Jensen Ch. 22: Neurological and Mental Status

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 stenosis. 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?"

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?"

When the nurse is assessing a client's mental status as part of the neurological examination, which question would be most appropriate to ask?

"Can you tell me where you are right now?"

The nurse is assessing CN V (trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of assessment?

"Clench your teeth together tightly."

The nurse is providing teaching to a client with type 1 diabetes. When providing information about reducing the risk of diabetic neuropathy, the nurse should be sure to include which point?

"Effective blood glucose regulation can prevent this problem."

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?"

The nurse assesses brisk reflexes in a client during a neurological assessment. How would the nurse document this finding?

3+

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

A client has just undergone a lumbar puncture to rule out meningitis. How long must the client remain flat in bed?

6 to 8 hours

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

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

Which of the following is usually the first sign of neurological deterioration?

Altered mentation and decreasing level of consciousness

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?

An oral contraceptive

While participating in a research class, a nursing student learns that maternalexposure to pesticides is linked to increased incidence of what?

Anencephaly

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. What would the nurse do?

Ask a client to identify scents.

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.

A nurse is testing a client's corneal reflex but notices that the reflex appears to be reduced. The client is otherwise alert and oriented, with no signs of neurologic degeneration. What is an appropriate action by the nurse?

Ask the client about the presence of contact lenses

A client reports the feeling of being unsteady when walking. What is an appropriate action by a nurse to assess for a problem with gait and balance?

Ask the client to walk in a heel to toe fashion and watch for an unsteady gait

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?

Assess for nonverbal signs.

A nurse is preparing to assess a client's cerebellar function. Which of the following would the nurse expect to test?

Balance

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

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

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 nurse is assessing the client's coordination and finds that her movements are clumsy, unsteady, and inappropriately varying in their speed, force, and direction. The nurse notes that client has dysmetria. What would the nurse know this client has?

Cerebellar disease

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?

Cerebellum

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?

Clonus

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 client has sustained an injury to the cerebellum. Which area should be the nurse's primary focus for assessment?

Coordination

A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment?

Coordination

As adults age, peripheral nerve function and impulse conduction decrease. What is the result of this decrease?

Decreased proprioception

When documenting assessment of the nervous system, a nurse should keep in mind what important principle?

Describe the response

A client cannot differentiate between sharp and dull pain sensations when a nurse tests with a safety pin. What is an appropriate action by the nurse?

Determine the ability to differentiate hot and cold temperatures

Which of the following are types of diabetic neuropathies? (Select all that apply.)

Diabetic amyotrophy Autonomic dysfunction Mononeuritis multiplex

A client has a disorder of the hypothalamus. The nurse recognizes that this structure is found in which area of the brain?

Diencephalon

What would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident?

Difficulty speaking

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

A nurse performs a neurologic 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?

Dorsiflexion of the great toe and fanning of all toes

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

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)

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

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.

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 and finds a unilateral dilated pupil that is unresponsive to light or accommodation. The nurse recognizes that which cranial nerve is responsible for the damage of pupillary response?

III

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

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

Impulses from the ear

A nurse is reviewing a client's health record while interviewing her. The nurse sees in the client'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?

Increased or brisk, but not pathologic

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

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

L2 to L4

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

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

When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence?

Mental status, cranial nerves, motor/cerebellar, sensory, reflexes

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

When testing sensory function of the trigeminal nerve (CN V), which of the following sensations would the nurse assess?

Obtunded Pain and light touch

Which cranial nerve controls pupillary constriction?

Oculomotor

The nurse suspects that a client is experiencing meningitis. Which assessment finding caused the nurse to make this clinical determination?

Pain and hip flexion when the neck is flexed

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

A nurse has been asked to provide an educational event for the families of clients of a nursing home. What would the nurse teach during this educational event?

People older than 75 years experience more consequences of traumatic brain injury.

A 20-year-old comatose high school student arrives at the emergency room. His friends have accompanied him and report that they have been shooting up heroin tonight and think their friend may have had too much. The client is unconscious and cannot protect his airway so he is intubated. His heart rate is 60 and he is breathing through the ventilator. He is not posturing and he does not respond to a sternal rub. On neurological examination with a penlight, what type of pupils is the examiner likely to see in this comatose client?

Pinpoint

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

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.

Quitting smoking Regularly exercising Maintaining a healthy weight

The emergency department nurse's rapid assessment of a young adult client admitted unresponsive reveals fixed, constricted pupils bilaterally. The nurse should consider what possible cause for this assessment finding?

Recent narcotic use

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.

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 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

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.

An adult client has asked the nurse about actions that she can take to reduce her future risk of stroke. What health promotion activity should the nurse prioritize?

Smoking cessation

Where do the cell bodies of the lower motor neurons lie?

Spinal cord

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

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.

The nurse is performing the Romberg test as part of a client's focused neurological assessment. What finding would constitute a positive Romberg test?

The client moves her feet apart to prevent herself from falling.

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.

A client with a history of seizure disorder and taking several seizure medications reports that a friend noted "jumping eye movements." The client describes a sensation of movement at rest since his medications were adjusted upward following a breakthrough seizure several weeks ago. Examination shows that both eyes slowly move to the right then quickly jump to the left. Based on these signs, which of the following is true?

This is called nystagmus to the left.

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

True

Which action by a nurse demonstrates the correct technique to use the reflex hammer?

Use rapid wrist movement and strike the tendon

When assessing cranial nerves IX and X, what would the nurse consider as a normal finding?

Uvula and soft palate rising bilaterally

During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve?

VIII

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 preparing to assess a client's cranial nerves using a screening neurologic examination. Which of the following should the nurse include in this assessment? (Select all that apply.)

Visual acuity Eye movements Hearing Facial strength

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

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

While assessing the neurologic system of a confused older adult, the nurse observes that the client is unable to recall past events. The nurse suspects that the client may be exhibiting signs of

cerebral cortex disorder.

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.

The portion of the brain that rims the surfaces of the cerebral hemispheres forming the cerebral cortex is the

gray matter.

During morning report the nurse learns that an assigned client needs assistance with ambulation because of spastic hemiparesis. What should the nurse expect when ambulating with this client?

image with left hand and leg turned in

A client reports resting and skipping exercise during a holiday from work. Which part of the nervous system is controlling this client's behavior?

parasympathetic

A client is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would be most appropriate to test?

patellar

The nurse is caring for a client during the immediate postoperative period after abdominal surgery. While performing a "neuro check" the nurse should assess the client's

sensation in the extremities.

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 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?

shrug shoulders against resistance Cerebellum

The hypothalamus is responsible for regulating

sleep cycles.

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

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 diencephalon of the brain consists of the

thalamus and hypothalamus