Chapter 25 - Assessing Neurologic System

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?"

Upon assessment, the nurse suspects the client is having a stroke. What symptoms might the nurse have found? Select all that apply.

- slurred speech - severe headache - left arm weakness

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

Ability to read

A 7-year-old boy is performing poorly in school. His teacher is frustrated because he is frequently seen "staring off into space" and not paying attention. If this is a seizure, it most likely represents which type?

Absence

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. What aspect of neurological function should the nurse address?

Balance

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 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?

Cerebellar ataxia

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 performing the Romberg test. Which of the following indicate a normal finding?

Client stands erect with minimal swaying

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

Coordination

A client sustains an injury to the brain stem. What is the most important assessment parameter that the nurse should perform for this client?

Depth of respirations

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.

After testing deep tendon reflexes, the nurse documents 2+. The nurse should evaluate further.

False

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

L2 to L4

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

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.

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 cerebrum is divided into right and left hemispheres, which are joined together by the

corpus callosum.

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

glossopharyngeal.

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 blinks when the right eye is lightly touched with a cotton wisp. Which cranial nerve should the nurse document as being intact?

trigeminal