Unit 13 - Neurologic System

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

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.

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.

1

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? 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).

1, 2

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? 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, 2, 4

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? Select all that apply. 1. Tuning fork. 2. Paper clip. 3. Safety pin. 4. Cotton ball. 5. Tongue blade.

1, 3

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.

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.

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."

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.

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.

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.

2

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? 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, 4

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 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.

3

The nurse is performing a neurological assessment on a client experiencing anosmia. 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).

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.

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.

3

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."

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.

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.

4

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.

1

The nurse is performing a neurological assessment and needs to test cranial nerves. The nurse asks the client to close both eyes and report when a touch with a wisp of cotton is felt on their face. Which cranial nerve is the nurse assessing? 1. Trigeminal nerve (cranial nerve V). 2. Abducens nerve (cranial nerve VI). 3. Facial nerve (cranial nerve VII). 4. Optic nerve (cranial nerve II).

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."

1

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.

4

The nurse has assessed a client and notes diminished reflexes. How would the nurse document this finding in the medical record? 1. 4+. 2. 3+. 3. 2+. 4. 1+.

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