Chapter 60: assessment of neurologic function

the nurse is performing a neurologic assessment of a client whose injuries have rendered the client unable to follow verbal commands. How should the nurse proceed with assessing the client's level of consciousness? a. assess the client's vital signs and correlate these with the client's baselines b. assess the client's eye-opening and response to stimuli c. document that the client currently lacks a LOC d. facilitate diagnostic testing in an effort to obtain objective data

b. assess the client's eye-opening and response to stimuli

a nurse is performing a neurological assessment on a client at home. during the assessment, the nurse notices that the client has a flat affect. which lobe of the brain is responsible for a person's affect? a. parietal lobe b. temporal lobe c. frontal lobe d. occipital lobe

c. frontal lobe

the nurse is preparing to assess a client with neurologic dysfunction. what does accurate and appropriate assessment require? SATA a. the ability to select basic medications for the neurologic dysfunction b. understanding of the tests used to diagnose neurologic disorders c. knowledge of nursing interventions related to assessment and diagnostic testing d. knowledge of the anatomy of the nervous system e. the ability to interpret the results of diagnostic tests

B, C, D

in which specific instance should the nurse assess the client's cranial nerves? SATA a. when a neurogenic bladder develops b. when the level of consciousness is decreased c. with brain stem pathology d. in the presence of peripheral nervous system disease e. when the spinal reflex is interrupted

B,C,D

a client is being given a medication that stimulates the parasympathetic system. following administration of this medication, the nurse should anticipate what effect? a. constricted pupils b. dilated brochioles c. decreased peristaltic movement d. relaxed muscular walls of the urinary bladder

a. constricted pupils parasympathetic stimulation results in constricted pupils, constricted bronchioles, increased peristaltic movement, and contracted muscular walls of the urinary bladder.

a client is admitted to the medical unit with an exacerbation of MS. when assessing the client, the nurse has the client stick out the tongue and move it back and forth. what is the nurse assessing? a. function of the hypoglossal nerve b. function of the vagus nerve c. function of the spinal nerve d. function of the trochlear nerve

a. function of the hypoglossal nerve

what neurologic assessment should the nurse perform to gauge the client's function of cranial nerve 1? a. have the client identify familiar odors with the eyes closed. b. assess papillary reflex c. utilize the snellen chart d. test for air and bone conduction (rinne test)

a. have the client identify familiar odors with the eyes closed.

when assessing a 36 year old male, the nurse gently strokes the client's right palm using a cotton applicator. As the nurse strokes the client's palm the nurse then checks to see if the client will begin to grasp the applicator. this assessment is associated with which of the following reflexes? a. pathologic b. superficial c. deep tendon d. brachioradialis

a. pathologic there are 3 classes of reflexes: pathological, superficial, or deep tendon. pathological reflexes often represent the emergence of earlier reflexes that disappeared with the maturity of the nervous system.

a trauma client in the ICU has been declared brain dead. what diagnostic test is used in making the best determination that the brain's electrical activity has ceased? a. MRI b. EEG c. EMG d. CT

b. EEG

a nurse is preforming a complex neurological assessment on a client recently diagnosed with alzheimer disease. what question should the nurse anticipate to ask when assessing the client's language ability? a. how are a pencil and pen alike? b. can you write your name on this blank sheet of paper? c. can you tell me what year it is? d. what is the name of the president of the united states?

b. can you write your name on this blank sheet of paper? when assessing written and spoken language ability, clients are usually asked to read a newspaper article and explain the meaning. clients are also asked to write their name or copy a simple figure drawn by the examiner.

the nurse is planning the care of a client with parkinson disease. the nurse should be aware that treatments will focus on what pathophysiological phenomenon? a. premature degradation of acetylcholine b. decreased availability of dopamine c. insufficient synthesis of epinephrine d. delayed reuptake of serotonin

b. decreased availability of dopamine

in the course of a focused neurologic assessment, the nurse is palpating the client's major muscle groups at rest and during passive movement. data gleaned from this assessment will allow the nurse to describe which of the following aspects of neurologic function? a. muscle dexterity b. muscle tone c. motor symmetry d. deep tendon reflexes

b. muscle tone

the nurse is doing an initial assessment on a client newly admitted to the unit with a diagnosis of cerebrovascular disease. the client has difficulty copying a figure that the nurse has drawn and is diagnosed with visual receptive aphasia. what brain region is primarily involved in this client's deficit? a. temporal lobe b. parietal-occipital area c. inferior-posterior frontal areas d. posterior frontal area

b. parietal-occipital area difficulty copying a figure that the nurse has drawn would be considered visual receptive aphasia, which involves the parietal-occipital area.

a gerontologic nurse planning the neurologic assessment of an older adult is considered normal, age related changes that may influence the assessment results. a. hyperactive deep tendon reflexes b. reduction in cerebral blood flow c. increased cerebral metabolism d. hypersensitivity to painful stimuli

b. reduction in cerebral blood flow reduction in cerebral blood flow is normal in the aging process.

