Ch 25: assessing neurologic system prepU quizzes
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?"
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?"
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."
when evaluating a clients risk for cerebrovascualar accident, which client would the nurse identify as being at highest risk?
68 yo african american male with hypertension
What should the nurse assess to test the function of the occipital lobe?
Ability to read
A nurse is testing a client's corneal reflex but notices that the reflex appears to be reduced. The client is otherwise alert and oriented, with no signs of neurologic degeneration. What is an appropriate action by the nurse?
Ask the client about the presence of contact lenses
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 is assessing an newly admitted client with a seizure disorder. The nurse would asses the client for what?
Aura
A nurse is preparing to assess a client's cerebellar function. What aspect of neurological function should the nurse address?
Balance
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
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 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 nurse is assessing the client's coordination and finds that her movements are clumsy, unsteady, and inappropriately varying in their speed, force, and direction. The nurse notes that client has dysmetria. What would the nurse know this client has?
Cerebellar disease
The nurse is examining a child with severe cerebral palsy. On sudden movement of the child's foot dorsally, a sustained "beating" of the foot against the nurse's hand ensues. What does this represent?
Clonus
Which of the following would the nurse expect to assess if a client has a lesion of the sympathetic nervous system?
Constricted pupil unresponsive to light
The spinothalamic tracts transmit which of the following sensory impulses from the contralateral side of the body?
Crude touch, pain, temperature
As adults age, peripheral nerve function and impulse conduction decrease. What is the result of this decrease?
Decreased proprioception
A client sustains an injury to the brain stem. What is the most important assessment parameter that the nurse should perform for this client?
Depth of respirations
When documenting assessment of the nervous system, a nurse should keep in mind what important principle?
Describe the response
A client cannot differentiate between sharp and dull pain sensations when a nurse tests with a safety pin. What is an appropriate action by the nurse?
Determine the ability to differentiate hot and cold temperatures
A client has a disorder of the hypothalamus. The nurse recognizes that this structure is found in which area of the brain?
Diencephalon
While performing a neurological assessment on a 56-year-old male, the nurse identifies the client may be experiencing a stroke. What symptoms would the nurse identified? Select all that apply.
Difficulty following instructions Slurred speech Impaired vision
The nurse has assessed pupil size in a newly admitted client on the neuro-trauma unit. The client's pupils are unequal in size, and the healthcare provider is notified. The nurse is instructed that the findings indicate physiological anisocoria based on the healthcare provider's knowledge of the client's history. What is the nurse's best action?
Document the findings and healthcare provider's response.
A nurse performs a neurologic examination on a client who sustained an injury to the spinal cord. What finding should the nurse expect when stroking the bottom of the client's feet?
Dorsiflexion of the great toe and fanning of all toes
A nurse cares for a client diagnosed with cranial nerve III disorder. What should the nurse expect to find in the client?
Drooping of eyelids
Nursing students are doing a class presentation on stroke. What is the term they would use for deficits in speech articulation?
Dysarthria
Characteristics of the 12 cranial nerves include all of the following except that:
Each has motor and sensory functions.
When testing the biceps reflex, what type of response should the nurse expect if normal?
Elbow flexes and muscle contracts
The nurse is assessing the biceps tendon reflex of a client. Place the following steps in the order the nurse should perform them.
Encourage the patient to relax, then position the limbs properly and symmetrically. Hold the reflex hammer loosely between the thumb and index finger so that it swings freely in an arc within the limits set by the palm and other fingers. With the wrist relaxed, strike the tendon briskly using a rapid wrist movement. Note the speed, force, and amplitude of the reflex response and grade the response. Compare the response of one side with the other.
A 7-year-old child comes to the clinic with her mother, who states that her daughter is doing poorly in school because she has some kind of "ADD" (attention deficit disorder). The nurse asks the mother what makes her think the child has ADD. The mother says that both at home and at school her daughter just zones out for several seconds and licks her lips. She states it happens at least four to six times an hour. She says this has been happening for about 1 year. After several seconds of lip licking, her daughter seems normal again. She states her daughter has been generally healthy with just normal childhood colds and ear infections. The client's parents are both healthy; no other family members have had these symptoms. What type of seizure disorder is most likely?
