ASSESSING NEUROLOGIC SYSTEM PREPU

While performing a neurological assessment on a 56-year-old male, the nurse identifies the client may be experiencing a stroke. What symptoms would the nurse identified? Select all that apply. - Hypotension - Slurred speech - Difficulty following instructions - Orientation x 3 - Impaired vision

- Difficulty following instructions - Slurred speech - Impaired vision

The nurse is doing a neurologic screening examination. The nurse should include some aspect of which areas? Select all that apply. - reflexes - motor system - cranial nerves - sensory system - mental status - cardiovascular system

- reflexes - motor system - cranial nerves - sensory system - mental status

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? A. "Walk across the room and back." B. "Walk on your toes then on your heels." C. "Hop on one spot." D. "Walk heel to toe."

A. "Walk across the room and back."

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? A. Cerebellar disease B. Cerebral disease C. Brainstem disease D. Basal ganglia disease

A. Cerebellar disease

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

A. Decreased proprioception

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. Delirium B. Hypoxia C. Dementia D. Amnesia

A. Delirium

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

A. Generalized absence seizure

The nurse suspects the client has increased intracranial pressure due to meningitis. What should the nurse assess? A. Neck mobility B. Confusion C. Extraocular movements D. Decreased level of consciousness

A. Neck mobility

A nurse is performing a focused cranial assessment on a client. The nurse observes that the client is unable to shrug their shoulders. The nurse documents this as a dysfunction of which cranial nerve? A. XI B. XII C. VII D. VIII

A. XI

The nurse is caring for a client with a history of seizure disorder. The nurse observes the client making severe jerky movements (extending and contracting extremities) and the client loses consciousness. The nurse will identify this as which type of seizure? A. generalized seizure B. absence seizure C. partial seizure D. petit mal

A. generalized seizure

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

B. 68-year-old African American male with hypertension

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? A. Touch the cornea with a small piece of cotton B. Ask the client about the presence of contact lenses C. Rinse the eye and then attempt the test again D. Allow the client to blink a few times then repeat test

B. Ask the client about the presence of contact lenses

While conversing with a 42-year-old client, the nurse notes the client's tendency to repeatedly wink and shrug his shoulders at irregular intervals. The movements do not appear to correlate with the client's conversation. How should the nurse best follow up this observation? A. Assess the client's cranial nerves VIII, IX, and X. B. Assess the client's medication regimen and history of recreational drug use. C. Order a CT (computed tomography) of the client's head. D. Assess the client's immunization history.

B. Assess the client's medication regimen and history of recreational drug use.

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

B. Cerebellar ataxia

The nurse is performing the Romberg test. Which of the following indicate a normal finding? A. Client maintains balance when walking B. Client stands erect with minimal swaying C. Client prevents himself from falling D. Client sways when eyes are closed

B. Client stands erect with minimal swaying

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. As the client repeats the maneuver, movements will be less accurate B. Dominant side will be more coordinated than nondominant side C. Most clients will hesitate before touching the nose to check their position D. Uncoordinated movements can be expected in the elderly

B. Dominant side will be more coordinated than nondominant side

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? A. Vagus (X) B. Glossopharyngeal (IX) C. Hypoglossal (XII) D. Spinal accessory (XI)

B. Glossopharyngeal (IX)

A client has presented with signs and symptoms that are suggestive of Bell's palsy. What assessment finding is most consistent with this diagnosis? A. Closure of the affected eye from swelling B. Inability to wrinkle the forehead C. Muscle spasm of the lower face on the affected side D. Inability to detect sharp and dull stimuli

B. Inability to wrinkle the forehead

A client makes this movement when the nurse assesses for the plantar response. What should this movement indicate to the nurse? A. Hyperactive deep tendon reflexes B. Lesion of the corticospinal tract C. An expected response D. Pain in the foot and toes

B. Lesion of the corticospinal tract

During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve? A. V B. VIII C. XII D. I

B. VIII

The hypothalamus is responsible for regulating A. eye reflexes. B. sleep cycles. C. nerve impulses. D. memory.

