Assessment Test 5 Prep-U Questions

A client presents to the health care facility for a routine health checkup. The nurse learns that the client has a long history of cardiovascular disease, including hypertension and carotid artery disease. When assessing this client for potential problems in the nervous system, which question by the nurse is appropriate?

"Are you having any dizziness or lightheadedness?" (because of the increased difficulty in circulating enough blood and oxygen to the brain).

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

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

The nurse is assessing CN V (trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of assessment?

"Clench your teeth together tightly".

During a routine follow up visit, an older adult client asks the nurse, "I've noticed that my sense of smell has decreased over the years and I'm concerned about the cause." What is the nurse's best response?

"Over time the sense of smell decreases in some people, and this is normal."

What instruction should a nurse give a client when having trouble eliciting a response from testing the patellar deep tendon reflex?

"Place your hands together, lock your fingers, and squeeze."

While the client is sitting quietly, the thumb and index finger of the left hand are moving in a circular motion. The nurse identifies this finding as which of the following problems?

A resting tremor

Which of the following is usually the first sign of neurological deterioration?

Altered mentation and decreasing level of consciousness

On assessment of a client, the nurse finds that the client has difficulty in producing and understanding language. How should the nurse document this finding in the client's record?

Aphasia

A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. Which of the following would the nurse do?

Ask a client to identify scents.

The nurse has completed a Glasgow Coma Scale assessment and assigns the client a score of three. Which is the best way for the nurse to assess pain in this client?

Assess for nonverbal signs.

The nurse has positioned a client supine and asked her to perform the heel-to-shin test. An inability to run each heel smoothly down each shin should prompt the nurse to perform further assessment in what domain?

Balance and coordination

A nurse cares for a client who suffered a cerebrovascular accident and demonstrates the inability to speak clearly. The nurse recognizes that injury has occurred to what portion of the brain?

Broca's area

A nurse observes a client's gait and notes it to be wide based and staggering. The Romberg test results were positive. The nurse recognizes this as what type of abnormal gait?

Cerebellar ataxia

The nurse working in the emergency department is assessing an intoxicated driver involved in a motor vehicle crash when the client insists on ambulating to the bathroom. The nurse escorts the client and calls for help while anticipating which abnormal gait in this client that places him at risk for falls?

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 walks into a client's room and finds that the client is disoriented to time and place but is awake and responsive. What term best describes this client?

Confused

A client has sustained an injury to the cerebellum. Which area should be the nurse's primary focus for assessment?

Coordination

The nurse is doing a brainstem assessment on an unconscious client. Which of the following will the nurse examine during this part of the acute assessment? Select all that apply

Corneal reflex Gag reflex Oculocephalic reflex (doll's eye maneuver)

A client who was injured by a fall at a construction site has been admitted to the hospital. He has suffered nerve damage such that his gag reflex is no longer intact, requiring him to receive intravenous total parenteral nutrition. Which nerve should the nurse suspect to be involved in this client's injury?

Glossopharyngeal (IX)

Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions and maintains overall autonomic control?

Hypothalamus

A nurse is reviewing a client's health record while interviewing her. The nurse sees in the client's record a score of 3+ on the biceps reflex test from her previous visit. The nurse understands that this finding indicates which of the following?

Increased or brisk, but not pathologic

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

What task should a nurse ask a client to perform to assess the function of cranial nerve XII?

Move the tongue from side to side

What would be most appropriate for the nurse to do when assessing motor function of a client's trigeminal nerve?

Palpate temporal and masseter muscles while client clenches the teeth.

Examination of a client's gait reveals that the client is stooped over when walking and that he slowly shuffles. As well, the client maintains a stiff posture when walking. The nurse should document what type of gait?

Parkinsonian gait

The nurse is assessing a client exhibiting dystonic movements. The nurse should review the client's medications from home to check whether he is taking which medications that may cause the dystonia?

Psychiatric medications

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 documents "Romberg test positive" on a client's medical record. What did the nurse most likely assess in this client?

Swaying

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.

The nurse is conducting a focused neurological assessment of an 81-year-old client. When analyzing the assessment data, the nurse should be aware of what age-related neurological change?

Tremors accompanying intentional movements

Which action by a nurse demonstrates the correct technique to use the reflex hammer?

Use rapid wrist movement and strike the tendon

During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve?

VIII

The nurse plans to test which cranial nerve when testing an elderly client's hearing status?

VIII

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.

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

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.

A nurse is performing a focused cranial assessment on a client. The nurse observes that the client is unable to shrug their shoulders. The nurse documents this as a dysfunction of which cranial nerve?

XI

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

ability to read

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.

The brain is a network of interconnecting neurons that control and integrate the body's activities. What components make up these neurons? Select all that apply.

cell body, axon, dendrite

While the nurse is assessing a client's coordination, the client exhibits uncoordinated, jerky movements and is unable to touch either finger to the nose. Which condition should the nurse suspect?

cerebellar disease

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

communication

While the nurse is performing as assessment of the eyes for a client, the nurse notes that one of the client's pupils is dilated and unresponsive to light. Which condition should the nurse suspect?

cranial nerve III (oculomotor) damage

Dysarthria

defect in muscular control of speech caused by lesions of the nervous system, Parkinson's disease, or cerebral disease.

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.

The portion of the brain that rims the surfaces of the cerebral hemispheres forming the cerebral cortex is the

gray matter.

When testing sensory function of the trigeminal nerve (CN V), which of the following sensations would the nurse assess?

pain and light touch

A client is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would be most appropriate to test?

patellar

What task should a nurse ask a client to perform to assess the function of cranial nerve XI?

shrug shoulders

When the nurse is assessing the motor function of cranial nerve VII as part of the neurological examination, what should the nurse instruct the client to do?

smile

The diencephalon of the brain consists of the

thalamus and hypothalamus

The nurse is planning to test position sensation in an adult female client. To perform this procedure, the nurse should ask the client to close her eyes while the nurse moves the client's

toes up or down.

Touching the client's face for dullness or sharp sensations tests the sensory function of the

trigemonial nerve

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