Chapter 22: Neurological and Mental Status
A client complains of headaches each morning that disappear after getting out of bed. Which of the following would be most appropriate for the nurse to do?
Refer the client for immediate follow-up Morning headaches that subside after arising may be an early sign of increased intracranial pressure and require immediate evaluation. Asking about dizziness or seizures, and completing a neurologic exam would most likely occur with the additional follow up.
The nurse documents "Romberg test positive" on a client's medical record. What did the nurse most likely assess in this client?
Swaying
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
The diencephalon of the brain consists of the
thalamus and hypothalamus.
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?"
What instruction should a nurse give a client who is having trouble relaxing with the testing of the patellar deep tendon reflex?
"Place your hands together, lock the fingers, and squeeze" Many clients, especially the elderly, may find it difficult to relax when the nurse attempts to elicit the deep tendon reflexes. When testing the leg reflexes, have the client interlock the hands and squeeze. Closing the eyes will not aid in relaxing the muscles. Clenching the teeth is a reinforcement technique that is helpful to get the client to relax when assessing the arm reflexes.
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."
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 the seizures?
"What happens after the seizure?" If the client has had postictal state, this suggests generalized seizures. To assess characteristic symptoms of a generalized seizure, the nurse should ask the client what occurs after the seizure. Asking about the age at which the seizures began assesses the onset. Asking when the client last had a seizure also assesses the onset. Asking how often the seizures occur assesses the duration.
When a nursing instructor is describing the peripheral nervous system to a group of students, the instructor would explain that there are how many pairs of spinal nerves?
31
The nurse assesses brisk reflexes in a client during a neurological assessment. How would the nurse document this finding?
3+ Brisk reflexes or reflexes that are more active than normal are documented as 3+. Reflexes that are decreased and less active than normal are documented as 1+; reflexes that are normal are documented as 2+; reflexes that are hyperactive and pathological are documented as 4+.
A client who has had a stroke has no eye or verbal response but withdraws from painful stimuli. How would the nurse score these responses using the Glasgow Coma Scale?
6
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 with hypertension
The nurse has asked the client to stand for 30 seconds with his arms forward, palms up, and eyes closed. The client pronates (turns downward) his left palm during the test. What health problem should the nurse first suspect in light of this assessment finding?
A lesion in the corticospinal tract Pronator drift suggests a contralateral lesion in the corticospinal tract. It does not indicate a CN abnormality. The Romberg test is the specific test for ataxia from loss of position sense. Cerebellar disease is usually indicated by a loss of coordination, not pronator drift.
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
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
The nurse suspects that a client has a lesion in the sensory cortex. Which assessment finding did the nurse use to make this clinical decision?
Absent two-point discrimination on the lower right arm The inability discriminate between two points may be seen in lesions of the sensory cortex. The inability to sense vibrations may be seen in posterior column disease or peripheral neuropathy. Increased sensation is termed hyperesthesia. The inability to identify the directions of movements may be seen in posterior column disease or peripheral neuropathy.
A client has an injury that affects the posterior sensory nerve columns of the spinal cord. Which of the following will the nurse most likely find during the examination of the sensory system? (Select all that apply.)
Alteration in the perception of position Changes in the perception of vibration Fibers conducting the sensations of position, vibration, and fine touch pass directly into the posterior columns of the spinal cord and travel to the medulla. With this client's injury, the nurse will most likely find an alteration in the perceptions of position and vibration. Fibers conducting pain and temperature sensations pass into the posterior horn of the spinal cord. An injury to the posterior sensory nerve columns of the spinal cord will not cause a loss of depth perception.
Which of the following is usually the first sign of neurological deterioration?
Altered mentation and decreasing level of consciousness
While participating in a research class, a nursing student learns that maternalexposure to pesticides is linked to increased incidence of what?
Anencephaly Maternal exposure to pesticides is linked to increased incidence of menstrual disorders, infertility, spontaneous abortion, stillbirth or infant death, low birth weight, and congenital abnormalities.
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.
