Chapter 25: Assessing the Neurologic System
What should the nurse assess to test the function of the frontal lobe? A. Communication B. Impulses from the ear C. Ability to read D. Tactile sensation
A. Communication Explanation: Assessment of the frontal lobe is done by testing the client's communication. To assess the function of the parietal lobe, the nurse should test for tactile sensation. The function of the temporal lobe is assessed by testing for impulses from the ear. To assess the function of the occipital lobe, the nurse should test the ability to read. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, Central Nervous System, p. 573.
When testing the biceps reflex, what type of response should the nurse expect if normal? A. Elbow flexes and muscle contracts B. Elbow extends and muscle contracts C. Forearm adducts and wrist rotates D. Forearm flexes and supinates
A. Elbow flexes and muscle contracts Explanation: To elicit the biceps reflex, the nurse should ask the client to partially bend the arm at elbow with palm up. The nurse places the thumb over the biceps and strikes the thumb with the reflex hammer. The normal finding with this reflex is the elbow flexes and contraction of the biceps muscle occurs. When assessing the brachioradialis reflex, the normal finding is flexion and supination of the forearm. The other two are not findings elicited with upper extremity reflexes. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, HEALTH ASSESSMENT, p. 598.
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? A. Falls B. Impaired mobility C. Stroke D. Pressure ulcers
A. Falls Explanation: The client is at risk for falls due to impaired mobility and decreased movement of his lower extremities. There is no evidence to support the client is at risk for a stroke or pressure ulcers. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, HEALTH ASSESSMENT Collecting Subjective Data: The Nursing Health History, p. 579.
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? A. Loss of position sense, vibration, and motor function on same side of the body B. Individual nerve damage along the corresponding dermatome C. Sensory loss in the periphery in a very diffuse pattern D. Loss of all motor function below the level of the lesion
A. Loss of position sense, vibration, and motor function on same side of the body Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, Collecting Objective Data: Physical Examination, p. 597.
Lifestyle can play a big part in developing risk factors for stroke. Which of the following can greatly reduce a client's risk for stroke? Select all that apply. A. Quitting smoking B. Maintaining a healthy weight C. Regularly exercising D. Following a sedentary lifestyle E. Eating a high-sodium diet
A. Quitting smoking B. Maintaining a healthy weight C. Regularly exercising Explanation: Clients with obesity, in particular abdominal obesity, are at increased risk for ischemic stroke. Nurses should teach clients to reduce calorie intake and to gradually increase activity. Smokers are also at increased risk for stroke. Nurses should counsel clients at every visit about willingness to quit smoking. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, HEALTH ASSESSMENT Collecting Subjective Data: The Nursing Health History, p. 584.
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 A. some impairment. B. deep coma. C. no verbal response. D. severe impairment.
A. some impairment. Explanation: The points associated with the Glasgow Coma Scale are determined to assess levels of consciousness and coma. Points are allotted for each of the 3 areas: eye opening, verbal response and motor responses. A score of 13 indicates some impairment. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, Collecting Objective Data: Physical Examination, p. 585.
The nurse lightly strokes the sides of a client's abdomen, above and below the umbilicus. For which reflex is the nurse testing? A. Cremasteric B. Abdominal C. Babinski D. Ankle clonus
B. Abdominal Explanation: Abdominal reflexes are assessed by lightly stroking the abdomen on each side, above and below the umbilicus. This evaluates the function of the spinal levels T8-T10 with the upper abdominal reflex and spinal levels T10-T12 with the lower abdominal reflex. The sole of the foot is stroked to assess for the presence of the Babinski reflex. The inner thigh is stroked when assessing the cremasteric reflex in a male client. The ankle is dorsiflexed when assessing for ankle clonus. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, Collecting Objective Data: Physical Examination, p. 601.
