CP Chapter 20: Nervous System

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? A. Balance and coordination B. Deep tendon reflexes C. Light touch sensation D. Leg strength

A. Balance and coordination Deviation of the heel to one side or the other during the heel-to-shin test may be seen in cerebellar disease. As such, further assessment of balance and coordination is likely indicated. This assessment finding is not suggestive of deficits in reflexes, sensation, or strength.

When preparing to test a client for meningeal irritation, what would the nurse to do first? A. Ensure no injury to the cervical spine B. Position the client prone C. Check for a Babinski reflex D. Check for evidence of fever and chills

A. Ensure no injury to the cervical spine Before testing a client for meningeal irritation, the nurse needs to ensure that there is no injury to cervical vertebrae or the cervical cord. Otherwise further injury could occur because testing involves flexing the neck. It is not necessary to check for fever or chills or a Babinski reflex. The client is positioned supine for these tests.

A nurse is reviewing a client's health record while interviewing her. The nurse sees in the patient'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? A. Increased or brisk, but not pathologic B. Normal C. Present but decreased D. Exaggerated; indicator of possible upper motor neuron lesion

A. Increased or brisk, but not pathologic Normal reflex scores range from 1+ (present but decreased) to 2+ (normal) to 3+ (increased or brisk, but not pathologic). Absent or markedly decreased (hyporeflexia) deep tendon reflexes (rated 0) occur when a component of the lower motor neurons or reflex arc is impaired and may be seen with spinal cord injuries. Markedly hyperactive (hyperreflexia) deep tendon reflexes (rated 4+) may be seen with lesions of the upper motor neurons and when the higher cortical levels are impaired.

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? A. Parkinsonian gait B. Footdrop C. Spastic hemiparesis D. Scissors gait

A. Parkinsonian gait A parkinsonian gait is characterized by a shuffling gait with turns accomplished in a very stiff manner. The client also has a stooped-over posture with flexed hips and knees. A scissors gait involves thigh overlap. Spastic hemiparesis is characterized by dragging one toe. In footdrop, the client lifts the foot and knee high with each step, then slaps the foot down hard on the ground.

The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following? A. 2+ B. 1+ C. 4+ D. 3+

D. 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 very brisk with rhythmic oscillations are documented as 4+

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? A. 8 B. 11 C. 24 D. 31

D. 31 The peripheral nervous system consists of 12 pairs of cranial nerves and 31 pairs of spinal nerves. The other options are distracters to the question.

The nurse is tapping the spine for the level of vertebral pain. The nurse is testing the dermatomes. True OR False

True

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? A. Risk for Aspiration B. Unilateral Neglect C. Risk for Altered Skin Integrity D. Impaired Verbal Communication

A. Risk for Aspiration Due to the client's decreased mental status and slurred speech, he is at greatest risk for aspiration. Measures must be implemented by the nurse to prevent aspiration, such as NPO, elevating the head of bed, and assessment of lung sounds. Impaired Verbal Communication is a psychosocial issue, and physiologic problems take precedence over mental health at this point in time. Unilateral neglect is not as much of a priority as is the risk for aspiration. There is no indication that there is a risk for altered skin integrity.

The nurse is performing the Romberg test as part of a client's focused neurological assessment. What finding would constitute a positive Romberg test? A. The client moves her feet apart to prevent herself from falling. B. The client experiences pain during neck flexion and extension. C. The client is unable to consistently touch her finger to her nose while her eyes are close. D. The client experiences pain when clenching her teeth.

A. The client moves her feet apart to prevent herself from falling. The Romberg test assesses balance; swaying or repositioning during the test constitutes positive findings. The Romberg test does not address pain during neck flexion or teeth clenching. It does not require the client to touch the nose with a finger.