While conversing with a 42-year-old client, the nurse notes the client's tendency to repeatedly wink and shrug his shoulders at irregular intervals. The movements do not appear to correlate with the client's conversation. How should the nurse best follow up this observation?
Assess the client's medication regimen and history of recreational drug use. The client's movements would likely be characterized as tics, causes of which can include drugs such as phenothiazines and amphetamines. A CT scan is not likely warranted, and CNs VIII, IX, and X do not affect movements of either the eyes or shoulders. An infectious etiology is unlikely, so the client's immunization history is not relevant.
A nurse is preparing to assess a client's cerebellar function. Which of the following would the nurse expect to test?
Balance Balance and coordination are functions of the pyramidal and extrapyramidal tracts of the motor and cerebellar systems. Remote memory and mental status exam provide information about the client's cognitive ability. Testing for sensation would address issues with specific cranial nerves or problems involving the parietal lobe.
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
When assessing the client, the nurse notes bradykinesia. The nurse would know that this abnormality is caused by damage to what?
Basal ganglia system Damage to the basal ganglia system produces changes in muscle tone (most often an increase), disturbances in posture and gait, a slowness or lack of spontaneous and automatic movements termed bradykinesia, and various involuntary movements.
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.
The nurse is caring for a client who suffered a stroke and is able to carry out simple instructions correctly but has trouble writing responses to questions. The nurse plans to review the client's MRI report of the brain and expects to find that which area of the brain has been adversely affected?
Broca area The Wernicke area integrates understanding of spoken and written words, whereas the Broca area regulates verbal expression and writing ability. The primary visual area is the occipital lobe at the back of the brain, with visual associative areas that interpret and integrate stimuli. The temporal lobe registers auditory input and is responsible for hearing, speech, behavior, and memory.
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
During the health history a client reports a decrease in his ability to smell. During the physical assessment, the nurse would make sure to assess which cranial nerve?
CN I
During the health history, a client reports a decrease in his ability to smell. During the physical assessment, the nurse would make sure to assess which cranial nerve?
CN I
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
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 she 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
A young woman comes in with brief, rapid, jerky, irregular movements. They occur at rest or during intentional movements and involve mostly her face, head, lower arms, and hands. How would you describe these movements?
Chorea These movements represent chorea because they are brief, rapid, unpredictable, and irregular. Tics are irregular but tend to be stereotyped and can be vocalizations (throat clearing), facial expressions, or shoulder shrugs. Athetosis is a slow squirming motion usually affecting the face and distal extremities. Dystonia is similar to athetosis, but the movements are coarser and can involve twisted postural changes.
What should the nurse assess to test the function of the frontal lobe?
Communication
The nurse is assessing the eyes of a client who has a lesion of the sympathetic nervous system. What assessment finding should the nurse anticipate?
Constricted pupils, unresponsive to light A constricted pupil unresponsive to light or accommodation suggests a lesion of the sympathetic nervous system. Sympathetic nervous system stimulation would lead to bilateral dilated pupils. A unilaterally dilated pupil unresponsive to light or accommodation would suggest damage to cranial nerve III. Argyll-Robertson pupils are associated with central nervous system syphilis, meningitis, brain tumor, or alcoholism. Nystagmus is most often the result of congenital disorders or drug toxicity, not lesions affecting the sympathetic nervous system.
A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment?
Coordination
The nurse asks a client to hold her arms up, with her palms up, then to close her eyes. The right arm begins to move downward after a few seconds and her thumb rotates upward. This is most likely a problem with which part of the nervous system?
Corticospinal tract The client's movements describe a pronator drift, which signifies decreased position sense and involvement of the corticospinal tract. This tract does not travel through the thalamus. This is commonly tested as an early sign of stroke. This would not occur with a dorsal root ganglion problem.
The spinothalamic tracts transmit which of the following sensory impulses from the contralateral side of the body?
Crude touch, pain, temperature Pain, crude touch, and temperature are transmitted via the spinothalamic tracts, while other sensory impulses pass through the posterior column.
What is the level of the spinal cord associated with the knee (patellar) deep tendon reflex?