What should the nurse assess to test the function of the occipital lobe? A. Impulses from the ear B. Ability to read C. Communication D. Tactile sensation
B. Ability to read Explanation: To assess the function of the occipital lobe, the nurse should test the ability to read. To assess the function of the parietal lobe, the nurse should test for tactile sensation. The function of the temporal lobe is assessed by testing for impulses from the ear. Assessment of the frontal lobe is done by testing the client's communication. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, Central Nervous System, pp. 573-574.
A nurse is preparing to assess a client's cerebellar function. What aspect of neurological function should the nurse address? A. Remote memory B. Balance C. Mental status exam D. Sensation
B. Balance Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, Collecting Objective Data: Physical Examination, p. 593.
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? A. Reinforcement B. Clonus C. A focal seizure D. Extinction
B. Clonus Explanation: Clonus is a sustained rhythmical "beating" that correlates with CNS disease and hyperreflexia. A focal seizure could be virtually ruled out by stopping the stimulus and watching the phenomenon stop. Extinction is a term applied to sensory testing in which one side of a simultaneous, bilateral stimulus is not felt because of damage to the cortex. Reinforcement applies to enhancing reflex examination by distracting the client (e.g., pulling his hands against each other). Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, Collecting Objective Data: Physical Examination, p. 601.
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? A. Medulla B. Hypothalamus C. Cerebral cortex D. Brain stem
B. Hypothalamus Explanation: The hypothalamus controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions. It maintains overall autonomic control. The medulla, part of the brain stem, controls the cardiac, respiratory, vomiting, and vasomotor centers, dealing with autonomic (involuntary) functions of breathing, blood pressure, and heart rate. The brain stem also contains the pons and midbrain. The cerebral cortex is the covering of the cerebrum. Its role is in memory, attention, and consciousness. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, Central Nervous System, pp. 574-575.
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? A. Cover one eye. B. Smile. C. Clench the teeth. D. Smell coffee beans.
B. Smile. Explanation: Cranial nerve VII is the facial cranial nerve and is responsible for facial movements such as facial expressions. Clenching the teeth is associated with cranial nerve V, the trigeminal nerve. The nurse should instruct the client to cover one eye if assessing cranial nerves III, IV, and VI otherwise, oculomotor, trochlear, abducens, respectively. Smelling coffee beans would assist in assessing cranial nerve I, the olfactory nerve. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, Collecting Objective Data: Physical Examination, p. 589.
The portion of the brain that rims the surfaces of the cerebral hemispheres forming the cerebral cortex is the A. brainstem. B. gray matter. C. diencephalon. D. cerebellum.
B. gray matter. Explanation: The lobes are composed of a substance known as gray matter, which mediates higher-level functions such as memory, perception, communication, and initiation of voluntary movements. Consisting of aggregations of neuronal cell bodies, gray matter rims the surfaces of the cerebral hemispheres, forming the cerebral cortex. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, Central Nervous System, p. 573.
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? A. "Can you tell me about your mood today?" B. "Do you feel like crying often?" C. "Can you tell me where you are right now?" D. "Do you have a history of psychotic disorder?"
C. "Can you tell me where you are right now?" Explanation: The nurse should only assess for orientation to date and place when conducting a mental status assessment as part of the screening neurological examination. Asking details about mood, history of psychiatric disorders, and fluctuations in emotions is better done when conducting a full mental status assessment, not as part of the screening neurological assessment. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, General Routine Screening versus Focused Specialty Assessment for the Neurologic System, p. 585.
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? A. Use a verbal 0-10 rating scale. B. Utilize the FACES scale. C. Assess for nonverbal signs. D. Clients assigned this low score are pain free.
C. Assess for nonverbal signs. Explanation: The GCS is a tool for assessing a client's response to stimuli. Scores range from 3 (deep coma) to 15 (normal). Eye opening response: Spontaneous 4 To voice 3 To pain 2 None 1 Best verbal response: Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 Best motor response: Obeys command 6 Localizes pain 5 Withdraws 4 Flexion 3 Extension 2 None 1 Total 3-15. A score of three indicates deep coma; therefore, the client is unable to verbalize pain level on numerical scale or FACES scale. A client in a coma can still experience pain. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, Collecting Objective Data: Physical Examination, p. 585.
