. Alterations in sensation or paralysis indicate dysfunction in the spinal column.

Lower motor neuron lesions cause

flaccid muscles.

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?

"There is a strong familial tendency."

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?

Brain stem

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?

Comatose

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

Constricted pupils Constricted pupils are a parasympathetic effect; dilated pupils are a sympathetic effect.

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?

Cranial nerve XII Assessment of the movement of the tongue is cranial nerve XII . Cranial nerve I is the olfactory nerve. Cranial nerve V is the trigeminal nerve responsible for sensation to the face and chewing. Cranial nerve XI is the spinal or accessory nerve responsible for head and shoulder and shoulder movement.

Which of the following is a sympathetic nervous system effect?

Decreased peristalsis

Low levels of the neurotransmitter serotonin lead to which of the following disease processes?

Depression

Which is a sympathetic effect of the nervous system?

Dilated pupils

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?

Frontal lobe

A primary nursing assessment for a patient who has sustained a fracture involving the basilar skull is inspection for:

Leakage of CSF from the ear.

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?

Left frontoparietal region

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

Sympathetic Sympathetic Nervous System: This division of the autonomic nervous system regulates the expenditure of energy.

A 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?

cerebral angiography

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:

convert glycogen to glucose for immediate use.

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:

response due to interrupted impulses from the central nervous system

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.

Keep a food diary. Maintain a headache diary. The clients should be encouraged to keep food and headache diaries to identify triggers and to track frequency and characteristics of the migraines. The clients should maintain a routine sleep pattern and avoid fatigue. Limiting sleep to 5 hours may cause fatigue. The associated symptoms of a migraine are nausea, vomiting, and photophobia. Being in a dark room may ease the photophobia, but exercise may worsen the headache and associated symptoms. Clients who are taking medications specific for migraines should avoid St. John's Wort due to potential drug interactions.

A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for:

hypoxia. Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature control, vision, and gait aren't lower brain stem functions.

If a client has a lower motor neuron lesion, the nurse would expect to observe which manifestation upon physical assessment?

Decreased muscle tone

During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to:

support the joint where the tendon is being tested.

A patient is having a lumbar puncture and the physician has removed 20 mL of cerebrospinal fluid. What nursing intervention is a priority after the procedure?

Have the patient lie flat for 6 hours. Post-lumbar puncture headache may be avoided if a small-gauge needle is used and if the patient remains prone after the procedure. When more than 20 mL of CSF is removed, the patient is positioned supine for 6 hours.

The nurse is preparing a client for a neurological examination by the physician and explains tests the physician will be doing, including the Romberg test. The client asks the purpose of this particular test. The correct reply by the nurse is which of the following?

"It is a test for balance."

A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following?

"The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid."

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? Helicopod Dystrophic Ataxic Steppage

Helicopod A helicopod gait is an abnormal gait in which the client's feet make a half circle with each step. An ataxic gait is staggering and unsteady. In a dystrophic gait, the client waddles with the legs far apart. In a steppage gait, the feet and toes rise high off the floor and the heel comes down heavily with each step.

A neurological nurse is conducting a focused neurological assessment of a patient who has just been admitted to the rehabilitative facility. During this assessment, the nurse has asked the patient to swallow and has tested the patient's gag reflex with a tongue depressor. These assessments test the function of which of the patient's cranial nerves?

IX (glossopharyngeal) and X (vagus)

A male client is scheduled for an electroencephalogram (EEG). When the nurse caring for the client is preparing him for the test, the client states that during childhood he was mildly electrocuted but miraculously lived. Therefore, he is quite afraid of going through an EEG. In what ways can the nurse help dispel the client's fear regarding the test?

Inform the client that he will not experience any electrical shock.

What nursing intervention will best assist the client with chorea?

Monitor the client on bed rest Chorea is a rapid, jerky, involuntary, purposeless movement of the extremities that interferes with walking, sitting, and activities of daily living. It can involve facial muscles. For safety reasons, the client should be monitored on bed rest.

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?

The weakness is primarily on the left side of the patient's body.