L2 to L4
The nurse notes that a client in bed has the following posture. How should the nurse document this finding?
Decerebrate rigidity In decerebrate rigidity the jaws are clenched and the neck is extended. The arms are adducted and extended at the elbows with the forearms pronated and wrist and fingers flexed. The legs are stiffly extended at the knees with the feet planar flexed. In decorticate rigidity the upper arms are flexed tightly to the sides with the elbows, wrists, and fingers flexed. In early hemiplegia the arm and leg on the same side of the body are slack. The leg may be externally rotated and the arm has no response. The neck would not be extended with the arms adducted and extended in a normal supine posture.
Which of the following are types of diabetic neuropathies? (Select all that apply.)
Diabetic amyotrophy Autonomic dysfunction Mononeuritis multiplex Diabetes causes several types of neuropathy, including a slowly progressive distal symmetric sensorimotor polyneuropathy, the "stocking" of the "stocking-glove" changes and the most common of the diabetic neuropathies; autonomic dysfunction leading to erectile dysfunction, orthostatic hypotension, and gastroparesis; mononeuritis multiplex, causing patchy sensory and motor deficits in at least two separate nerve areas; and diabetic amyotrophy, causing thigh pain and proximal lower extremity weakness, initially unilateral.
The nurse is assessing a 51-year-old morbidly obese client who is seeking care for the recent loss of sensation in his feet and toes. The client also complains of intermittent burning and tingling in his feet that radiate up his legs. For which of the following health problems should the nurse first assess?
Diabetic peripheral neuropathy
A 48-year-old grocery store manager comes to the clinic complaining of her head being "stuck" to one side. She says that today she was doing her normal routine when it suddenly felt like her head was being moved to her left and then it just stuck that way. She says it is somewhat painful because she cannot move it back to a normal position. She denies any recent neck trauma. Her past medical history consists of type 2 diabetes and gastroparesis (slow-moving peristalsis in the digestive tract, seen in diabetes). She is taking oral medication for each. She is married with three children. She denies tobacco, alcohol, or drug use. Her father has diabetes and her mother passed away from breast cancer. Her children are healthy. Examination reveals a slightly overweight Hispanic woman appearing her stated age. Her head is twisted grotesquely to her left otherwise, her examination is normal. What form of involuntary movement does she have?
Dystonia
When testing the biceps reflex, what type of response should the nurse expect if normal?
Elbow flexes and muscle contracts
After teaching a group of students about the brain and spinal cord, the instructor determines that the students demonstrate the need for additional teaching when they identify what as being controlled by the brain stem?
Equilibrium The brain stem consists of the midbrain, pons, and medulla oblongata. The midbrain serves as the relay center for ear and eye reflexes and relays impulses between the higher cerebral centers and the lower pons, medulla, cerebellum, and spinal cord. The pons links the cerebellum to the cerebrum and the midbrain to the medulla. It is responsible for various reflex actions. The medulla has centers that control and regulate respiratory function, heart rate and force and blood pressure.
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 Rapid assessment includes level of consciousness using the Glasgow coma scale, which scores verbal response, eye opening, and motor function. If the client can respond verbally, basic orientation is assessed. This also allows a basic speech/language assessment. Vital signs are part of an acute assessment. As soon as is practical, obtaining health history information helps identify potential sources of the problem, but it is not a part of the emergency assessment.
When assessing a client's deep tendon reflexes, which technique would be most appropriate for the nurse to use?
Hold the reflex hammer between the thumb and index finger. When eliciting deep tendon reflexes, the nurse should hold the reflex hammer between the thumb and index finger so that it swings freely. The nurse should use the pointed end to strike smaller areas and the blunt end to strike a wider area. The nurse should palpate the tendon to be used to elicit the reflex and use a rapid wrist movement to briskly strike the tendon.
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 finds unilateral dilated pupils that are unresponsive to light or accommodation. The nurse recognizes that which cranial nerve is responsible for the damage of pupillary response?