Which assessment procedure should a nurse institute to test a client for stereognosis? A. With eyes closed, ask the client to identify a familiar object that is placed in their hand B. With eyes closed, move the client's finger up or down and ask the direction C. Ask the client to identify the number of points touched with two ends of an applicator D. Use a blunt instrument to write a number in the client's hand and ask them to identify it

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

The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the A. glossopharyngeal. B. vagus. C. trigeminal. D. hypoglossal.

A. glossopharyngeal. The glossopharyngeal nerve contains sensory fibers for taste on posterior third of tongue and sensory fibers of the pharynx that result in the gag reflex when stimulated.

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? A. Use a Snellen chart to test visual acuity. B. Ask a client to identify scents. C. Perform the Weber test. D. Test extraocular eye movements.

B. Ask a client to identify scents. Cranial nerve I is the olfactory nerve, which would be tested by having the client occlude one nostril and identify a scent. Using the Snellen chart tests CN II, the optic nerve. Testing extraocular eye movements evaluates tests CN III (oculomotor), CN IV (trochlear), and CN VI (abducens). The Weber test evaluates CN VIII (acoustic/vestibulocochlear).

The husband of a 65-year-old female tells the nurse, "My wife is having trouble navigating the steps in our home and 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? A. Cranial nerves B. Cerebellum C. Temporal lobe D. Deep tendon reflexes

B. Cerebellum The cerebellum's primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone. The temporal lobe is part of the cerebrum and helps with receiving and interpreting impulses from the ear. The cranial nerves evolve from the brain or brain stem and transmit motor or sensory messages. Deep tendon reflexes are part of the sensory pathway of the spinal cord, which relay an impulse to the motor nerve and then to the muscles.

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.Dementia B. Delirium C. Amnesia D. Hypoxia

B. Delirium 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.

Which of the following would the nurse most likely expect to find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident? A. Blurred vision B. Difficulty speaking C. Inability to hear high-pitched sounds D. Loss of tactile sensation

B. Difficulty speaking The frontal lobe contains Broca's area, which is responsible for speech. Injury to this area may lead to difficulty speaking. Difficulty with sounds would be associated with the temporal lobe. Loss of tactile sensation would be associated with the parietal lobe. Blurred vision would be associated with the occipital lobe.

When testing the biceps reflex, what type of response should the nurse expect if normal? A. Elbow extends and muscle contracts B. Elbow flexes and muscle contracts C. Forearm adducts and wrist rotates D. Forearm flexes and supinates

B. Elbow flexes and muscle contracts 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.

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. Complex partial seizure B. Generalized absence seizure C. Generalized tonic-clonic seizure D. Simple partial seizure (Jacksonian)

B. Generalized absence seizure 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.

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? A. Limited lateral gaze of the eyes B. Inability to wrinkle the forehead C. Drooping of the eyelids D. Paralysis of the lower lip

B. 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 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.

A 77-year-old retired school superintendent comes to the office with a report of unsteady hands. He says that for the past 6 months when his hands are resting in his lap they shake uncontrollably. He says that when he holds them out in front of his body or uses his hands, the shaking improves. He also complains of some difficulty getting up out of his chair and walking around. He denies any recent illnesses or injuries. His past medical history is significant for high blood pressure and coronary artery disease, requiring a stent in the past. He has been married for more than 50 years and has five children and 12 grandchildren. He denies any tobacco, alcohol, or drug use. His mother died of a stroke in her 70s and his father died of a heart attack in his 60s. He has a younger sister with arthritis. His children are all essentially healthy. Examination reveals a fine pill-rolling tremour of his left hand. His right shows less movement. His cranial nerve examination is normal. He has some difficulty rising from his chair, his gait is slow, and it takes him time to turn around to walk back towards the examiner. He has almost no "arm swing" with his gait. What type of tremour is most likely? A. Postural B. Resting C. Intention

B. Resting Resting tremours occur when the hands are literally at rest, such as sitting in the lap. These are slow, fine tremours, such as the pill rolling seen in Parkinson's disease, which this client most likely has. Decreased arm swing with ambulation is one of the earliest objective findings of Parkinson's disease.