A client is scheduled for MRI has arrived at the radiology dep. the nurse who prepares the client for MRI should prioritize what action? a. withholding stimulants 24-48 hours prior to exam b. removing all metal-containing objects c. instructing the client to void prior to the MRI d. initiating an IV line for administration of contrast.

b. removing all metal-containing objects

the nurse is providing information to a client about neurological disorders associated with genetic defects. the nurse knows which disease is considered an autosomal dominant disorder? a. duchenne muscular dystrophy b. parkinson disease c. huntington disease d. fragile x syndrome

c. huntington disease

a client has been recently diagnosed with myasthenia gravis. which is indicative of a person diagnosed with myasthenia gravis? a. excessive serotonin activity in the brain b. decreased dopamine activity in the brain c. impairment of acetylcholine binding to muscle cells d. defects in the expression of acetylcholine receptors

c. impairment of acetylcholine binding to muscle cells In MA acetylcholine binging to muscle cells is impaired. this results in weakness of extremities and difficulties with speech and chewing.

a client is having a "fight or flight response" after receiving a bad disease prognosis. what affect will this have on the client's sympathetic nervous system? a. constriction of blood vessels in the heart muscle b. constriction of bronchioles c. increased in the secretion of sweat d. constriction of pupils

c. increased in the secretion of sweat sympathetic nervous system stimulation results in dilated blood vessels in the heart and skeletal muscle, dilated bronchioles

the nurse is caring for a client with an upper motor neuron lesion. what clinical manifestations should the nurse anticipate when planning a client's neurologic assessment? a. decreased muscle tone b. flaccid paralysis c. loss of voluntary control of movement d. slow reflexes

c. loss of voluntary control of movement

when caring for a client with an altered LOC, the nurse is preparing to test cranial nerve VII. what assessment technique would most likely elicit a response from cranial nerve VII? a. palpate trapezius muscle while client shrugs shoulders against resistance b. administer the whisper or watch tick test. c. observe for facial movement symmetry, such as a smile d. note any hoarseness in the client's voice

c. observe for facial movement symmetry, such as a smile CN VII is the facial nerve, the appropriate assessment technique for this cranial nerve would include observing for symmetry while the client performs facial movements.

a trauma client was admitted to the ICU with a brain injury that resulted in a change in level of consciousness and altered vital signs. the client subsequently became diaphoretic and agitated. the nurse should recognize which of the following syndromes as the most plausible cause of these symptoms? a. adrenal crisis b. hypothalamic collapse c. sympathetic storm d. cranial nerve deficit

c. sympathetic storm sympathetic storm is a syndrome associated with changes in LOC, altered vital signs, diaphoresis, and agitation.

the nurse is conducting a focused neurologic assessment and is assessing the client's gag reflex. how should the nurse best perform this aspect of the assessment? a. depress the client's tongue w/a sterile tongue depressor b. ask the client to swallow a small amount of any soft food c. observe the client swallowing a small mouthful of water d. lightly touch the client's pharynx with a cotton swab

d. lightly touch the client's pharynx with a cotton swab the gag reflex is elicited by gently touching the back of the pharynx with a cotton-tipped applicator, first on one side of the uvula and then the other.

a 72 year old man has been brought to his PCP by the client's daughter, who claims that the client has been experiencing uncharacteristic lapses in memory. what principle should underline the nurse's assessment and management of this client? a. loss of short term memory is normal in older adults, but loss of long-term memory is pathologic. b. lapses in memory in older adults are considered benign unless they have negative consequences. c. gradual increase in confusion accompany the aging process. d. thorough assessment is necessary because changes in cognition are always considered to be pathologic

d. thorough assessment is necessary because changes in cognition are always considered to be pathologic yes the mental processing time decreases as we get old. But memory, language, and judgment capacities remain intact.