III Cranial nerve III is responsible for the damage of pupillary response. Cranial nerve I disorders cause damage of sense of smell. Cranial nerve V is responsible for the function of masseter muscle contraction. Cranial nerve II disorders damage vision due to retinal detachment or due to a lesion in the nerve.
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 Inability to close eyes occurs due to damage of cranial nerve VII. The client with disorder of cranial nerve III will have drooping of the eyelids. Loss of visual field and swelling of the optic nerve occur due to damage of cranial nerve II.
A nurse assesses a client who presents to the health care clinic with suspected Bell's palsy. What finding should the nurse anticipate on examination?
Inability to wrinkle the forehead Bell's palsy is a peripheral injury to cranial nerve VII (facial) that causes the inability to close the eyes, wrinkle the forehead, or raise the forehead, along with paralysis of the lower part of the face. Drooping of the eyelids (ptosis) is seen with weak eye muscles such as in myasthenia gravis. Limited lateral gaze of the eyes may indicate increased intracranial pressure. Paralysis of the lower lip is not seen in any common disorder of cranial nerve function.
Jim, an HIV-positive client, reports back pain in addition to several other complaints. On percussion, there is slight tenderness over the T7 vertebrae. When the nurse flexes the client's thigh to 90 degrees and extends his lower legs, strong resistance occurs at about 45 degrees of extension. What are likely causes of this constellation of sympto
Infection This represents Kernig's sign. When present bilaterally it often indicates meningeal irritation. Kernig's sign is useful in cases of chronic inflammation of the meninges, as seen in TB and cryptococcal disease. No trauma was reported, and these signs are too important to ascribe to malingering. Such localized physical findings are unlikely to be caused by medication side effects.
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
A nurse is performing a test of cranial nerve XII (hypoglossal) on an elderly client. When the client protrudes her tongue for the test, the tongue moves in and out uncontrollably. Which of the following should the nurse most suspect?
Intentional tremor Older adults may experience intentional tremors (tremors that occur with intentional movements). This may be seen with extending the hands, head nodding for "yes or no," or extending one's tongue, which may protrude back and forth. Such tremors are not associated with disease, but they may cause embarrassment or emotional distress. Fasciculations and atrophy of the tongue may be seen with peripheral nerve disease. Injury of the central spinal cord is associated with extremity weakness. Sudden numbness and weakness of the muscles of the face, arms, and legs are associated with cerebrovascular accident (stroke).
A client makes this movement when the nurse assesses for the plantar response. What should this movement indicate to the nurse?
Lesion of the corticospinal tract Dorsiflexion of the big toe and fanning of the other toes, is a "present" Babinski response, arising from a CNS lesion affecting the corticospinal tract. An expected response is plantar flexion with the toes curving down and inward. This movement does not indicate the presence of pain or hyperactive deep tendon reflexes.
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 Risk reduction for a CVA includes controlling blood pressure, stopping smoking (not just reducing it), limiting alcohol to no more than 1 drink per day for women and 2 drinks for men, exercising, lowering cholesterol and fat intake, controlling blood sugar, and avoiding drugs such as cocaine. Increasing estrogen levels and protein intake are not associated with reducing risk for CVAs.
The nurse is caring for an adult client who suffers from a spinal cord hemisection due to a tumor. The client is unable to feel pain or temperature changes below the level of the tumor. What other symptoms should the nurse teach the family to expect the client to experience?
Loss of position sense, vibration, and motor function on same side of the body Following a spinal cord hemisection, pain and temperature sensation, are lost below the level of the injury or lesion on the opposite side of the body. Position sense, vibration, and motor function are affected on the same side of the body.
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
The nurse is examining a "sleepy" client who will open her eyes and look at the examiner, but responds slowly and is confused. The client does not appear interested in her surroundings. How would the nurse describe the client's level of consciousness?
Obtunded
A client presents to the emergency room after being hit in the face with a baseball. The health care provider orders vision testing to be performed to assess the intactness of the cranial nerves. The nurse should prepare to test which cranial nerves? Select all that apply.