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? A. "Have you noticed any changes in your vision?" B. "Have you noticed any weakness in your muscles?" C. "Are you having any dizziness or lightheadedness?" D. "Do you have trouble hearing people when they talk to you?"

C. "Are you having any dizziness or lightheadedness?" Clients with carotid artery disease may experience dizziness or lightheadedness, especially with ambulation because of the increased difficulty in circulating enough blood and oxygen to the brain. Trouble hearing and changes in vision may signal cranial nerve dysfunction. Weakness in the muscles of the extremities is an indication of a CVA or nerve injury.

During the Romberg test, a client is unable to stand with the feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would interpret this finding as suggestive of which of the following? A. Scissors gait B. Parkinsonian gait C. Cerebellar ataxia D. Spastic hemiparesis

C. Cerebellar ataxia A wide-based, staggering, unsteady gait and positive Romberg's test (client unable to stand with feet together) suggests cerebellar ataxia. Spastic hemiparesis is characterized by a flexed arm held close to the body while the client drags the toes of the leg or circles it stiffly outward and forward. A Parkinsonian gait is a shuffling gait. A scissors gait is a short stiff gait with the thighs overlapping each other with each step.

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? A. Footdrop gait B. Parkinsonian gait C. Cerebellar ataxia D. Spastic hemiparesis

C. Cerebellar ataxia Cerebellar ataxia is recognized by the wide-based and staggering gait. The Romberg test will be positive. This gait can be seen in persons with cerebellar disease or alcohol or drug intoxication. The characteristic abnormality in Parkinson's disease is the shuffling gait with a stooped-over posture and flexion of the hips and knees. Spastic hemiparesis presents with the arm flexed and held close to the body while the client drags the toes and circles the leg outward and forward. Footdrop is seen when the client lifts the foot and knee high with each step, then slaps the foot hard to the ground.

When assessing deep tendon reflexes in an elderly client what finding would the nurse anticipate? A. Normal reaction time B. Increased reaction time C. Decreased reaction time D. Absent

C. Decreased reaction time Older clients usually have deep tendon reflexes intact, although a decrease in reaction time may slow the response.

What would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident? A. Blurred vision B. Loss of tactile sensation C. Difficulty speaking D. Inability to hear high-pitched sounds

C. Difficulty speaking The frontal lobe contains Broca's area, which is responsible for speech. Injury to this area may lead to difficulty speaking. Difficulty with sounds would be associated with the temporal lobe. Loss of tactile sensation would be associated with the parietal lobe. Blurred vision would be associated with the occipital lobe.

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. Pressure ulcers B. Impaired mobility C. Falls D. Stroke

C. Falls 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.

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? A. Lethargic B. Comatose C. Obtunded D. Stuporous

C. Obtunded An obtunded client is responsive but slow speaking and less interested in her surroundings. A client with lethargy opens her eyes to verbal cues and may respond appropriately, but promptly falls back to sleep. The stuporous client responds only to painful stimuli--when the stimulus is withdrawn, she lapses into unconsciousness again. Stuporous clients have little awareness of self or the environment. In the comatose client, there is no obvious response to external stimuli.

The nurse is testing for Kernig's sign in a newly admitted client. What would indicate meningeal inflammation? A. Hips and knees remain relaxed an motionless B. Neck resistance C. Pain and resistance to knee extension bilaterally D. Resistance to neck flexion

C. Pain and resistance to knee extension bilaterally Pain and resistance to knee extension bilaterally is a positive Kernig's sign. Hips and knees remaining relaxed an motionless is a normal Brudzinski's. Neck resistance is not part of Kernig's assessment.

