Ch 22 PrepU

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?"

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."

When 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?

31

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

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 male 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

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 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

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.

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 walks into a client's room and finds that the client is disoriented to time and place but is awake and responsive. What term best describes this client?

Confused

The nurse notes that a client in bed has the following posture. How should the nurse document this finding?

Decerebrate rigidity

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 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)

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

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

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

When providing client teaching, what can the nurse assess?

Patient's ability to perform ADLs

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

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 nurse documents "Romberg test positive" on a client's medical record. What did the nurse most likely assess in this client?

Swaying

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.

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

Uvula and soft palate rising bilaterally on phonation

Which tests are appropriate for a nurse to perform to test the cranial nerve VIII?

Whisper test, Rinne, and Weber

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?

XI

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.

While the nurse is assessing a client's coordination, the client exhibits uncoordinated, jerky movements and is unable to touch either finger to the nose. Which condition should the nurse suspect?

cerebellar disease

While the nurse is performing as assessment of the eyes for a client, the nurse notes that one of the client's pupils is dilated and unresponsive to light. Which condition should the nurse suspect?

cranial nerve III (oculomotor) damage

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

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

glossopharyngeal.

The nurse is testing a client for Kernig sign. Which finding(s) should cause the nurse to suspect meningeal irritation? Select all that apply.

pain when the knee is extended resistance to knee extension

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

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

shrug shoulders against resistance

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

spinothalamic tract.