Oculomotor Abducens Trochlear The cranial nerves that control motor and sensation of the eyes are II (optic), III (oculomotor), IV (trochlear), and VI (abducens). Cranial nerve I is olfactory which assesses the client's sense of smell. The trigeminal is cranial nerve C which tests the temporal and masseter muscles.
When reviewing the neural pathways, a group of students identify which of the following as sensations that travel via the spinothalamic tract. Select all that apply.
Pain Temperature Light touch Sensations of pain, temperature, and crude and light touch travel by way of the spinothalamic tract, whereas sensations of position, vibration, and fine touch travel by way of the posterior columns.
When reviewing the neural pathways, a group of students is identifying sensations that travel via the spinothalamic tract. Which sensations are carried by this tract? Select all that apply.
Pain Temperature Light touch Sensations of pain, temperature, and crude and light touch travel by way of the spinothalamic tract, whereas sensations of position, vibration, and fine touch travel by way of the posterior columns.
When testing sensory function of the trigeminal nerve (CN V), which of the following sensations would the nurse assess?
Pain and light touch
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. To test the motor function of the trigeminal nerve (CN V), the nurse asks the client to clench the teeth and palpates the temporal and masseter muscles for contraction. Touching the client's face for dullness or sharp sensations tests the sensory function of the trigeminal nerve. Having the client frown, smile, and wrinkle the forehead tests the motor function of the facial nerve (CN VII). Assessing pupillary dilation tests the oculomotor (CN III) nerve.
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
When providing client teaching, what can the nurse assess?
Patient's ability to perform ADLs You use assessment information to identify client outcomes. An outcome related to neurological problems include: Patient improves motor function and becomes independent with activities of daily living (ADLs).
A nurse is conducting an assessment of an elderly client's nervous system. The client mentions that he has experienced decreased taste and scent sensations recently. Which of the following should the nurse do at this point?
Record the findings and proceed with the assessment Decreased taste and scent sensation occurs normally in older adults. Therefore, the nurse should simply record the finding and proceed with the assessment. A head injury could cause nerve damage that would explain loss of such senses, but the client's age is a much more likely cause. Sudden numbness or weakness in the face or arms is a warning sign of a stroke. The Weber test is used to test a client's hearing.
A client has sustained nerve damage as a result of an automobile accident and has lost the ability to sense position, vibration, and fine touch. Which neural pathway should the nurse suspect to be damaged?
Posterior columns Sensations of pain, temperature, and crude and light touch travel by way of the spinothalamic tract, whereas sensations of position, vibration, and fine touch travel by way of the posterior columns. The motor neurons of the pyramidal tract carry impulses to muscles and produce voluntary movements that involve skill and purpose. The extrapyramidal tract conducts impulses to the muscles related to maintenance of muscle tone and body control.
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 nurse is working with a client who suffered nerve damage during surgery for removal of a tumor. The client, who is an artist, lost fine motor control in his hands and can no longer manipulate a paintbrush. Which neural pathway should the nurse suspect to be damaged?
Pyramidal tract The motor neurons of the pyramidal tract carry impulses to muscles and produce voluntary movements that involve skill and purpose. The extrapyramidal tract conducts impulses to the muscles related to maintenance of muscle tone and body control. Sensations of pain, temperature, and crude and light touch travel by way of the spinothalamic tract, whereas sensations of position, vibration, and fine touch travel by way of the posterior columns.
The nurse is obtaining the health history of a young adult client. During the interview, the client tells the nurse, "I banged my head pretty good when I was snowboarding last weekend." The client states that he did not subsequently seek care. What is the nurse's most appropriate action?
Refer the client for medical assessment and possible treatment.
What functions are attributed to sensory impulses? (Select all that apply.
Regulation of internal autonomic functions Body position in space Conscious sensation Sensory impulses not only participate in reflex activity, as previously described, but also give rise to conscious sensation, calibrate body position in space, and help regulate internal autonomic functions like blood pressure, heart rate, and respiration.
What functions are attributed to sensory impulses? (Select all that apply.)