A 28-year-old book editor comes to the clinic reporting strange episodes. He states that about once a week for the last 3 months his left hand and arm will stiffen and then start jerking. After a few seconds his whole left arm and then his left leg also start to jerk. He denies any loss of consciousness or loss of bowel or bladder control. When the symptoms resolve, his arm and leg feel tired; otherwise, he feels fine. His past medical history is significant for a cyst in his brain that was removed 6 months ago. He is married with two children. His parents are both healthy. Examination shows a scar over the right side of his head, but otherwise his neurological examination is unremarkable. What type of seizure disorder is most likely? A. Generalized tonic clonic seizure B. Generalized absence seizure C. Simple partial seizure (Jacksonian) D. Complex partial seizure

C. Simple partial seizure (Jacksonian) Simple partial seizures start with a unilateral symptom, have no loss of consciousness during the seizure, and have a normal postictal state. In a Jacksonian seizure the symptoms start with one body part and "march" along the same side of the body.

A nurse cares for an elderly client with right side hemiplegia and expressive aphasia. Which deficit should the nurse expect to find in the client? A. Inability to recognize familiar objects B. Trouble remembering familiar faces C. Slow speech with appropriate meaning D. Rapid speech with no meaning

C. Slow speech with appropriate meaning The client diagnosed with right side hemiplegia and expressive aphasia can verbally state wishes. Expressive aphasia is also called Broca's aphasia in which the speech is slowed with difficult articulation but fairly clear meaning. Clients with Wernicke's aphasia have rapid speech with no meaning. Inability to recognize familiar objects is called agnosia. Trouble remembering familiar faces is termed prosophenosia. Both of these conditions can occur with damage to the temporal and occipital lobes of the brain.

The nurse is planning to assess a client for graphesthesia. How will the nurse perform this phase of assessment? A. The client is asked to identify the number of points felt when the nurse touches the client with the ends of two applicators at the same time. B. The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred. C. 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. D. Have the client close the eyes. The nurse will then gently touch the client, and the client will identify where the touch occurred.

C. 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. Graphesthesia is the ability to identify what is being drawn on the client's body when the client's eyes are closed. Two-point discrimination is tested by having the client identify the number of points felts when touched with the ends of two applicators at the same time. Extinction is tested by simultaneously touching the client in the same area on both sides of the body at the same points and having the client identify the area touched. Point localization is tested by briefly touching the client and then asking the client to identify the points touched.

Which tests are appropriate for a nurse to perform to test the cranial nerve VIII? A. Gag reflex, rise of the uvula, ability to swallow B. Smile, frown, show teeth, and puff out cheeks C. Whisper test, Rinne, and Weber D. Clench the teeth, light touch, sharp/dull discrimination

C. Whisper test, Rinne, and Weber Cranial nerve VIII is the acoustic/vestibulocochlear which assesses the client's ability to hear. The nurse should perform the whisper test, and the Rinne and Weber test using the tuning fork. The gag reflex, rise of the uvula, and ability to swallow are tests to assess cranial nerves IX (glossopharygeal) and X (vagus). Asking the client to smile, frown, show teeth, and puff out cheeks assess the function of cranial nerve VII (facial).

What task should a nurse ask a client to perform to assess the function of cranial nerve XI? A. swallow water B. walk in heel-to-toe fashion C. shrug shoulders against resistance D. move tongue side to side

C. shrug shoulders against resistance The function of cranial nerve XI can be assessed by asking the client to shrug his or her shoulders against resistance. Asking the client to move the tongue from side to side assesses function of the hypoglossal nerve, Cranial nerve XII. The nurse asks the client to swallow water to assess the function of cranial nerves IX and X. Asking the client to walk in heel-to-toe fashion helps in assessment of balance.

When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk? A. 35-year-old African American who has sleep apnea B. 42-year-old Caucasian woman who smokes C. 55-year-old Caucasian male who has a two beers a week D. 68-year-old African American with hypertension

D. 68-year-old African American with hypertension Risk factors include older adulthood (risk doubling each decade after age 55), male sex, African American race, hypertension, smoking, chronic alcohol intake (more than 3 drinks per day), and sleep apnea. In the clients listed, the 68-year-old African American male with hypertension has the greatest risk due to his age, race, and hypertension. The other clients would be at risk but the risk would be less.