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? CN X CN III CN VII CN VIII

VIII CN VIII is the acoustic nerve. It has to do with hearing, air and bone conduction, and balance. CN X is the vagus nerve and has to do with the gag reflex, laryngeal hoarseness, swallowing ability, and the symmetrical rise of the uvula and soft palate. CN III is the oculomotor and has to do with pupillary response, conjugate movements, and nystagmus. CN VII is the facial nerve and has to do with symmetry of facial movements and the ability to discriminate between the taste of sugar and salt.

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?

XII Cranial nerve XII, the hypoglossal nerve, controls tongue movements involved in swallowing and speech. The tongue should be midline, symmetrical, and free from tremors and fasciculations. The nurse tests tongue strength by asking the client to push his tongue against his cheek as the nurse applies resistance. To test the client's speech, the nurse may ask him to repeat the sentence, "Round the rugged rock that ragged rascal ran." The trochlear nerve (IV) is responsible for extraocular movement (inferior medial). The glossopharyngeal nerve (IX) is responsible for swallowing movements and throat sensations. It's also responsible for taste in the posterior third of the tongue. The abducent nerves (VI) are responsible for lateral extraocular movements.

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

gag reflex. The gag reflex is governed by the glossopharyngeal nerve, cranial nerve IX. The other choices would not be involved in a cranial nerve assessment. Hand grip and arm drifting are part of motor function assessment. Orientation is an assessment parameter related to a mental status examination.

The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response? assessing the client's sensitivity to temperature, touch, and pain observing the reaction of pupils to light observing the client's response to painful stimulus using the Romberg test

observing the client's response to painful stimulus The nurse evaluates motor response in a comatose or unconscious client by administering a painful stimulus. This action helps determine if the client makes an appropriate response by reaching toward or withdrawing from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Pupils are examined for their reaction to light to assess sensitivity in the third cranial (oculomotor) nerve. Sensitivity to temperature, touch, and pain is a test to assess the sensory function of the client and not motor response.

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?

Reduction in cerebral blood flow (CBF)

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? "There's no other option but to assume the knee-chest position." "Although the required position may not be comfortable, it will make the procedure safer and easier to perform." "Lying on your left side will be fine during the procedure." "I'll report your concerns to the physician."

"Although the required position may not be comfortable, it will make the procedure safer and easier to perform." The nurse should explain that the knee-chest position is necessary to make the procedure safer and easier to perform. Lying on his left side won't make the procedure easy or safe to perform. The nurse shouldn't simply tell the client there is no other option because the client is entitled to understand the rationale for the required position. Reporting the client's concerns to the physician won't meet the client's needs in this situation.

What safety actions does the nurse need to take for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)?

Ensure that no client care equipment containing metal enters the room where the MRI is located.

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?

Flaccidity

Which cerebral lobes is the largest and controls abstract thought?

Frontal

The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?

Moving the head and chin toward the chest The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not to be assessed.

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?

Occipital

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?

Parasympathetic

A patient has difficulty interpreting his awareness of body position in space. Which lobe is most likely to be damaged? Parietal Temporal Occipital Frontal

Parietal The parietal lobe is the primary sensory cortex. It is essential to a person's awareness of his body in space, as well as orientation in space and spatial relations.

During a neurological assessment examination, the nurse assesses a patient for tactile agnosia. The nurse places a familiar door key in the patient's hand and asks him to identify the object with his eyes closed. The nurse documents his inability to identify the object and notes the affected area of the brain. Which of the following is the most likely affected area of the brain?

Parietal lobe

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? VI (Abducens) IV (Trochlear) VII (Facial) V (Trigeminal)

VI (Abducens) The abducens cranial nerve supports movement of the eye laterally. Damage to the nerve can cause double vision.

The provider orders the Romberg test for a patient. The nurse tells the patient that the provider wants to evaluate his equilibrium by assessing which cranial nerve?

VIII

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?

Variations in tissue density

During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to:

support the joint where the tendon is being tested. The nurse should support the joint where the tendon is being tested to prevent the attached muscle from contracting. The nurse should use the flat, not pointed, end of the reflex hammer when striking the Achilles tendon. (The pointed end is used to strike over small areas, such as the thumb placed over the biceps tendon.) Tapping the tendon slowly and softly wouldn't provoke a deep tendon reflex response. The nurse should hold the reflex hammer loosely, not tightly, between the thumb and fingers so it can swing in an arc.