HA CoursePoint: Neuro

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 lightly strokes the sides of a client's abdomen, above and below the umbilicus. For which reflex is the nurse testing?

Abdominal 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.

Cotton ball on eye

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 is assessing an newly admitted client with a seizure disorder. The nurse would asses the client for what?

Aura

The nurse working in the emergency department is assessing an intoxicated driver involved in a motor vehicle crash when the client insists on ambulating to the bathroom. The nurse escorts the client and calls for help while anticipating which abnormal gait in this client that places him at risk for falls?

Cerebellar ataxia

The nurse performs a neurological assessment and determines the Glasgow Coma Scale (GCS) score is 15. What is the nurse's best action?

Document the findings. A GCS score of 15 is the maximum score indicating the client's neurological status is normal.

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?

Dominant side will be more coordinated than nondominant side

Transient Blind Spots

Early sign of CVA

A client who was injured by a fall at a construction site has been admitted to the hospital. He has suffered nerve damage such that his gag reflex is no longer intact, requiring him to receive intravenous total parenteral nutrition. Which nerve should the nurse suspect to be involved in this client's injury?

Glossopharyngeal (IX)

What should the nurse assess to test the function of the temporal lobe?

Impulses from the ear

What is the level of the spinal cord associated with the knee (patellar) deep tendon reflex?

L2 - L4

The client presents at the clinic with a complaint of weakness that is made worse with repeated effort and improves with rest. The client's complaint is consistent with what health problem?

Myasthenia gravis

Which cranial nerve controls pupillary constriction?

Oculomotor

A nurse performs a neurological examination on a client who sustained an injury to the spinal cord. What finding should the nurse expect when stroking the bottom of the client's feet?

Plantar Flexion

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 A normal reflex response is documented as being +2. A diminished reflex response is documented as being +1. A 0 is no reflex response. A +3 is a brisker than average response. A +4 is a very brisk response.

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?

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 prosopagnosia. Both of these conditions can occur with damage to the temporal and occipital lobes of the brain.

Gaits

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 steps

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 trouble seeing in one or both eyes Sudden confusion, trouble speaking, or understanding speech Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe headache with no known cause

When conducting a Romberg test, why does the nurse ask the client to stand feet together with eyes open and then closed?

Vision can compensate for loss of position sense.

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

When testing motor function ask the client to smile, frown and wrinkle forehead, show teeth, puff out cheeks, and purse the lips.

A nurse is conducting a health history with a client who has recently had a stroke. The nurse notes the client has slurred speech, although language is intact. Which disorder of speech is the nurse observing in this client?

dysarthria

The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the

glossopharyngeal.

What task should a nurse ask a client to perform to assess the function of cranial nerve XI?

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.

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.

Sensations of temperature, pain, and crude and light touch are carried by way of the

spinothalamic tract.

The diencephalon of the brain consists of the

thalamus and hypothalamus