Generalized absence seizure
'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)
An ambulance brings an older adult client to the ED. The client's daughter found the client on the floor of the house; the client is almost unresponsive. It is unknown how long the client was on the floor. When performing an acute assessment on the client, which of the following may the health care team omit?
Health history
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
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 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
What should the nurse assess to test the function of the temporal lobe?
Impulses from the ear
A nurse cares for a client diagnosed with damage to cranial nerve VII. What should the nurse expect to find in the client?
Inability to close eyes
While testing a client's deep tendon reflexes the nurse asks the client to perform the action shown. What is the purpose of this action?
Increase reflex activity
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
A client reports that she is experiencing a tremor when she reaches for things. This worsens as she nears the "target." When the examiner asks the client to hold out her hands, no tremor is apparent. What type does this most likely represent?
Intention
A 37-year-old insurance agent comes to the office with a report of trembling hands. She says that for the past 3 months when she tries to use her hands to fix her hair or cook they shake badly. She says she doesn't feel particularly nervous when this occurs, but she worries that other people will think she has an anxiety or alcohol disorder. She admits to having some recent fatigue, trouble with vision, and difficulty maintaining bladder control. Her past medical history is remarkable for hypothyroidism. Her mother has lupus and her father is healthy. She has an older brother with type 1 diabetes. She is married with three children. She denies tobacco, alcohol, or drug use. On examination, when she tries to reach for a pencil to fill out the health form, she has obvious tremors in her dominant hand. What type of tremor is most likely?
Intention tremor
What is the level of the spinal cord associated with the knee (patellar) deep tendon reflex?
L2 to L4
Which of these factors should a nurse include when teaching about risk reduction for cerebrovascular accidents (CVA) to a group of middle-aged adults within the community? Select all that apply.
Limit alcohol to 1 drink per day for women and 2 for men Lower blood pressure
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
The client presents at the clinic with a complaint of weakness that is made worse with repeated effort and improves with rest. The client's complaint is consistent with what health problem?
Myasthenia gravis
Which cranial nerve controls pupillary constriction?
Oculomotor
The nurse suspects that a client is experiencing meningitis. Which assessment finding caused the nurse to make this clinical determination?
Pain and hip flexion when the neck is flexed
When testing sensory function of the trigeminal nerve (CN V), which of the following sensations would the nurse assess?
Pain and light touch
The nurse is testing for Kernig's sign in a newly admitted client. What would indicate meningeal inflammation?
Pain and resistance to knee extension bilaterally
A client is admitted to the health care facility with new onset of right-sided paralysis, slurred speech, and lethargy. A nurse obtains in the history that the client has uncontrolled hypertension and smokes 2 packs of cigarettes a day. Which nursing diagnosis is priority for the client upon admission?
Risk for Aspiration
Upon assessment, the nurse suspects the client is having a stroke. What symptoms might the nurse have found? Select all that apply.
Slurred speech Severe headache Left arm weakness
Where do the cell bodies of the lower motor neurons lie?
Spinal cord
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.
A client is visiting the health care facility for follow-up care for a stroke. Today he has increased muscle tone, some involuntary movements, an abnormal gait, and a slowness of response in movements. He most likely has involvement of which of the following?
The basal ganglia
A client with a history of seizure disorder and taking several seizure medications reports that a friend noted "jumping eye movements." The client describes a sensation of movement at rest since his medications were adjusted upward following a breakthrough seizure several weeks ago. Examination shows that both eyes slowly move to the right then quickly jump to the left. Based on these signs, which of the following is true?
This is called nystagmus to the left.
The nurse is assessing an client after a fall. What could indicate damage to the spinal cord?