Regulation of internal autonomic functions Body position in space Conscious sensation Sensory impulses not only participate in reflex activity, as previously described, but also give rise to conscious sensation, calibrate body position in space, and help regulate internal autonomic functions like blood pressure, heart rate, and respiration.
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
As people age, several neurological changes occur. Neurons, brain size, and neurotransmitters decrease. What are some of the results of aging on the neurological system? Select all that apply.
Slower thought processing, Reduced response to stimuli, Delayed reflexes
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 nurse is conducting a neurological assessment on an adult. Which findings indicate a need for further evaluation? (Select all that apply.)
Snout reflex when tapping a tongue blade across the lips Involuntary flexion of distal joint of thumb and index finger when nail on third finger is tapped Sucking movement of the lips when the lips are stroked with light touch Palmar grasping response when palmar stimulation applied An active knee jerk when the patellar tendon is tapped lightly is a normal reflexive response. A grasping response is associated with dementia and diffuse brain impairment. The snout reflex is an abnormal finding in adults and is elicited by tapping a tongue blade across the lips and observing for pursing of the lips. The Hoffman sign is abnormal and is elicited when tapping on the nail on the 3r or 4th finger eliciting flexion of the distal joint. The rooting reflex is abnormal in an adult and is elicited by stroking the lips with light touch and the client then moves the mouth toward the stimulus.
A nurse is instructing a client who has recently experienced a transient ischemic attack (TIA) on warning signs of a stroke that the client should be aware of in case they occur and she needs to call 911. Which of the following should the nurse mention? Select all that apply.
Sudden numbness or weakness of the face Sudden confusion, trouble speaking, or understanding speech Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe headache with no known cause Except for sudden chest pain, which is a symptom of a heart attack, not a stroke, all of the symptoms listed are associated with a stroke.
The nurse observes the client's pupils as shown. What should the nurse suspect is occurring with the client?
Temporal lobe herniation A pupil that is fixed and dilated can indicate herniation of the temporal lobe that causes compression of the oculomotor nerve and midbrain. Pupils that are large and reactive are seen in cocaine or other sympathetic nervous system agonist drugs. Pupils that are fixed in mid-position indicate structural damage in the midbrain. Small or pinpoint pupils indicate damage to the sympathetic pathways in the hypothalamus.
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 These findings are typical of disease in the basal ganglia.
The nurse is planning to assess a client for graphesthesia. How will the nurse perform this phase of assessment?
The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object.
The client is diagnosed with a peripheral neuropathy. The nurse knows that often the first sensation lost in a peripheral neuropathy is what?
Vibration
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 Older adults may experience intentional tremors (tremors that occur with intentional movements). Such tremors are not associated with disease. Impairments in judgment, remote memory, and limb sensation are considered pathologic in clients of all ages and warrant further assessment.
A nurse is testing a client's deep tendon reflex. The nurse taps the tendon above the olecranon process. The nurse is assessing which reflex?
Triceps The nurse tests the triceps reflex by tapping the tendon above the olecranon process. The nurse tests the brachioradialis reflex by tapping the tendon at the radius about 2 inches above the wrist. The nurse tests the biceps reflex by placing the thumb over the biceps tendon and striking the thumb with the reflex hammer. The nurse tests the Achilles reflex by tapping the Achilles tendon at the posterior aspect of the ankle above the heel.
Which is true of examination of the olfactory nerve?
Unexpected responses may be seen in otherwise healthy elderly. An abnormal olfactory nerve examination may be seen in otherwise healthy elderly, but may also be associated with other conditions such as Parkinson's disease. The examiner should try to determine if only one side is abnormal by occluding the contralateral nostril. The smell has only to be detected, not identified by name to indicate a normal examination. If nasal occlusion occurs for other reasons, such as allergic rhinitis or anatomical abnormalities, the nerve cannot be tested and may seem to be abnormal for unrelated reasons.
When assessing cranial nerves IX and X, what would the nurse consider as a normal finding?
Uvula and soft palate rising bilaterally
The nurse performs the action shown when assessing a client. Which cranial nerve is the nurse assessing in this client?