The cerebrum is divided into right and left hemispheres, which are joined together by the A. diencephalon. B. pons. C. Corpus Callosum D. medulla oblongata.
C. Corpus Callosum Explanation: The cerebrum is divided into the right and left cerebral hemispheres, which are joined by the corpus callosum—a bundle of nerve fibers responsible for communication between the hemispheres. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, Central Nervous System, p. 573.
Upon reviewing the client's medical record, the nurse finds the client has left ptosis. The nurse would assess the client for what? A. Swelling of the optic nerve B. Loss of visual fields on the left C. Drooping of the left side of the mouth D. Drooping of the left eye
C. Drooping of the left side of the mouth Explanation: Ptosis is drooping of the eye lid. Swelling of the optic nerve is papilledema. A loss visual fields may be associated with retinal detachment or damage. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, Collecting Objective Data: Physical Examination, p. 587.
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? A. Vagus (X) B. Spinal accessory (XI) C. Glossopharyngeal (IX) D. Hypoglossal (XII)
C. Glossopharyngeal (IX) Explanation: The glossopharyngeal nerve (cranial nerve IX) contains sensory fibers for taste on posterior third of tongue and sensory fibers of the pharynx that result in the "gag reflex" when stimulated. The vagus nerve (cranial nerve X) carries sensations from the throat, larynx, heart, lungs, bronchi, gastrointestinal tract, and abdominal viscera and promotes swallowing, talking, and production of digestive juices. The spinal accessory nerve (cranial nerve XI) innervates neck muscles (sternocleidomastoid and trapezius) that promote movement of the shoulders and head rotation and promotes some movement of the larynx. The hypoglossal nerve (cranial nerve XII) innervates tongue muscles that promote the movement of food and talking. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, HEALTH ASSESSMENT, p. 591.
When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence? A. Motor/cerebellar, sensory, reflexes, cranial nerves, mental status B. Cranial nerves, motor/cerebellar, sensory, reflexes, mental status C. Mental status, cranial nerves, motor/cerebellar, sensory, reflexes D. Reflexes, sensory, motor/cerebellar, cranial nerves, mental status
C. Mental status, cranial nerves, motor/cerebellar, sensory, reflexes Explanation: The nurse should perform the assessment of the nervous system from a level of higher cerebral integration to a level of lower reflexes. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, HEALTH ASSESSMENT, p. 584.
The nurse documents "Romberg test positive" on a client's medical record. What did the nurse most likely assess in this client? A. Weak hand grasps B. Poor brachial reflex C. Swaying D. Unsteady gait
C. Swaying Explanation: A positive Romberg test is when the client sways and moves the feet apart to prevent falling. The Romberg test is not used to assess gait, hand grasps, or the brachial reflex. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, Collecting Objective Data: Physical Examination, p. 593.
Which of the following assessments is most likely to provide insight into the function of the client's CN VIII? A. Test the client's ability to identify a familiar smell with his or her eyes closed. B. Ask the client to shrug both shoulders upward against the examiner's hands. C. Test the client's hearing for lateralization and bone and air conduction. D. Ask the client to raise his or her eyebrows, frown, and close both eyes tightly.
C. Test the client's hearing for lateralization and bone and air conduction. Explanation: CN VIII is the acoustic nerve; function is thus tested by assessing the client's hearing. Shoulder shrugging tests CN XI; frowning and closing the eyes depend on CN VII. CN I is tested by assessing the client's ability to identify smells. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, Collecting Objective Data: Physical Examination, p. 602.
The nurse plans to test which cranial nerve when testing an elderly client's hearing status? A. VI B. V C. VIII D. VII
C. VIII Explanation: Cranial nerve VIII contains sensory fibers for hearing and balance. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, Peripheral Nervous System, p. 577.
