Ch 22 Neuro and Mental Status Assessment PrepU

During a routine follow up visit, an older adult client asks the nurse, "I've noticed the 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."

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

Broca's area

A nurse assesses a client for pupillary response of the eyes and finds a unilateral dilated pupil that is unresponsive to light or accommodation. The nurse recognizes that which cranial nerve is responsible for the damage of pupillary response?

III

Which of the following is usually the first sign of neurological deterioration? a. altered mentation and decreasing LOC b. dilating pupils c. no response to painful stimulation d. posturing

a. altered mentation and decreasing LOC

The nurse has positioned a client supine and asked her to perform the heel-to-skin test. An inability to run each heel smoothly down each shin should prompt the nurse to perform further assessment in what domain? a. balance and coordination b. light touch sensation c. deep tendon reflexes d. leg strength

a. balance and coordination

While the nurse is performing an 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? a. cranial nerve III (oculomotor) damage b. lesions of the sympathetic nervous system c. cranial nerve V (trigeminal) injury d. central nervous system dysfunction

a. cranial nerve III (oculomotor) damage

What would the nurse MOST likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident? a. inability to hear high-pitched sounds b. loss of tactile sensation c. difficulty speaking d. blurred vision

c. difficulty speaking

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

communication

A client has sustained an injury to the cerebellum. Which area should be the nurse's primary focus for assessment? a. vital signs b. respiratory status c. cardiac function d. coordination

d. coordination

The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam? a. romberg b. tandem walking c. gait d. hop on one foot

d. hop on one foot

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)

During morning report the nurse learns that an assigned client needs assistance with ambulation because of spastic hemiparesis. What should the nurse expect when ambulating with this client?

see picture

What task should a nurse ask a client to perform to assess the function of CNXI?

shrug shoulders against resistance

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 Glasgow Coma Scale measures the LOC in clients who are at high risk for rapid deterioration of the nervous system. A score of 13 indicates:

some impairment

Which tests are appropriate for a nurse to perform to test CNVIII?

whisper, rinne, and weber tests

Which assessment procedure should a nurse institute to test a client for stereognosis?

with eyes closed, ask the client to identify a familiar object that is placed in their hand