The nurse is assessing a 39-year-old woman who has a 20-year history of cigarette smoking. When reviewing the client's current medication administration record, what drug would the nurse identify as increasing the woman's risk of stroke? A. A beta-adrenergic blocker B. ASA C. Acetaminophen D. An oral contraceptive

D. An oral contraceptive The use of oral contraceptives, especially in smokers over 35, constitutes a significant risk factor for stroke. Acetaminophen, ASA, and beta blockers usually decrease an individual's risk of stroke

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? A. CN IX B. CN VII C. CN II D. CN I

D. CN I CN I (olfactory) would be evaluated to determine if the client was experiencing a problem here related to a report of a decrease in smell. Evaluation of CN II (optic) would be indicated if the client reported changes in vision. Evaluation of CN VII (facial) or IX (hypoglossal) would be indicated if the client reported a decrease in his or her ability to taste.

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? A. Scissors movement B. Spastic Hemiparesis C. Sensory ataxia D. Cerebellar ataxia

D. Cerebellar ataxia Cerebellar ataxia, a wide-based gait with staggering and lurching, is often due to alcohol intake or cerebral palsy. Spastic hemiparesis is usually caused by stroke, not alcohol intoxication. Scissors gait is spastic diplegia associated with bilateral spasticity of the legs. Sensory ataxia is due to cerebral palsy also resulting in a wide-based gait.

As adults age, peripheral nerve function and impulse conduction decrease. What is the result of this decrease? A. Increased myelinization B. Decreased cognitive function C. Increased need for sleep D. Decreased proprioception

D. Decreased proprioception In older people peripheral nerve function and impulse conduction decreases with resultant decreased proprioception and potential for a Parkinson-like gait.

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? A. Test the client's visual fields and cranial nerves for third nerve palsy. B. Insist the provider come see the client immediately. C. Ask for a second opinion from an opthamologist. D. Document the findings and healthcare provider's response.

D. Document the findings and healthcare provider's response. Physiological anisocoria is not associated with any disease; therefore the nurse can document the findings. A second opinion is not needed; and the client does not need to be seen right away. Third nerve palsy presents with sudden ptosis, diplopia, and pain with a fixed and dilated pupil.

When assessing a client's coordination by asking the client to touch the nose with the finger, what should a nurse keep in mind about a client's movements? A. Uncoordinated movements can be expected in the elderly B. As the client repeats the maneuver, movements will be less accurate C. Most clients will hesitate before touching the nose to check their position D. Dominant side will be more coordinated than nondominant side

D. Dominant side will be more coordinated than nondominant side A nurse should ask a client to touch the tip of the nose with the right index finger, then the left. This should be repeated three (3) times. Movements should be smooth and performed without hesitation. The nurse should keep in mind that the client's dominant side will be more coordinated than nondominant side. The elderly client may be slower but the movement should still be smooth and accurate.

The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam? A. Tandem walking B. Romberg C. Gait D. Hop on one foot

D. Hop on one foot Hoping on one foot is often impossible for the older adult because of decreased flexibility and strength and may place the client at risk. The nurse needs to ensure the client's safety by standing close by, especially with tandem walking and Romberg testing, because some older clients may have difficulty with maintaining balance. However, these tests would not be omitted. Older clients may have a slow uncertain gait. This test, however, would not be omitted.

What should the nurse assess to test the function of the temporal lobe? A. Ability to read B. Communication C. Tactile sensation D. Impulses from the ear

D. Impulses from the ear The function of the temporal lobe is assessed by testing for impulses from the ear. To assess the function of the parietal lobe, the nurse should test for tactile sensation. Assessment of the frontal lobe is done by testing the client's communication. To assess the function of the occipital lobe, the nurse should test the ability to read.