Which assessment procedure should a nurse institute to test a client for stereognosis? A. Ask the client to identify the number of points touched with two ends of an applicator B. With eyes closed, move the client's finger up or down and ask the direction C. With eyes closed, ask the client to identify a familiar object that is placed in their hand D. Use a blunt instrument to write a number in the client's hand and ask them to identify it
C. With eyes closed, ask the client to identify a familiar object that is placed in their hand Explanation: To test a client for stereognosis, with the eyes closed, the nurse should ask the client to identify a familiar object that is placed in their hand. To test graphesthesia, the nurse should use a blunt instrument to write a number in the client's hand and ask them to identify it. When testing sensitivity to position, the nurse should ask the client to close their eyes then move the finger up or down and ask the direction it is moved. Asking the client to identify the number of points touched with two ends of an applicator at the same time is two-point discrimination. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, HEALTH ASSESSMENT, p. 597.
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 A. "How old were you when you began working?" B. "What did you have for breakfast?" C. "Can you repeat rose, hose, nose, clothes?" D. "Can you repeat brown, chair, textbook, tomato?"
D. "Can you repeat brown, chair, textbook, tomato?" Explanation: Remote memory (past dates and historical accounts) may be impaired in cerebral cortex disorders. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, HEALTH ASSESSMENT Collecting Subjective Data: The Nursing Health History, p. 581.
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? A. "Walk on your toes then on your heels." B. "Walk heel to toe." C. "Hop on one spot." D. "Walk across the room and back."
D. "Walk across the room and back." Explanation: It is important to ask the client to walk across the room and walk back first because this will reveal deficits in the gait. This, in turn, will allow the nurse to focus the assessment. Asking the client to walk across the room and then back assists the nurse in observing posture, balance, swinging of the arms, and movements of the legs. Asking the client to walk heel to toe is called "tandem walking." It would be appropriate to instruct the client to do this to determine if there is ataxia that was not previously obvious. Asking the client to walk on the toes then on the heels assists the nurse in assessing for plantar flexion of the ankles as well as for balance. The nurse should instruct the client to do this if problems with balance are noted initially. Asking the client to hop in place provides information about the client's position sense and cerebellar function. If the nurse is not yet aware whether the client is at risk for falls, this assessment should be left until the quality of gait has been assessed. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, HEALTH ASSESSMENT Collecting Subjective Data: The Nursing Health History, p. 579.
The nurse is caring for a client in the hospital and identifies the client to be experiencing acute confusion after cardiac surgery. The nurse recognizes this as what? A. Hypoxia B. Dementia C. Amnesia D. Delirium
D. Delirium Explanation: Delirium in an acute onset of confusion related to an underlying cause such as medication, disease or traumatic event. Dementia occurs over a time, amnesia is a loss of memory and hypoxia may be a cause of delirium. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, HEALTH ASSESSMENT Collecting Subjective Data: The Nursing Health History, p. 581.
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? A. Simple partial seizure (Jacksonian) B. Generalized tonic-clonic seizure C. Complex partial seizure D. Generalized absence seizure
D. Generalized absence seizure Explanation: In an absence seizure there is no tonic-clonic activity. There is a sudden brief lapse of consciousness with blinking, staring, lip smacking, or hand movements that resolve quickly to full consciousness. It is easily mistaken for daydreaming or ADD. Some will try to induce these episodes with hyperventilation. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, HEALTH ASSESSMENT Collecting Subjective Data: The Nursing Health History, p. 579.
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? A. Instruct the client to smile B. Ask the client to close the eyes C. Instruct the client to state the current date and place D. Instruct the client to flex and extend the right elbow
D. Instruct the client to flex and extend the right elbow Explanation: Instructing the client to flex and extend the right elbow is assessing strength, which is a part of the motor system assessment. Instructing the client to state the current date and place is part of the mental status assessment. Instructing the client to smile and close the eyes is part of the cranial nerve assessment. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 25: Assessing Neurologic System, Collecting Objective Data: Physical Examination, pp. 598-599.
After testing deep tendon reflexes, the nurse documents 2+. The nurse should evaluate further. True False
False
