305 Exam 3- Neuro

You are the nurse taking a patient's history. The patient tells you, "It feels like the room is spinning around me." You would document this as: An aura Syncope Diplopia Vertigo

vertigo

A 21-year-old woman has been admitted to the emergency department following an accident that is suspected of being a suicide attempt. When assessing the client's perceptions, what question should you ask the client? "Are you able to smell and taste as well as you've been able to in the past?" "If you found a stamped envelope on the street, what would you do?" "Can you tell me the circumstances surrounding your accident?" "How would you describe your health these days?"

"How would you describe your health these days?"

Of the following changes, which is the earliest sign of progressing brain herniation that originates in the cerebral hemispheres? Reflex posturing of extremities Widening pulse pressure with bradycardia An enlarging pupil that is sluggishly reactive to light Altered mentation

Altered mentation

Your interview with a patient who has been diagnosed with a mental illness reveals that they possess several delusions and are demonstrating paranoid thinking. What nursing diagnosis is most appropriate? Altered thought process Impaired social interaction Self-esteem disturbance Risk for suicide

Altered thought process

When conducting a mental health examination, what should you carefully assess as signs of depression in an older, recently widowed patient? Select all that apply. Family violence Firearms in the home Anhedonia Difficulty making decisions Sleep disorder

Anhedonia , Difficulty making decisions , Sleep disorder

If the great toe extends upward and the other toes fan out in response to stroking the lateral aspect of the sole of the foot, this is documented as which of the following? Cushing response Babinski's sign Hyporeflexia Normal plantar reflex

Babinski's sign

The finger-to-nose and the rapid-alternating movements tests are used to assess: Cerebellar function Cerebral function Occipital function Temporal function

Cerebellar function

the patient with a head injury and increasing ICP is likely to have which assessment findings? Decreased LOC and sluggish pupil Dilated left pupil and receptive aphasia Right-sided ptosis and loss of vision Left-sided weakness and facial droop

Decreased LOC and sluggish pupil

True or false: Confusion is an abnormal finding with children, but not with older adults. FALSE TRUE

FALSE

A woman has accompanied her 80-year-old husband to a scheduled clinic visit and expresses concern about subtle declines in his cognition. Which of the following principles should guide your assessment of the client's mental status? I must modify the cognitive assessment to exclude assessments requiring reading or writing. I must explain that the results of the assessment will be used to determine if admission to long-term care is necessary. I must differentiate between age-related changes and the signs and symptoms of dementia. I should first explain to the couple that senility is expected among adults over age 80.

I must differentiate between age-related changes and the signs and symptoms of dementia.

Clinical situations that require urgent communication of neurological assessment findings include a change in _________ , papillary reaction, and verbal or motor response.

LOC level of consciousness

When assessing a patient's mental status, which of the following would you least likely include in your evaluation of level of awareness? Ability to state where he is Ability to state name Orientation to time Level of consciousness.

Level of consciousness.

Delirium can be caused by which factors? (Select all that apply.) Metabolic disturbances Fluid imbalances Alzheimer disease Vitamin deficiencies Cerebrovascular accident (CVA)

Metabolic disturbances , Fluid imbalances , Vitamin deficiencies

Which possible causes should you consider when assessing a patient with an acute change in mental status? (Select all that apply.) Psychiatric disorders Drugs or alcohol Adverse medication effects Delirium Electrolyte imbalances

Psychiatric disorders , Drugs or alcohol , Adverse medication effects , Delirium , Electrolyte imbalances

You begin a physical examination of a newly admitted client by assessing the client's mental status. What is your best rationale for performing the mental status exam early in the assessment? The client's fears about having a serious illness may be alleviated by the results of the exam. The exam provides data about mental health problems that the client may be afraid to report. The exam can provide clues about the validity of the client's responses now and throughout. The client will be less anxious early, providing me with more accurate and reliable data.

The exam can provide clues about the validity of the client's responses now and throughout.

When assessing a patient's level of consciousness using the Glasgow Coma Scale (GCS), you will evaluate which aspects? (Select all that apply.) Verbal response Eye opening Insight Motor response Judgment

Verbal response , Eye opening , Motor response

The chart states that a 62-year-old woman has a stroke in the right parietal area of the brain. The nurse expects to note which of the following? Weakness in the left arm Weakness in the right arm Tremors on the right side of the face Tremors on the left side of the face

Weakness in the left arm

The nervous system is divided into the _______ nervous system, consisting of the brain and spinal cord, and _________ nervous system, which includes the cranial, spinal, and peripheral nerves.

central peripheral

When assessing a patient's pupil reaction to light stimuli, you expect them to: Constrict Converge Dilate Accommodate

constrict

Davio, a 54-year-old male, reports to the clinic for a deep wound on his finger. He weighs 300 pounds, has high blood pressure, and leads a sedentary lifestyle. He appears well-groomed and has normal speech and movements. He is proud of recently completing a 6-week alcohol treatment program and denies current use of any alcohol or drugs. The nurse notices breath odor of alcohol. Which factors could be the cause of this odor? Select all that apply. diabetic ketoacidosis diet alcohol withdrawal pain medication

diabetic ketoacidosis , alcohol withdrawal

Damage to Broca area causes problems with speaking or finding words. This is called ______ aphasia.

expressive aphasia

Assessment of the function of CNS is performed at the bedside through observation of vision, pupils, __________ , facial expression and strength, and uvula and tongue movement.

extraocular movements (EOMs)

Brain tumors and other malignancies of the neurologic system are a common cause of traumatic brain injury (TBI). FALSE TRUE

false

Delirium and dementia are reversible disturbances in cognition that have similar presentations but different causes. TRUE FALSE

false

Fibers connect the CNS with organs (including the heart and kidneys), smooth muscles, and glands in the voluntary division of the nervous system. TRUE FALSE

false

The two components of the autonomic nervous system are the parasympathetic (fight or flight) and sympathetic (rest and digest). TRUE FALSE

false

A patient who has a cerebrovascular accident (stroke) in the right side of the brain will have motor and sensory deficits on the side of the body.

left side

A 26-year-old man was in a motor vehicle accident and suffered a complete spinal cord injury to L3. What area should the nurse assess the patient for loss of motor function? Chest Arms Abdomen Legs

legs

When assessing the eyes and eyelids of an adult patient, the nurse observes drooping. The nurse should document this as: Ptosis Diplopia Strabismus Anisocoria

ptosis

A patient with an injury at T6 would have arm movement and sensation but no leg movement or sensation. TRUE FALSE

true

Nurses perform neurological assessment primarily to identify actual or potential health difficulties related to neurological dysfunction and the patient's response to those difficulties. TRUE FALSE

true

True or false: Poor academic performance and increased conflicts at school may indicate altered mental status in children. FALSE TRUE

true

ncreases in CSF pressure can lead to herniation of the brain and compression of the brainstem; such compression may alter respiratory function and reduce consciousness. TRUE FALSE

true

Use of the GCS provides relatively objective assessment of LOC. The three functions assessed are: Verbal response, pupil reaction, and motor response Verbal response, eye opening, and motor response Pupil reaction, orientation, and sensation Eye opening, motor response, and sensation

verbal response, eye opening, and motor response