A client presents to the health care clinic with a 3-day history of fever, chills, neck pain and stiffness, and headache. The nurse observes an elevated temperature of 102.5°F and pain with rotation of the head side to the side and decreased ability to flex the head forward. The nurse recognizes these findings as most likely the onset of what infectious process? A. Arthritis B. Bursitis C. Spondylitis D. Meningitis

D. Meningitis Impaired range of motion and neck pain associated with fever, chills, and a headache may be indicative of a serious infection such as meningitis. Arthritis is inflammation or infection within a joint. Spondylitis is an inflammation of the vertebra. Bursitis is an inflammation in the bursa (small sacs) of synovial fluid in the body.

What task should a nurse ask a client to perform to assess the function of cranial nerve XII? A. Shrug shoulders against resistance B. Swallow water C. Water in heel-to-toe fashion D. Move the tongue from side to side

D. Move the tongue from side to side Asking the client to move the tongue from side to side assesses function of the hypoglossal nerve, cranial nerve XII. The function of cranial nerve XI can be assessed by asking the client to shrug the shoulders against resistance. The nurse asks the client to swallow water to assess the function of cranial nerves IX and X. Asking the client to walk in heel-to-toe fashion helps in assessment of balance.

Which cranial nerve controls pupillary constriction? A. Trochlear B. Optic C. Trigeminal D. Oculomotor

D. Oculomotor The oculomotor nerve causes pupillary constriction, opening the eye (lid elevation), and most extraocular movements.

Which of the following would lead the nurse to suspect meningeal irritation? A. Discomfort behind the knee with full extension of the leg B. Hips and knees remain relaxed and motionless when neck is flexed C. Reports of decreased pain with flexion of the hips and knees D. Pain and flexion of the hips and knees with neck flexion

D. Pain and flexion of the hips and knees with neck flexion Pain and flexion of the hips and knees are positive Brudzinski's signs and suggest meningeal irritation. Pain and increased resistance to extending the knee when the client's leg is flexed at both the hip and knee and then straightened is a positive Kernig's sign, suggesting meningeal irritation. Discomfort behind the knee during full extension when testing for Kernig's sign occurs in many normal people.

The nurse suspects that a client is experiencing meningitis. Which assessment finding caused the nurse to make this clinical determination? A. Hips and knees relaxed B. Neck flexes to the chest C. Pain behind the knees when fully extended D. Pain and hip flexion when the neck is flexed

D. Pain and hip flexion when the neck is flexed Pain and flexion of the hips and knees is a positive Brudzinski sign that suggests meningeal inflammation. If the hips and knees remain relaxed and the neck is able to be flexed to the chest, the client is not demonstrating signs of meningeal irritation. Pain behind the knees when fully extended is a normal finding in some people.

When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding? A. Deviation of uvula when client says "ah" B Stationary soft palate on phonation C. Asymmetrical soft palate D. Uvula and soft palate rising bilaterally

D. Uvula and soft palate rising bilaterally Normal findings associated with testing CN IX and CN X include a uvula and soft palate rising bilaterally and symmetrically on phonation. A stationary or asymmetrical soft palate or deviation of the uvula would be considered an abnormal finding.

After testing deep tendon reflexes, the nurse documents 2+. The nurse should evaluate further. True OR False

False

spastic hemiparesis

Spastic hemiparesis is seen in clients with corticospinal tract lesions from a stroke. There is poor control of flexor muscles during the swing phase of walking. The client's toe may drag. The scissors gait is seen in spinal cord disease. This gait is stiff, each leg is moved slowly, and the thighs tend to cross forward on each other at each step. The steppage gait is seen in foot drop, usually caused by peripheral motor unit disease. The client either drags the feet or lifts them high with the knees flexed. The foot is then brought down with a slap on the floor. The Parkinsonian gait is characterized by stooped posture, flexed head, arms, hips, and knees, and short shuffling step