B. sleep cycles.

The nurse is assessing an older adult client when the client tells the nurse that she has experienced transient blind spots for the last few days. The nurse should refer the client to a physician for possible A. spinal cord compression. B. stroke. C. Parkinson disease. D. vagus nerve damage.

B. stroke.

When the nurse is assessing a client's mental status as part of the screening neurological examination, which question would be most appropriate to ask? A. "Can you tell me about your mood today?" B. "Do you have a history of psychotic disorder?" C. "Can you tell me where you are right now?" D. "Do you feel like crying often?"

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

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? A. Try another object and test only the upper dermatomes B. Strike a tuning fork and place it on the top of one foot C. Determine the ability to differentiate hot and cold temperatures D. Use a wisp of cotton to test light touch sensation

C. Determine the ability to differentiate hot and cold temperatures

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. Romberg B. Tandem walking C. Hop on one foot D. Gait

C. Hop on one foot

While testing a client's deep tendon reflexes the nurse asks the client to perform the action shown. What is the purpose of this action? A. Keeps the knee in position B. Positions the arms for assessing reflexes C. Increase reflex activity D. Focus on the hammer striking the knee

C. Increase reflex activity

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

C. Move the tongue from side to side

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

C. Pain and hip flexion when the neck is flexed

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? A. This represents a subclinical seizure. B. This is called saccadic eye movement. C. This is called nystagmus to the left. D. This most likely has an ominous cause.

C. This is called nystagmus to the left.

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 A. ability to speak. B. recent memory. C. sensation in the extremities. D. deep tendon reflexes.

C. sensation in the extremities.

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 A. "Can you repeat rose, hose, nose, clothes?" B. "How old were you when you began working?" C. "What did you have for breakfast?" D. "Can you repeat brown, chair, textbook, tomato?"

D. "Can you repeat brown, chair, textbook, tomato?"

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? A. Utilize the FACES scale. B. Use a verbal 0-10 rating scale. C. Clients assigned this low score are pain free. D. Assess for nonverbal signs.

D. Assess for nonverbal signs.

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. Sensory ataxia C. Spastic Hemiparesis D. Cerebellar ataxia

D. Cerebellar ataxia

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? A. Extinction B. A focal seizure C. Reinforcement D. Clonus

D. Clonus

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? A. Instruct the client to state the current date and place B. Ask the client to close the eyes C. Instruct the client to smile D. Instruct the client to flex and extend the right elbow

D. Instruct the client to flex and extend the right elbow

Which action by a nurse demonstrates the correct technique to use the reflex hammer? A. Instruct the client to tense the muscles before striking B. Strike the tendon then palpate for a response C. Tap the tendon gently to avoid pain and tingling D. Use rapid wrist movement and strike the tendon

D. Use rapid wrist movement and strike the tendon

The portion of the brain that rims the surfaces of the cerebral hemispheres forming the cerebral cortex is the A. cerebellum. B. brainstem. C. diencephalon. D. gray matter.

D. gray matter.

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

D. impulses from the ear

A client reports resting and skipping exercise during a holiday from work. Which part of the nervous system is controlling this client's behavior? A. central B. cranial nerves C. sympathetic D. parasympathetic

D. parasympathetic

What should the nurse assess to test the function of the parietal lobe? A. impulses from the ear B. communication C. ability to read D. tactile sensation

D. tactile sensation

The diencephalon of the brain consists of the A. cerebellum and midbrain. B. medulla oblongata and cerebrum. C. pons and brainstem. D. thalamus and hypothalamus.

D. thalamus and hypothalamus.

The nurse is planning to test position sensation in an adult female client. To perform this procedure, the nurse should ask the client to close her eyes while the nurse moves the client's A. hand forward and then backward. B. leg away from the body. C. arm away from the body. D. toes up or down.

D. toes up or down.

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. Parkinsonian gait b. Cerebellar ataxia c. Spastic hemiparesis d. Foot drop gait

b. Cerebellar ataxia

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? a. I b. II c. III d. V

c. III

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? a. Parkinson disease b. Lyme disease c. Myasthenia gravis d. Ischemic stroke

c. Myasthenia gravis