V Assessing for corneal reflex tests the sensory function of cranial nerve V. Cranial nerve II is assessed by using the Snellen chart. Cranial nerves III and IV are assessed with the use of extraocular movements and pupil response to light and accommodation.
The nurse notes that a client does not blink the left eye when the cornea is lightly touched with a cotton wisp. On which cranial nerve should the nurse focus additional assessment?
V Testing for the corneal reflex assesses a branch of cranial nerve V, the trigeminal nerve. Cranial nerve II is the optic nerve. Cranial nerve III is the oculomotor nerve. Cranial nerve IV is the trochlear nerve. Cranial nerves II, III, and IV do not control the corneal reflex.
The nurse plans to test which cranial nerve when testing an elderly patient's hearing status?
VIII
A client presents to the health care clinic with reports of difficulty swallowing. Which cranial nerves will provide the nurse with information related to the problem? Select all that apply.
Vagus Hypoglossal Glossopharyngeal Difficulty swallowing can be a finding with CVA, Parkinson's disease, myasthenia gravis, Guillain Barre, or cranial nerve dysfunction. The cranial nerves that the nurse should be aware of are IX (glossopharyngeal), X (vagus), and XII (hypoglossal). Cranial nerve VI (abducens) controls lateral eye movement. Cranial nerve XI (spinal accessory) innervates the neck and shoulder muscles.
Which tests are appropriate for a nurse to perform to test the cranial nerve VIII?
Whisper test, Rinne, and Weber
Which tests are appropriate for a nurse to perform to test cranial nerve VIII?
Whisper, Rinne, and Weber tests Cranial nerve VIII is the acoustic/vestibulocochlear nerve, which is associated with the client's ability to hear. The nurse should perform the whisper test and, using the tuning fork, the Rinne and Weber tests. The gag reflex, rise of the uvula, and ability to swallow are tests to assess cranial nerves IX (glossopharyngeal) and X (vagus). Asking the client to smile, frown, show teeth, and puff out the cheeks assesses the function of cranial nerve VII (facial). Clenching the teeth, identifying light touch, and discriminating between sharp and dull stimuli are assessments of cranial nerve V (trigeminal).
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
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
The nurse is preparing to percuss a client's reflexes in his arms. To use the reinforcement technique, the nurse should ask the client to
clench his jaw. A reinforcement technique causes other muscles to contract and thus increases reflex activity, assists in eliciting a response if no response can be elicited.
The Glasgow Coma Scale is predictive of outcome from a traumatic brain injury when combined with
client's age and pupillary response GCS is predictive of outcome from a traumatic brain injury when combined with the client's age and pupillary response.
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
The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the
glossopharyngeal.
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 is newly diagnosed with myasthenia gravis. What should the nurse expect to assess in this client?
intact deep tendon reflexes
The nurse is preparing to test the sensory cranial nerves. The nerves being tested include (Select all that apply.)
olfactory optic acoustic
A patient is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would be most appropriate to test?
patellar
The symptom that would alert the nurse to a problem with cranial nerve III would be
ptosis Ptosis is seen with damage to cranial nerve III.
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
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. The hypothalamus (part of the autonomic nervous system, which is a part of the peripheral nervous system) is responsible for regulating many body functions including water balance, appetite, vital signs (temperature, blood pressure, pulse, and respiratory rate), sleep cycles, pain perception, and emotional status.
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
Which body functions are related to the hypothalamus? Select all that apply.
sweating on a hot day feeling worried about an exam experiencing a regular menstrual cycle The hypothalamus is responsible for regulation of temperature, governing emotions, and secretion of hormones. Withdrawing a hand from a hot stove involves production of sensory impulse; this is the role of the thalamus. Learning a dance move requires coordination of movement; this is the role of the cerebellum.
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 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. Test sensitivity to position. Ask the client to close both eyes. Then hold the client's toe or a finger on the lateral sides and move it up or down. Ask the client to tell you the direction it is moved. Repeat on the other side.