Tingling
A client is clenching the jaw closed to avoid taking a prescribed oral medication. The nurse can use this observation to confirm the client is demonstrating motor function of which cranial nerve?
Trigeminal
Which action by a nurse demonstrates the correct technique to use the reflex hammer?
Use rapid wrist movement and strike the tendon
The nurse plans to test which cranial nerve when testing an elderly patient's hearing status?
VIII
A nurse is providing a client with discharge instructions after being diagnosed with seizures. What discharge teaching should the nurse provide? Select all that apply.
Wear a medical identification bracelet." "Take medication as prescribed." "You will need to take safety precautions when using machinery." "You may be evaluated as to whether or not you may safely drive a motor vehicle."
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
a nurse is perfoming 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
The nurse lightly strokes the sides of a client's abdomen, above and below the umbilicus. For which reflex is the nurse testing?
abdominal
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 is most likely represents which type?
absence
a nurse is preparing to assess a cleint's cerebellar function. what aspect of neurological function should the nurse address?
balance
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 performing the Romberg test. Which of the following indicate a normal finding.?
client stands erect with minimal swaying
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
The cerebrum is divided into right and left hemispheres, which are joined together by the
corpus callosum.
the nurse is caring for a client in the hospital and identifies the client to be experiencing acute confusion after caridac surgery. the nurse recognizes this as what?
delirium
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
When the nurse is assessing a client who is comatose, which actions should be included in the assessment? Select all that apply.
determining level of consciousness assessing airway, breathing, and circulation obtaining the medical history
the nurse performs a neurological assessment and determines the glasgow coma scale (GCS) score is 15. what is the nurses best action?
document findings
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
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 cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the
glossopharyngeal
The portion of the brain that rims the surfaces of the cerebral hemispheres forming the cerebral cortex is the
gray matter.
The nurse is doing a neurologic screening examination. The nurse should include some aspect of which areas? Select all that apply.
mental status cranial nerves motor system sensory system reflexes
While assessing the pupils of a hospitalized adult client, the nurse observes that the client's pupils are dilated to 6 mm. The nurse suspects that the client is exhibiting signs of
oculomotor nerve paralysis.
A client reports resting and skipping exercise during a holiday from work. Which part of the nervous system is controlling this client's behavior?
parasympathetic
a client is in the emergency room with what could be a lumbar injury. what deep tendon relfex would be most appropriate to test?
patellar
lifestyle can play a big part in developing risk factors for stroke. which of the following can greatly reduce a clients risk for stroke?
quitting smoking regularly excecising maintaining a healthy weight
the client is admitted to the health care facility with new onset of right sided paralysis, slurred speech and lethargy. a nurse obtains in the history that the client has uncontrolled hypertension and smokes 2 packs of cigarettes a day. which nursing diagnosis is priority for the client upon admission?
risk for aspiration
The nurse is caring for a client during the immediate postoperative period after abdominal surgery. While performing a "neuro check" the nurse should assess the client's
sensation in the extremities.
What task should a nurse ask a client to perform to assess the function of cranial nerve XI?
shrug shoulders against resistance
The hypothalamus is responsible for regulating
sleep cycles.
when the nurse assessing the motor function of cranial nerve VII as part of the neurological examination, what should the nurse instruct the client to do?
smile
Sensations of temperature, pain, and crude and light touch are carried by way of the
spinothalamic tract.
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 working with a client who is victim of a shooting. the cleint 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
What should the nurse assess to test the function of the parietal lobe?
tactile sensation
which of the following assessments is most likely to provide insight into the function of the clients CN VIII?
test the clients hearing for lateralization and bone and air conduction.
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.
The nurse is preparing to assess a client's cranial nerves using a screening neurologic examination. Which of the following should the nurse include in this assessment? Select all that apply.
visual fields and fundoscopic examination eye movements hearing facial strength
during the health history of the nervous system, a client report having a history of generalized seizures. which of the following should the nurse ask the client to determine characteristic symptoms of seizures?
what happens after the seizure?
