Prep U 25

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 neurological examination, which question would be most appropriate to ask?

"Can you tell me where you are right now?"

The nurse is providing teaching to a client with type 1 diabetes. When providing information about reducing the risk of diabetic neuropathy, the nurse should be sure to include which point?

"Effective blood glucose regulation can prevent this problem."

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."

How many pairs of cranial nerves exit from the brain?

12

When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk?

68-year-old African American male with hypertension

The nurse lightly strokes the sides of a client's abdomen, above and below the umbilicus. For which reflex is the nurse testing?

Abdominal

What should the nurse assess to test the function of the occipital lobe?

Ability to read

A 7-year-old boy is performing poorly in school. His teacher is frustrated because he is frequently seen "staring off into space" and not paying attention. If this is a seizure, it most likely represents which type?

Absence

A nurse is preparing to assess a client's cerebellar function. What aspect of neurological function should the nurse address?

Balance

After conducting a screening neurological examination, the nurse identifies the client is at risk for a stroke. Which of the following client education should the nurse provide at this time?(Select all that apply.)

Begin smoking cessation Take prescribed antihypertensive medication Warning signs of a stroke Use continuous positive airway pressure (CPAP) device as prescribed.

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 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

The nurse is performing the Romberg test. Which of the following indicate a normal finding?

Client stands erect with minimal swaying

What should the nurse assess to test the function of the frontal lobe?

Communication

When assessing deep tendon reflexes in an elderly client what finding would the nurse anticipate?

Decreased reaction time

During an admission assessment, the nurse notes that the client has diabetes with peripheral neuropathy. What finding would the nurse expect to find?

Decreased sensation in the feet

The nurse performs a neurological assessment and determines the Glasgow Coma Scale (GCS) score is 15. What is the nurse's best action?

Document the findings.

When testing the biceps reflex, what type of response should the nurse expect if normal?

Elbow flexes and muscle contracts

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 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

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

What is the level of the spinal cord associated with the knee (patellar) deep tendon reflex?

L2 to L4

When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence?

Mental status, cranial nerves, motor/cerebellar, sensory, reflexes

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

The nurse is planning a presentation to a group of adults on the topic of strokes. Which of the following should the nurse plan to include in the teaching plan?

Smoking and high cholesterol levels are risk factors for STROKE.

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.

Which is true of examination of the olfactory nerve?

Unexpected responses may be seen in otherwise healthy elderly.

Which tests are appropriate for a nurse to perform to test cranial nerve VIII?

Whisper, Rinne, and Weber tests

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.

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.

A client is concerned about tripping when walking and feeling uncoordinated. Which part of the brain might be causing this client's symptoms?

cerebellum

While assessing the neurologic system of a confused older adult, the nurse observes that the client is unable to recall past events. The nurse suspects that the client may be exhibiting signs of

cerebral cortex disorder.

The cerebrum is divided into right and left hemispheres, which are joined together by the

corpus callosum.

The nurse is assessing the neurologic system of a client who has spastic muscle tone. The nurse should explain to the client that spastic muscle tone is associated with impairment to the

corticospinal tract.

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.

A nurse is planning care for a client who has been diagnosed with restless leg syndrome. Which intervention is the most effective for temporary relief of the symptoms?

exercising the legs

A client with a diagnosis of type 1 diabetes is admitted to the hospital with acute symptomatic seizures. Given the client's underlying condition, what would be the most likely cause of this type of seizure?

hyperglycemia

A client says that an object placed in the hand is a pair of scissors when the object is a paper clip. Which aspect of the client's neurologic system should the nurse identify as being compromised?

sensory

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.

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.

A nurse is preparing to offer a community education session on anxiety. Which part of the nervous system should the nurse include in the discussion?

sympathetic nervous system

The diencephalon of the brain consists of the

thalamus and hypothalamus.